Sexuality and sexual dysfunction

SEXUALITY AND SEXUAL
DYSFUNCTION
Prof . M.C.Bansal.
MBBs. MD. MICOG. FICOG.
Founder Principal & Controller;
Jhalawar Medical College And Hospital,Jhalawar.
Ex. Principal & Controller ;
Mahatma Gandhi Medical College And Hospital Sitapura, Jaipur.

Sexuality
“ Sexual rights include right of an individual to
achieve the highest attainable standard of health
in relation to sexuality and to pursue a satisfying,
safe and pleasurable sexual life”
Who Working Definition , 2002.

Factors
Modulate
women’s
Sexual
function

Women’s Sex Desire
 There are different phases of sex response, including desire, arousal ,
orgasm followed by relation , felling of wellbeing and satisfaction.
 In established relationship , women mostly initiate sex or accept their
partner’s invitation without any marked her own sense of sexual desire
at that time.
 Qualitative research has classified many reasons a woman instigates
or accepts sexual engagement such as enhancement of emotional
closeness with her partner, finding herself more responding to romantic
environment and more specifically , to erotic cues.
 Other reasons include wanting to feel better and completeness about
herself/ her partner , more normal more loved and lovable, more
committed to relation ship, to conceive and some times for more
nefarious reasons.
 Sexual desire , as typified by sexual fantasizing , positively anticipating
sexual experience and spontaneously crazy need of partner’s sex or
her self stimulation , has a broad spectrum of frequency across women.
 It is also clear that this overt desire is quite frequent in many sexually
functional and self motivated craziness for sex.

Model of Woman’s Sexual response

Women’s sexual response cycle
 Woman’s desire for sex or her motivation for sex by
other reasons --- women deliberately attends sexual
stimuli– subsequent subjective arousal( excitement ) ---
pleasure, intense felling to have sex are triggered.
 Desire and arousal co-exhibit and compound each
other; provided that the duration is sufficiently prolong ,
continue to attend stimuli , pleasure, sexual satisfaction
with one many discrete orgasms there by fulfilling her
recently required sexual need.
 Response is circular with overlapping phases of variable
order--- once triggering can increase the motivation to
attend stimuli and to accept request to ---Psycho -
physical act of sex.
 This desire –orgasm also simultaneously reflects male
sexuality . Male usually has ignition of desire earlier
and far more frequently than woman .

Physiology of Desire and Drive ---
sexual arousal
 Felling of sex desire can be triggered by (A) internal cues such
as pleasant memories of sexual experiences , positive feeling
for partner , positive expectations for firm bondages and
relationship. or by(B) external one as a romantic environment
and are dependent on certain biologic mechanism( not yet fully
understood).
 Multiple neurotransmitters, peptides and hormones modulate
desire and subjective arousal: noradrenalin , dopamin
,melanocortin , oxytocin , PGs, serotonin and catecholamine's
acting on some serotonin receptors are prosexual.
 Where as prolactin and serotonin acting on s5
Hydroxiyryptaminas 2 ,3 receptors glutamte and Gamma
Amniobutric Acid (GABA) are inhibitory.
 There is also a complex interplay between environmental and
neuro- endocrine factors.
 Study on animal models and human volunteers are unable to
explain it.

Sexual Arousal
 Women’s sexual arousal is complex and correlates
positively with in sexual stimuli and its emotional
context.
 This subconscious reflex organized by ANS and
processed by limbic system in response to mental
and physical stimuli( generated desire and drive)
that are recognized as sexual.
 There are also affective response to sexual arousal ,
fulfilling of joy and affirmation of felling of fear /
guilt and awkwardness serves as cognitive feed
back and modulate arousal.

Physiological changes of sexual
arousal
 Physical changes of sexual arousal include rise in Bp, Hr , respiratory rate ,
temperature , perspiration , breast engorgement, nipple erection
,increased skin sensitivity to stimuli, mottling of skin e.g. sexual flush on
face and upper chest along with increased congestion and lubrication of
genital tract( increase sympathetic tone ).
 ANS stimulation immediately increases blood flow in bloods paces and
sinuses of genital tract ( clitoris, vagina, vulva , perineum .
 There is increased relaxation of smooth muscles around arterioles .
 It is hypothesitized that during intercourse , penile thrusting on cervix
might result in dilatation of upper vagina and constriction of lower 3rd
vaginal and pelvic and perineal muscles --- known as penile cervix reflex.
 Neurotransmission of genital congestion ---- is brought by Nitrous Oxide
(NO) released by parasympathetic along with VIP .

Physiological changes of sexual
arousal---
 Simultaneously Acetylcholine (Ach) blocks sympathetic
vaso constriction .
 There are enough evidences regarding communication
between NO containing Cavernous nerves to clitoris a
branch of pudendal nerve.
 Input from the gangalion of caudal sympathetic chain
containing noradrenalin and neuro peptide Y produce
vasoconstriction on one hand and hypo gastric nerve (
sympathetic pathway ) passing through ganglion relay
stations in the pelvic plexus can produce vaso- dilatation
.
 In sexually functional women prior viewing of visuals
triggers anxiety --- increases sexual arousal to
subsequent erotic cues.

FactorsIts role
Cervix
Uterus
Factors affecting sex desire &
arousal
Ovaries
Spinal cord Injury Below T 1o
Graffinberg’s Spot
Adrenals
Testosterone (DHES)
Estrogens
Progesterone
Alcohol
cocaine
Dopaminergic drugs(dopamine)
Prolactin
Hypothyroidism
Cervical sex reflex ?—its absence do not decrease it.
Removal of uterus --- no decreased sexuality—post
hysterectomy psychology --+/-
Their removal / failure ---+/-
no decreased orgasm –Vegas takes the function.
no definite point on anterior vaginal wall– its massage ---
massage of periurethral erectile tissue increase orgasm.
-Androgen – estrogen precursors – converted in
estrogen by aromatization ----+ ve role
not clear.
helps in maintenance of blood supply, thickness of
epithelium and vaginal lubrication
No role.
excess --- takes away the sex performance.
excess ---- decreases it.
Dopaminergic drug therapy in Parkinson patient –
improve it. Dopamine --?
Hyperprolactinaemia --- decreased desire for sex.
Decreased desire and arousal

Risk Factors
 Mental Health  Depression , low self esteem
,frequent mood changes , lack of emotional
wellbeing --- associated with decreased desire and
sex arousal . Anti depressants ( SSRIs) also do the
same in some women. Depressed woman may
masturbate more frequently.
 Sexual Relationship  decreased satisfaction with
partner’s relationship. Most influencing factor is
presence/ absence of partner’s sex dysfunction.
 Partner’s Sex Function main reason to cease
sexual activity is lack of sexual function or sex drive
in partner.

Risk Factors---
 Personality Factor  woman develops orgasmic
disorders when body’s reaction / circumstances are not
under her control . Fear of –ve evaluation by others ,
marked self criticism , somatization and catastrophized
woman develops vulvar vestibulitis syndrome (VVS)---
vaginismus –a phobic quality to their fear of vaginal
penetration.
 Duration of Partnership Ease for response and
heightened desire is typically more for new partner, but
it declines by the end of one year . Desire for tender care
increases more in woman than man .Symptomatic
heterosexual woman in long term reports that her
partner is cold – less romantic to her --- reveal her
feeling / hopes and fear.

Painful Sex Decreased
Desire
Unsatisfactory
- encounters
Decreased -
Orgasm
Inadequate sex stimulatio n
Decreased Arousal
Sex Dysfunction
Veganism's

Drugs Affecting Sexual
Arousal

Overview of Medical And Psychological
effects of chronic illness on sexual
function

Influence of OB-GY Problems on
Sexual Function
 Infertility  The goal oriented sex while
trying to conceive such as in induction
ovulation , drugs –chlomiphene, GnRH
antagonist / OCPs used in down regulation ,
ART / IVF /ICSI--- stress , waiting for multiple
test reports and result --- disturb the
emotional aspect of both partners . Even a
semen collection / or its below standard
report puts an emotional stress .

Influence of OB-GY Problems on Sexual
Function----
*Endometriosis & PID  Dyspareunia—marked sexual
disorder.
* PCOD Low level of desire and sexual response –
emotional , though increased androgens still sexual
dysfunction is more frequent– treatment with anti
androgens to treat hirsutism improves sex desire and
drive.
*STD  recent STD infection --- fear of spreading it ,
explanation and discussion with partner/ doctor /
recurrence / chronicity / its sequelies/ emotion feeling of
guilt / shin lead to decrease desire .
* Vulval Dystrophy– particularly the Lichen sclerosis
involving clitoral hood and clitoris --- loss of sexual
sensitivity , dysparenia in perineal involvement –
decreases desire and increased fear.

Function----
 Cancer Cervixits diagnosis, post coital
bleeding / foul smelling discharge / fear of
spread , death – emotional upsets , radical
Hysterectomy ) damage to nerves and blood
supply to vagina/ chemotherapy / radiotherapy /
lack of psychotherapy ---- vaginal fibrosis
dyspareunia --- loss of decreased desire and to
some extend decreased sexual interest by
partner.
 Irregular acyclic bleeding in AUB  decrease
available dry days for sex – emotional upset.

Function----
 Breast Cancer After its diagnosis, surgery / chemo –
radiotherapy women develops emotional instability / induced
premature menopause, --- sexual function may develop and
continue for more than one year. Use of aromatase inhibitors (
litrazole ) leads to decreased peripheral production of estriole--
-- dyspareunia, dry vagina .
 Diabetes --- increased chances of depression . Obesity ,
recurrent candidacies—prone to develop VVS – peripheral
neuropathy- poor conduction of tactile sensation and tissue
response.
 Lower urinary tract diseases ---- urinary incontinence (stress
/urge / true –Urinary fistula), TVT surgery / anterior and
posterior colpoperineorrhaphy / Burch suspension for
prolapsed --- de enervation of anterior wall / dyspariunia ( in 8-
20 % women ) ---sexual dysfunction.

Function----
 Pregnancy  her physiological changes – emotional
versatility/ social restrictions / her own sexual value
system folklore . Religious taboos/ fear of repetition of
events of previous confinement / abortion APH preterm
labour / PROM in cases of incompetent os ---- can lead
to decreased interest in sexual activity.
 Post partum period --- associated with reduced
motivation for sexual activity--- contributory factors
may be ---mood swings / fatigue fear of waking of baby
. Continuous discharge from vagina/ painful perineal
repair or episiotomy / sore breast / decrease vaginal
lubrication due to decrease estrogen levels and
increased prolactin levels and many more .

Assessment Of Sexual
Dysfunction
 Interview assessment 
* It is better and always fruitful to assess bith
partners alone and together.
* Partner’s insight is helpful and
recommendations for changes in behavior
both asexual and sexual are difficult if
another partner is assessed and his opinion
is not heard.

Assessment by interview of Both Partners ---
-

Quick Assessment of Assessment

Treatment modalities of Female
Sexual Dysfunctions

Reasoning for combined
Therapy
 Central brain studies have recently shown that
Serotonin , Norepinehrin ,and dopamine are
implicated in sexual function.
 Melanocyte stimulating hormone ( MSH ) agonists
have also been investigated as possible modulator of
sexual function .
 Estrogen and Testosterone are helping in vulval-vaginal
health --- epithelium , blood vessels .
Neurosensitivity and lubrication.
 Biological , psychological . Physical and socio-cultural
factors do influence widely and in variable
way the sexual interplay between two partners.

Methods of therapy
 Sex Re education– about structures / functions of sex organs and
reproductive systems of both sexes---- their role in sexual arousal ,
provocation of desire , sex play and achievement of sexual satisfaction.
 Psycho therapy--- psycho analysis , moral boost up , regeneration of self
esteem , hope and winning the goal --- removal of depression / clearing all
doubts about oneself sexual capability and capacity and so also about the
sex partner too.
 Motivation to follow the instructions and stick to treatment with full hope.
 Slides show session about --- making mood , alteration of environment and
surroundings . Learning care and respect for feeling of each other ,
amusement , enjoyable breaks in the routine hectic life schedules , fore play
.body massage and identify / discovery of erotic points on the partners body
to stimulate her / his sexual desire and orgasm .
 Eros clitoral stimulators --- FDA approved ---2000.
 Conjugate Equine estrogen for moderate to severe dyspareunia.
 Drugs ---
Estrogens , testosterone , DHEA , Vaginal Lubrications , Lybridos and
lybroidos, Dopamine agonists , MSH analog s and Viagra etc.

female-sexual-problems-
s3-photo-of-
troubled-couple-lying-
in-bed

s5-photo-of-troubled-
couple-in-bed

s1-
photo-of-depressed-
wife

s6-photo-of-
woman-in-bed

s7-
photo-of-sad-woman-
in-bed

s8-photo-of-
couple-with-problems

sex_drive_killer
s_s3_arguing_c
ouple_on_sofa

Viewing Romantic Scenes And enjoying together in Bed

Going out Together And Improving Relations

Develop Your own games and ways to improve
understanding and Love

Ankhon Hi Ankhon Main Fore play

female-sexual-problems-s2-
photo-of-couple-talking-
to-doctor

s11-
photo-doctor-with-
laptop

s13-photo-of-
happy-couple-on-couch

s14-photo-of-
woman-getting-massage

s15-
photo-of-playful-couple-
on-bed

s16-
photo-of-comforting-couple

sex_drive_killers_s8_
woman_looking_at_b
ehind_in_mirror
Viewing self body image in mirror on 3rd party ‘s comments and developing Negative
thoughts about her own figures

sex_drive_killers_s12
_woman_consoled_b
y_man

Sexual Dysfunction ----- Husbands disappointment ---Takes sleeping
Pills

Treatment Of Sexual Arousal
disorder
 Lyriana ---A little sex pill for woman – it revokes the
libido, it addresses the lowe Dopamine level --- it
provides precursor L-Dopy. Body is able to convert it in
to Dopamine – increase biological Trigger that control
sex .
 Tibolone ---Phospho diesterase inhibitors .
 Zestra , T oil for gentle massage of genital Pvt parts ,
Vacuum therapy – battery operated device increase
blood supply of clitoris and increase nerve sensitivity.
 Self designed sex games. Erotic massage. Fellatio Tips
pressing your lips / mouth to partners genitalia .
 Cognitive behavior ---approach.

disorder
 Commercial Available --vaginal Lubricants, Vit.E and
mineral oils.
 Encouraging adequate fore play .
 Use of clitoral/ anterior vaginal wall and perineal vibrators.
 Scented (aromatic smell)Warm water bath before sex.
 Eliminate anxiety by engaging in distraction techniques .
 Treat urogenital atrophy --- post menopausal /
oophrectomized women – with estradiol vaginal cream,
ERT wit 5mg medroxy progesterone. Est ring ,
 sidenophil – tab 1-2 hr before sex?

EROS-Clitoral-Therapy-Device-
For-Female-Sexual-Dysfunction-c-
pz
It is hand operated with
rechargeable battery ---
produce radio-frequency
vibrations to stimulate
clitoris

disorder--
 For Woman Only ---A Revolutionary Guide
to overcome Sexual dysfunction and
recover your Sex Life ---by L Bussens, J
Burma , etal New York Herrittoolt. 2001.
 How to have Magnificent Sex . ---The 7
Dimensions of vital connection by L
.Hostein New york, Harmony books 2oo1.
 Resource of prone pictures / tapes, music
,and general information about sexuality
and spirituality ---WWW. Tantra .com

Treatment of orgasmic
disorders
 Androgenic substances --- testosterone / DHEs are quite
effective in few cases but there side effe3cts are likely to be
troublesome after a prolong use or use in higher doses
.Maximizing stimulation and minimizing inhibitions
simultaneously can also help .
 Stimulation with masturbation , clitoral vibrator , gentle
massage of anterior vaginal wall with lubricated finger ( self
/ partner ), Kegal exercise training , touching at vulva with
lips / whole face while woman is standing or lying in bed
naked by the partner , kissing of nipples and there gentle e
tickling with lips and fingers, kissing from head to toe ,
rubbing the organ at her back ( lumbo sacral spine and
buttocks

Treatment Of Orgasmic disorders----
 Kegal exercise—Its prudential uses are ---increase
pubococcygeal tone , increase orgasm intensity
,correction of orgasmic urine leakage, one of
distraction technique during coitus , improves
patient awareness of sexual response. It’s proper
training by consultant is helpful .
 Decrease inhibition  distraction by “ Spectoring “
e.g. observing oneself from a 3rd party perspective.
Fantasizing / listening erotic music and dialogues .
Viewing romantic videos
 No response in given period of 3-4 months refer her
to specialist and multi disciplinary approach.

Newer Drugs --- In Pipe Line
 Flibanserin –5HT (1A) agonist / 5HT-2 antagonists for hypo sexual
desire disorder --- 100 mg at bed time was associated with
clinical meaningful and significant improvement.
 Librido And lybroidons are in pipe line for Hyposexual desire
disorder( HSDD). Libridos contain testosterone with Phospho
diastrase inhibitor ( PDE5 inhibition )
Lybroidons --- testosterone with alpha 5HT(1A) agonists
(Buspirone) . Testosterone increase desire and sexual motivation .
PDE5 is inhibitors increase genital sensitivity to sexual afferent
signals.
Buspirone converts the inhibition generated in fr5ontal area of
brain .
- Librigel – low dose 300ug testosterone topical cream --- helpful
in VVS and post menopausal women .
- TB s-2 –Tefrin –TBS -2 is an intra nasal gel preparation of low
dose testosterone for women with orgasmic disorder .

Newer Drugs In Pipe line ---
 Alprostedil ( Femprox ) – PGE -1 , a potent vasodilator . It is
alprostatil based cream marketed for Rx of FSAD. , 900 ug dose
showed improvement in arousal and sexual performance /
satisfaction out come .
 MSH Analogs – Bremalanotick – a melano cortin receptor 4
agonist (MCR4 agonist ) for Rx of HSDD and FSAD. It has
adverse effect on BP and cardiovascular system , hence it is on
trial in low dose to minimize the side effects .
 Apomorphine– a dopamine agonist used as oral preparation
help in Rx of orgasmic problems.
 Intra Vaginal suppositories of DHEA in low dose for VVS case ---
has promising effect on HSDD.
 Osperifene– Estrogen specific receptor modulator with
agonist and antagonist action --- for VVS with sexual pain ---
increased improvement.
 VIVENE Therapy – mono polar radio-frequency thermal therapy
for laxity of vagina and its introitus and improves sexual
satisfaction of both partners.

Functional Sexual Disorders
( FSD)
 When to refer?
Long standing sexual dysfunction .
Multiple dysfunction.
Current / past Sex abuse.
Psychological disorders of acute onset with
unknown etiology .
No sufficient response to therapy till given.

Sex Pain ( Dyspareunia)
 Progressive muscle relaxation and vaginal dilatation to accommodate
the penetrating male organ facilitate the sex performance and
satisfaction to both during normal sexual act. It is seldom painful.
 But when the pain is felt by women at her introitous or deep in pelvis ,
the sex is no more completed and causes a chronic sexual disorder
called Dyspareunia.
 Vaginismis / a synonym of Dyspareunia is mainly associated with
voluntary contraction / spasm of muscles around lower 3rd of vagina
as soon as vaginal penetration by penis / examining fingers of doctor
and even the tampon by herself.
 It is an intense type of phobia culminating in physical act and sexual
disorder / marital disharmony .
 Past experience of sexual abuse (rape/ an attempt ) , disliking with
husband precipitates it while she may be comfortable with lover.
 It may be complete / situational .

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