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FEMALE SEXUAL DISORDERS: DO YOU HAVE A PROBLEM?
WARNING: For an accurate diagnosis leading to an effective therapy, a trusting and open relationship with your gynaecologist is vital! Only by looking at a complete clinical history and carrying out the necessary examinations, can he/she prescribe a suitable therapy. The following information is written here to broaden your own personal knowledge and ease the communication with your own physician. It is not a substitute for an honest and direct doctor-patient relationship. This said, enjoy the reading!
LOSS OF LIBIDO FROM THE PERI-MENOPAUSE ONWARDS
LOSS OF LIBIDO: YOUR WORDS
“I never imagined that sexual desire could
disappear so quickly. I’ve always liked making love. Now it’s as if I’ve
frozen, as if I have suddenly become frigid. This all started to happen soon
after the removal of my uterus and ovaries because of fibromata and ovarian
cysts. I don’t have anymore feelings of desire, no enthusiasm, neither for my
husband nor anyone else. It seems a hundred years since I became excited for a
kiss, for a caress, or for a new game. I do have other menopausal symptoms but
this lack of sexual drive is the problem that bothers me the most. Also for my
husband, that doesn’t deserve my indifference … Our sexual intimacy has always
been the core of our marital commitment and satisfaction!”
Lydia
“You must do something, doctor. This
menopause has disrupted our sex life. We’ve always been a happy couple, also
sexually. We don’t have children and maybe for this reason we’ve always
dedicated more time to ourselves. I’m really sorry to see my wife feeling so
bad, she doesn’t experience pleasure at all anymore, she has become indifferent
to any sexual cues that I make. I’m not happy like this. Is it really not
possible to do something to get us back to how we were before?”
Thomas
DID YOU KNOW THAT?
- Libido = sexual appetite, desire and drive, sexual impulse and
interest; it includes the physical
drive and the motivation to behave
sexually (that are not necessarily always contemporarily present!)
- Libido is a Latin word that
means “desire”
- Libido was first referred to
by Sigmund Freud to indicate the energy correspondent to the psychic side of
sex drive
WHAT EXACTLY IS LIBIDO?
- Libido is considered to be
that which motivates a person to obtain sex, and it focuses his/her attention
on that goal
- This subjective experience is accompanied
by, and partly consists of, various physiological changes, many of which are in
preparation for sexual behaviour. These are better addressed to as “arousal”
“Sexual desire is
normally an activated, unsatisfied mental state of variable intensity, created
by external – via the sensory modalities – or internal stimuli – fantasy,
memory, cognition – that induces a feeling of a need or want to partake of
sexual activity (usually with the object of desire) to satisfy the need”
Suggested readings:
Bancroft, J. Sexual desire and the brain. Sex. Marital Ther. 1988,3,1,11-27
Levine, S.B. An essay on the nature of sexual desire. J. Sex. Mar. Ther. 1984, 10, 2,
83-96
Levin, R.J. Human Male Sexuality: appetite and arousal, desire and drive. In Legg, C.
and Boott, D. Human appetite: neural and behavioural bases. New York and
London, Oxford University Press, 1994, pag. 127-16
Graziottin A. Libido, Maturitas 34, Suppl. 1-S9-S16, 2000
Basson, The female sexual response: a different model: J Sex Mar. Ther 26:51-65, 2000
IMPORTANT:
- Libido – or sexual
desire – is considered different from sexual arousal.
- Sexual desire is an
attitude towards an object while sexual arousal is a state with specific feelings
- mental
“subjective arousal”, ie when you feel “turned on”
- peripheral
non genital, when you feel warm because your skin is warm, when your mouth is
wet,when the nipples are erected and so on.
- genital,
when you feel an increase in vaginal congestion and lubrication, a clitoral
tingling and so on.
- There can be sexual
arousal without sexual desire, and sexual desire without arousal.
WHAT DOES THE PSYCHOLOGIST SAY ABOUT LIBIDO?
- Psychological processes
play an important role in human libido.
- We learn to feel sexual
drive at certain times and in certain situations
Can my mood affect my libido?
Yes. In a depressed mood we
are less likely to interpret experiences in pleasant sexual terms. In spite of
favourable external conditions, i.e. the availability of a willing and loving
partner, depression reduces the likelihood of sexual action and pleasure
WHAT DOES THE BIOLOGIST SAY ABOUT LIBIDO?
- In recent years, the
realm of libido has grown to include a
deeper understanding of its biological roots and of its vulnerability to
personal factors and external agents
- From the biologist’s
point of view, this sexual appetite can be divided in two “proceptivity”
and “receptivity”.
- Proceptivity refers to the
willingness to initiate and invite sexual contact or sexual stimulation.
- Receptivity describes the
preparedness of an individual to accept the sexual advances of another.
Levine, S.B. An essay on the nature of sexual desire. J. Sex. Mar. Ther. 1984, 10, 2,
83-96
WHAT
HAPPENS TO LIBIDO WITH THE ONSET OF MENOPAUSE?
- In our species, libido
has several roots, with a complex interplay between biological, motivational
and relational factors, that may all have an inhibiting or enhancing
role.
- Menopause may
represent a critical turning point for libido, as the above factors may
all undergo deep changes
What are the motivations for having sex?
- Reproduction – this is the primary biological goal.
- “Recreational” sex – the pursuit of pleasure.
- Instrumental” sex – as a means to obtain
advantages. The motivations are different from pleasure and/or procreation.
WHY DOES SEXUAL DESIRE
(i.e. LIBIDO) LESSEN, OR EVEN DISAPPEAR COMPLETELY FOR MANY WOMEN AFTER THE
MENOPAUSE?
- The ovaries produce less
of the hormones that “feed” sexual desire (changes in the body’s sexual
functions).
- Not only does the body
change, but so does its ability to respond to stimulants and “love-games” (changes
in the woman’s sexual identity and receptiveness to sexual cues).
- The couple go through a
significant phase of change that is not always easy to accept (changes in
the couple’s relationship).
WHY ARE HORMONES SO IMPORTANT FOR FEMALE
SEXUAL DESIRE AND FUNCTION?
- The female hormones,
above all oestrogen, feed physical desire in a woman and
nourish her inner sense of femininity. Oestrogens indeed
modulate the appearance and maintenance of breast well-being and beauty, of
skin silkiness, as they nourish all the components of the skin’s health, of
the appearance of the genitals, and even of periods themselves.
- Oestrogen is the permitting
factor for the action of the Vaso Intestinal Peptide, a neurotrasmitter that
“translates” sex drive into vaginal lubrication. The absence of oestrogen
can therefore lead to vaginal dryness and pain (dyspareunia) that can inhibit
libido.
- Oestrogen contributes to sensory organs – including skin – that are the
key receptors for external sexual stimuli. Sensory organs transmit the basic
information that, mixed with emotional and affective messages, contributes to the
structuring of core sexual identity and self-image, so relevant for the personal
perception of being an “object of desire”
- The peak of androgen
production at ovulation, is vital, along with oestrogen, in determining the
appetitive side of sexual behaviour.
- Androgen gives a woman vital energy and positivity.
A lack of androgen can lead to, not only a loss of pubic hair, a reduction
of muscle mass and strength, but also an unpleasant change of body-shape
(potentially impairing woman’s sexual identity), with an accumulation of
fat on the waist-line and stomach.
- Androgen also has a positive
effect both on the brain – increasing sexual fantasies and erotic dreams – and
on the general well-being of the external female genitalia. Together with
oestrogens it aids lubrication – thus making penetration more pleasurable – secondarily
maintaining libido due to the memory of
previous pleasant experiences.
Graziottin A.
Libido, Maturitas 34, Suppl. 1-S9-S16, 2000
AS WELL AS SKIN, WHAT OTHER SENSORY ORGANS
ARE AFFECTED BY HORMONES?
- Smell Chemoreception is the ability to receive chemical messages
from the environment
- Olfaction
(i.e. smell) is the most refined sense based on chemoreception; the other one
is taste. It is hormone dependent, thus
changes over the ovarian cycle, with increased smell sensitivity occurring
at times of ovulation.
- A reduction of the sense of smell alters responsiveness to feromones,
i.e. chemical messages emitted by animals of the same species.
- Sexual attraction is one of the key function modulated by feromones even in humans
- This, along with a reduction in the production
of feromones (chemically attractive substances) that contribute to the “
scent of a woman” typical of the fertile age,
could be responsible both for the reduced
self-perception as an object of sexual desire and for the reduced
attractiveness for the partner.
- Taste.Gustative receptors,
located on your tongue, are also modulated by sexual hormones.
They can perceive feromones as well.
- This
explains why if you like the smell of your partner’s skin, usually you like
also the taste of his/her kisses (obviously if the personal hygiene is
fine!). And, conversely, that if you do not like any more his/her smell, it
happens that you detest as well the taste of his/her kisses.
- Love, as well as sexual attraction or distaste, has its roots in
very primitive “arcaich” body signals, all nourished by sexual hormones
- Why so? Because receptors for sexual hormones are
distributed widespread in all the female tissues, including sensory organs,
besides the brain.
- Sexual
hormones are indeed a lymph that nourishes all the female body. To be simple,
if we compare an hormone to a key, then the receptors are locks. When they
interact, all the cell machinery is set off, thus activating all the
proliferative or reparative cellular processes and functions.
- Taste is another key biological and emotional
factor in the thrill of sex drive, specially in women.
- Increase of salivary secretion during sexual
desire and arousal is a strong predictive factor of the quality of the sexual
liking.
- Mouth dryness, frequent in
the menopause, could be a factor in the biological modulation of libido. It has
been reported in 45% of healthy post-menopausal women, up to 65% of those
on medications other than Hormonal ReplacementTherapy
- Touch.A highly sexually
communicative skin depends on a mixture of good genes, optimal endocrine
impregnation, good feromone production and reception, plus excellent brain
activity in the processing of peripheral information from the sensory organ
enhanced with internal sexual and emotional stimuli.
- Love, as well as libido, is the strongest attachment factor
for a couple to bond through skin touching
- The
loss of sexual homones deprives the skin of 2% of the total collagen per year,
up to 15 years after the menopause: this is why wrinkles do increase
dramatically after the menopause!
- This
loss also decreases the sebaceous gland production by 38%: this is why the skin
becomes drier. And it is also why your skin remains drier, in spite of being
hydrated with creams, unless you take a well tailored low dose HRT!
- The best you can do to maintain younger, silkier and more sexually attractive
skin is: 1) to have an appropriate life style (non smoking, high
fruit/vegetables intake, regular physical exercise, low sun exposure);2) to
have appropriate dermatologic skin care;3) to nourish it from within with a
well tailored HRT.
- Vision.35% of post-menopausal
women complain of ophthalmic disturbances due to the lack of oestrogen. Most of
them improve with HRT.
It is possible that all these subtle post-menopausal changes in the function of
sensory organs could contribute to the deterioration of libido with age.
Graziottin, A., Sexuality and the Menopause, in Studd J(ed) The Management of the
Menopause-Annual Review, London, Parthenon Publishing, 1998, 49-57
Graziottin,A., Estrogeni, Funzioni psichiche e organi di senso, Società italiana del
pavimento pelvico ed, Milano 1999
Brincat M. The skin at the menopause Parthenon Publishing, London, 2001
ARE THERE ANY OTHER
FACTORS THAT CAN LEAD TO A SECONDARY LOSS OF LIBIDO?
YES
a) Physical:
- Ongoing diseases or
illnesses
- Medicines
- Drugs
- Smoking
- Alcohol
b) Psychosomatic:
- Depression
- Anxiety
- Chronic stress, either
by family or work related problems
c) Psychosexual:
- Arousal disorders
- Orgasmic difficulties
- Sexual dissatisfaction (both physical and emotional)
d) Partner related:
- Partner physical and/or
sexual problems
- Couple conflicts,
frustrations, disappointments
IN SUMMARY, as previously stated, an accurate evaluation of all the
potential contributing factors should be made if a comprehensive diagnosis and
an appropriate treatment is to be made!
Indeed, the female sexuality is MULTIFACTORIAL: it depends on:
- biological
- psychosexual
- context-dependent factors
It is also MULTISYSTEMIC: ie it requires the integrity and appropriate
function of:
- hormones
- vessels
- nerves
- muscles
- immunitary system etc.
Last but not least, it shows a great variability according to the
context changes and life experiences; just think about the physiologic, ie
normal, changes of sexual drive and experience across pregnancy, puerperium,
family problems, menopause…
WHAT CAN BE DONE TO IMPROVE LIBIDO
DISORDERS AFTER THE ONSET OF MENOPAUSE?
- Begin an appropriate well-tailored Hormone Replacement Therapy (HRT) that acts on the
biological bases of sex drive after the menopause.It requires:
- only oestrogens if the woman is without uterus but has her ovaries in site;
- estrogens and progestins, if she still has her uterus and ovaries in site;
- Androgen should be considered if
she suffers from the so called “Female Androgen Deficiency Syndrome”. Indeed
androgens seems to be the most significant hormone for the sexuality of a
woman. Androgen replacement therapy would have a three fold action:
- Increase
the susceptibility to psychosexual stimulation, contributing to the “sexually
activated mental state” typical of a good libido.
- Increase the sensitivity of external genitalia.
- Increase the intensity of sexual gratification.
The appropriate treatment should
always be tailored by your physician after an accurate clinical evaluation of
biological, psychosexual and contextual factors!
SEXUAL AROUSAL DISORDERS
Sexual arousal disorder indicates the
persistent or recurrent inability to attain or maintain sufficient sexual
excitement, causing personal distress, which may be expressed as a lack of
subjective excitement, or genital (lubrication/swelling) or other somatic
responses.
The definition indicates that in
women their subjective perception of inadequate excitement may be the
leading complaint, if it causes personal distress. At the same time, and
differently from men who are more focused on the genital reaction leading to
erection, women may suffer from inadequate:
- central arousal, when they do not feel subjectively or mentally
excited
- non genital-peripheral arousal, when they say that the skin remains
cold, the nipples are non erected and unresponsive, the mouth remains poorly
lubricated or dry
- genital arousal, when the vagina is dry, not congested, and the
external genitalia do not present any congestion or swelling
How many woman suffer from arousal
disorders?
- Arousal disorders are reported in 19-20% of women in epidemiological surveys. This
figure may rise up to 39-50% in postmenopausal sexually active patients.
- Vaginal dryness is being reported as a specific complaint with increasing
years after the menopause, particularly in thin women who do not have the
endocrine contribution from the androgenic conversion to oestrogens in the
adipose tissue, and in those with a very low frequency of intercourse. No data
are reported for prevalence of specific subtypes of arousal disorders.
- Decrease of salivary secretion during arousal and oral intimacy
may only be inferred by studies reporting that up to 45% of women after the
menopause complain of some degree of mouth dryness, this figure rising to 65%
if they are on some kind of medication, other than HRT
What triggers arousal in women?
Mental arousal may be triggered through different pathways:
- biologically by androgen, which activate the cascade of
physiological events leading to the overt physical response of feeling “turned
on”, lubricated and congested;
- psychologically by motivational forces like "intimacy needs
", where the wording indicates all the affective needs of love, tenderness, attention, bonding
and committement women have.
What happens in the female body when arousal begins?
- Mental
arousal may activate both non-genital-peripheral and genital arousal.
- It
is also likely that physical stimulation, with non-genital and genital
foreplay, and response to sexual cues, may further increase both the mental
and genital arousal.
- On successful sexual arousal most women produce increased quantities of the vaginal
transudate, that contributes to vaginal lubrication.
- This
transudate production arises because the blood vessels supplying the capillary
bed become vasodilated due to the release of the neurotransmitter VIP (Vaso
Intestinal Peptide), the most powerful neurotrasmitter that translate sex drive
into vaginal lubrication.
- Estrogens are credited to be powerful “permitting factors” for the VIP.
How does arousal change
after the menopause?
- The
reduction in vaginal lubrication is one of the commonest complaints of
postmenopausal women
- Sarrel noted that when the plasma oestradiol concentration was
below 50pg/ml (fertile normal range being 100-200pg/ml)
vaginal dryness is reported.
- Laan and Lunsen however, interpreted their study in sexually aroused postmenopausal
women in terms of inadequate erotic stimulation (and preexisting arousal
disorder) rather than a postmenopausal vasculogenic dysfunction.
What happens in the
vagina after the menopause?
- After the menopause, physiological studies indicate that: there is
an increase in vaginal pH from 3,5-4,5 to 5.0-5.4, due to decreased glycogen production and
metabolism to lactic acid ;
- an average reduction of 50% of vaginal secretions
When does a woman notice
that an arousal problem is in play?
- Changes in quantity of secretions leading to the feeling of "dryness"
become subjectively perceivedfour to five years after the menopause.
- After one month of conjugated oestrogens (either 0,625 or 1,25/day orally)
there is a rapid increase in blood flow, with reduction in pH, and increase
in vaginal secretion
- Topical treatment with small vaginal tablets containing only 25 microgram of 17-beta
estradiol have been recently shown to be as effective and better tolerated than 1.25 mg
conjugated equine oestrogen vaginal cream to relieve symptoms of atrophic
vaginitis, including dryness and arousal difficulties .
WHICH
QUESTIONS WILL THE GYNECOLOGIST ASK TO ADDRESS THE DIAGNOSIS?
Due to the frequent comorbidity,
and the many common etiologies between different FSDs, many questions may
overlap with the ones previously presented for the Hypoactive Sexual Desire.
The questions listed below focus specifically on the arousal disorder around
the menopause.
1)When did
you noticed you had more difficulty in becoming aroused? Have you have had this
difficulty previously, since the beginning of your sex life ("lifelong")?
Or is it a new experience, worsening in the postmenopause ("acquired")?
A lifelong
problem is generally dependent on psychosexual issues, whist a problem
that appeared or worsened after the menopause may have a biological etiology in
the loss of hormones secondary to the menopause
2)Is it generalized or do you have this problem only with your current partner or
on special situations (situational)?
As mentioned, the generalized issue addresses more personal -biological and/or psychodynamic-
factors, whilst the situational indicates a more likely interpersonal etiology.
In the latter case, couple dynamics and/or partner’s problems should be addressed.
Do you suffer from a dry
mouth?
If yes, have you noticed that it does not change when you kiss your
partner?
This may indicate a
non-genital-peripheral arousal disorder, superimposed to the salivary glands
involution, secondary to long-lasting hypoestrogenism.
5)Are you normally
lubricated during foreplay and does the lubrication suddenly disappear when
intercourse begins?
This may suggest not only a phobic
reaction to coitus (in common with vaginismus) but also the appearance
of pain of different etiologies (see dyspareunia). Pain is the strongest reflex inhibitor of arousal in
non-masochistic women.
WHAT SHOULD THE
GYNECOLOGIST LOOK FOR?
In case of complained arousal
disorders, the clinician should look for:
a)hormonal profile
b)general and pelvic health,
focusing on pelvic floor WELL BEING: vaginal, clitoral, vulvar, connective and
muscular, looking for both hypertonic and hypotonic pelvic floor conditions;
c)biological factors causing introital and/or pelvic pain(see dyspareunia);
d)vascular factors that may impair the genital arousal response (smoking,
hypercholesterolemia, atherosclerosis);
e)marital status and partner-related problem (general and sexual health)
f)psychodynamic factors, either personal or interpersonal
g)quality of sexual foreplay, motivation to the intimacy and mantal & physical receptiveness
to sexual cues
- If the arousal problem appears to be acquired and generalized
and worsening after the menopause, then HRT may be the treatment of
choice
- Oestrogen, for vaginal lubrication and congestion, and
androgen, for clitoral and vestibular response, may
offer the best improvement, as they act in different dimensions of the sexual
circuit, improving sex drive and arousal (central, non-genital-peripheral and
genital) thus favoring also the orgasmic response.
- Sometimes the systemic treatment requires the addition of a topical dose, to
optimize the genital response .
- Topical oestrogenic treatment alone may be sufficient to restore a normal vaginal
lubrication, provided that other interpersonal inhibiting factors are not in
play.
- Topical androgen treatment may improve the clitoral arousal (congestion and
engorgement) although no prospective studies are reported so far in the
author's knowledge.
- Rehabilitation of the pelvic floor is necessary to ease the reflex contraction in response to
dryness that causes further pain and inhibition of lubrication when coitus is
initiated.
- It may also by useful to improve the tone of the elevator ani, thus
increasing the vaginal sensitivity and pleasure, provided that lubrication and
tvaginal wellbeing have been hormonally restored.
- Non-hormonal drugs, such as sildenafil, are being considered an incestigated in women complaining
of arousal disorders who cannot use hormones (for example, because of hormone
dependent cancer) or because they do not want to. Preliminary results are
encouraging when the diagnosis of pure (or dominant) female arousal disorders
is made.
References
Bancroft J. Graham C. McCord C Conceptualizing Women’s Sexual problems JSMT 27:95-103, 2001
Barlow DH, Cardozo L, Francis RM et al Urogenital ageing and its effect on sexual
health in older British women Br J Obstet Gynaecol 104: 87-91; 1997
Basson R.
Are pur definitions of women’s desire, Arousal and sexual pain disorders too
broad, and our definition or orgasmic disorder too narrow? JSMT 28:289-300,
2002
Basson
R A model of women’s sexual arousal JSMT 28, 1-10, 2002
Caillouette
JC Sharp CE. Zimmermann GJ Roy S Vaginal pH as a marker for bacterial
pathogens and menopausal status Am.J.Obstet.Gynecol. 176:1270-1277,1997
Graziottin
A. Sexual function in women with gynecologic cancer: a review
It.J.Gynec.Obstet.2:61-68, 2001
Levin
RJ The mechanism of human female sexual arousal Ann Rev Sex Res 3: 1-48;1992
Levin
RJ Measuring the menopausal genital changes- a critical account of laboratory
procedures past and for the future in Graziottin A (ed) Menopause and Sexuality
,Menopause Review, IV (4):49-57,1999
Goldstein
I, Berman JR Vasculogenic female sexual dysfunction: vaginal engorgement and
clitoral erectile insufficiency syndromes Int J Impotence Res 10: S84-S90; 1998
Hagedorn
M. Buxmeyer B. Schmitt Y Bauknecht T. Survey of lichen sclerosus in women and
men Arch. Gynecol. Obstet.266:86-91,2002
Notelovitz
M. A practical approach to postmenopausal hormone therapy Ob/Gyn, Special ed.
MacMahon>, New York, April 2002
Tarcan T.
Park.K Goldstein I Maio G Fassina A. Krane RJ histomorphometric analysis of age
related structural changes in human clitoral cavernosal tissue J.Urol
161:940-4,1999
ORGASMIC DISORDERS
The orgasmic
disorder defines the persistent or recurrent difficulty, delay in or absence
of attaining orgasm following sufficient sexual stimulation and arousal, which
causes personal distress.
How
frequent are the orgasmic disorders?
- the orgasmic disorder has been reported in an average of
25% of women during their fertile years in an epidemiological study.
- after the menopause, 20% of women consulting a menopausal
clinic quote that "their clitoris is dead",
according to Sarrel and Whitehead and even more - if properly listened to -
report an increasing difficulty and delay in achieving
orgasm and aprogressive intensity in its fading
- In the most recent population based sample of
postmenopausal women, difficulty reaching orgasm was reported as
"always" by 15.0%, "sometimes" 22.2%, "seldom"
37.8%. Only 25% said they never have orgasmic difficulties .
What does normally trigger orgasm?
- Orgasm is a sensory-motor reflex that may be triggered by
a number of different stimuli, physical and mental.
- It does not even require direct genital stimulation. Mental
orgasm, that has been demonstrated in laboratory conditions (for the
increase of the pain threshold when the orgasm was referred to being mentally
perceived), requires an optimal sex drive and intense mental arousal, both
biological and motivational.
- Genital orgasmrequires the integrity of the
cavernosal structures that, engorged and adequately stimulated, convey
sensory pleasant stimuli to the medullary center and the brain .
- Short medullary reflex may trigger the muscular response, characterized
by the involuntary contraction (between three to eight times, in single or
repetitive sequences) of the levator ani, ie the perivaginal muscles. This
is usually accompanied by a variable sensation of pleasure.
- The orgasmic reflex may be eased or blocked,
respectively, by corticomedullary fibers that may convey both excitatory
stimuli (when central arousal is maximal) or inhibitory ones when arousal is
poor, or when performance anxiety prevents abandonment and activates adrenergic
input that disrupts the arousal response. Inhibitory fibers are most
serotoninergic: this explains the inhibitory effects of SSRI on orgasm, both in
men and women.
- A biological correlate has recently been suggested for the
complaint of worsening clitoral responsiveness with age, particularly after the
menopause. The clitoral cavernosal erectile tissue consists of smooth muscle
and connective tissue. Tarcan et Al utilized computer assisted
histomorphometric image analysis to determine the age-associated changes
in clitoral cavernosal content of smooth muscle and connective tissue.<
- This study revealed a strong link between increase in
age and decrease clitoral cavernosal smooth muscle fibers, that may play an
as yet undetermined pathophysiology in age-associated clitoral sexual
dysfunction.
- It also indicates that vulvar aging is a "full
thickness" process, that involves all the genital structures,
cutaneous and mucosal, submucosal, cavernosal, vascular, muscular and
neurologic, thus impairing the complex biological background of the sexual
response.
WHICH QUESTIONS
WILL YOUR PHYSICIAN ASK TO CLARIFY THE DIAGNOSIS?
When did you
notice having orgasmic difficulty? Did you always have persistent or recurrent
orgasmic difficulty (lifelong), or did you notice its appearance or worsening
after the menopause (acquired)?
- Postmenopausal vulvar aging may further
worsen the congestive phase of the orgasmic response, more so in women
suffering from lichen sclerosus, an accelerated aging and dystropfy of
the vulva.
- Topical androgen treatment, approved for lichen sclerosus,
is anedoctically reported to improve physical sensation and clitoral pleasure
in three - six months of treatment. No controlled studies focusing on the
effect of topical androgen treatment on sexuality are reported so far in the
author's knowledge.
Is it generalized (in every situation and independent of the
partner) or is it situational?
- If generalized, it suggests more a biological component,
particularly if sex drive is maintained.
- Antidepressant use (SSRI and
clomipramine, particularly) should be investigated, as their use is one of the
most frequent and overlooked causes of acquired, generalized, biologically
based (and reversible) orgasmic difficulties in women (as well as in men)
What, in your opinion, is causing your orgasmic difficulty?"
This is a question useful to diagnose other
interfering factors. For example:
- worsening incontinence, particularly urge
incontinence, may block the orgasm for fear of leaking when reaching it;
- pain, depression
- too rapid foreplay;loss of sex
drive and arousal; dissatisfaction with the current relationship; sexual
and /or health difficulties of the partner
- alcohol abuse
Do you feel a selective loss in your clitoral sensitivity and
pleasure ability and/or a reduction in your coital pleasure?
- If the complaint is
focused on the clitoris, and involution or dystrophia is present, then topical
androgen treatment may be useful.
- If it is coital, two further points of
attention should be raised:
a)Do you have a decreased coital sensation?
- This latter may suggest
a worsening hypotonia of the perivaginal muscles. Menopausal loss
of oestrogens may cause not only a gradual loss of pelvic connective tissue
up to ten years after the menopause, but also a loss of the muscular
component, thus affecting the tonicity of the muscle itself.
- As vaginal pleasure
and sensitivity are physically dependent also on the tonus of perivaginal
muscles, this decrease may selectively damage the coital component of the
orgasmic experience.
- HRT, contributing to maintain a better connective, muscular and vascular trophism,
may indirectly concur to maintenance of a better orgasmic response
- Electromyographic vaginal biofeedback and/or physiotherapc rehabilitation of
the pelvic floor muscles, may improve the tonus, strenght and motor performance of perivaginal muscles,
thus improving both coital sensitivity and stress incontinence, often
associated to hypotonic pelvic floor conditions
b)Do you feel pain during intercourse?
Pain of whatever origin may cause a reflex block of the arousal and of orgasmic response
.
HOW WILL THE PHYSICIAN
CONFIRM THE DIAGNOSIS?
The
physician, expert in sexual medicine, when working with the perimenopausal
woman, should look for the following aspects, according to the scenario
emerging from the clinical history:
1)the hormonal balance;
2)signs and symptoms of vulvar dystrophia and,
specifically, of clitoral and vaginal aging; worsening consequences of
ritual genital mutilations should be evaluated;
3)signs and symptoms of incontinence, of hypotonic
or hypertonic pelvic floor;
4)iatrogenic orgasmic disorders, when potentially
orgasmic-inhibiting drugs,like antidepressant, are prescribed;
5)marital problems;
6)partner’s health or sexual problems, such
as erectile deficits or premature ejaculations;
7)psychological disturbances, depression, anxiety;
8)neurological diseases.
IS THERE ANY
TREATMENT FOR THE ORGASMIC DISORDERS IN THE PERI AND POST MENOPAUSE?
Yes, when the
diagnosis is accurate and different biological, psychosexual and/or couple
problems are well recognized and put in perspective to a meaninful
comprehensive picture.
References
Barlow, D.H., Cardozo, L., Francis,
R.M. et Al. Urogenital ageing and its effect on sexual health in older British
women Br.J.Obstet.Gynecol. 1997; 104:87-91
Barnes, T. The female partner in
the treatment of erectile dysfunction: what is her position? Sex. Marital Ther.
1998;13 (3): 233-8
Brincat M.(ed), Hormone Replacement Therapy and the Skin, New York, Parthenon Publishing,
2002
Cardozo L, Bachmann G, McClish D,
Fonda D, Birgerson L. Meta-analysis of estrogen therapy in the management of
urogenital atrophy in postmenopausal women: second report of the hormones and
urogenital therapy committe Obstet Gynecol 1998; 92: 722-734
Dennerstein, L., Lehert P. Burger,
H. Garamszegi C. Dudley, E.C ., in Studd J. (ed) The management of the
menopause. The millennium review Menopause and Sexual functioning Parthenon
Publishing, London, 203-210,2000
Kegel, A. Sexual function of the
pubococcygeus muscle West J.Surg.1952;60:521-4
Levin, R.J. The impact of the
menopause on the physiology of genital function. in Graziottin A. (Ed)
Menopause and Sexuality, Menopause Review, dec 1999; IV(4): 23-32
Madelska K. Cummings S. Tibolone
for post-menopausal women: systematic review of randomized trials J. Clin.
Endocrinol. Metabolism 87 (1):16-23,2002
Meeuwsen
IB, Samson MM, DuursmaVerhaar HJ. Muscle strenght and tibolone: a randomized,
double blind, placebo-controlled trial: Brit.J.Obstet. Gynecol.109 (1)
77-84,2002
O'Connell, H.E., Hutson, J.M., Anderson, C.R., Plenter, R.J.
Anatomical relationship betweeen urethra and clitoris J.Urol.1998;159:1892-7
Renshaw, D.C. Coping with an impotent husband,
Illinois Medical Journal, 1981;159: 29-33
Rioux, J.E., Devlin, M.C., Gelfand, M.M. et Al. 17 beta estradiol vaginal tablet
versus conjiugated equine estrogen vaginal cream to relieve menopausal atrophic
vaginitis, Menopause, 2000; 7 (3), 156-61
Rosen, R.C., Lane, R., Menza M., Effects of SSRIs on
sexual function: a critical review J Clin Pharmacol. 1999; 19 (1): 67-85
Shifren, J.L., Glenn, D.,
Brauntsein, M.D., et Al Transdermal testosterone treatment in women with
impaired sexual function after oophorectomy NEJM 2000;343(10): 682-8
Tarcan,T., Park, K., Goldstein. I., Maio, G., Fassina. A., Krane. R.J. Histomorphometric
analysis of age related structural changes in human clitoral cavernosal tissue
J.Urol.1999; 161:940-4
PAINFUL SEXUAL INTERCOURSE FROM THE PERI-MENOPAUSE ONWARDS
- 30 – 33% of peri-menopausal women complain of various degrees of
pain during sexual intercourse
- The pain can
be due to both physical and psychological factors
- All the
causing factors must be considered in the diagnosis before choosing an
effective therapy
- With a
suitable therapy, the success rate of being cured is very high
COITAL PAIN IN YOUR OWN WORDS:
“Pain increased more and more, doctor. I tried my best to carry on.
This dreadful pain will finish, I remember saying to myself. This was not to be
the case. I was sweating and shaking. I felt I was being tortured, I was in
such a bad state, that my husband, John, stopped disheartened. We tried again
another two times: the same tragedy. That was enough. Gradually our physical
intimacy has been practically reduced to nothing, even if we love each other to
bits…”
Carla
“The worst thing is the pain, doctor. Even if I try to force myself, I
am so dry that even small cuts form in my vagina that burn for days afterwards,
I’ve tried using lubricants, but they don’t help very much. In fact, sometimes
I even get cystitis. I can’t carry on like this. My partner is also very upset,
because he doesn’t like to see me suffering …”
Julie
“You must do something, doctor. This menopause has taken away our
intimacy. We’ve always been a happy couple, also sexually. We don’t have
children and maybe for this reason we’ve always dedicated more time to
ourselves. I’m really sorry to see my wife feeling so bad, she doesn’t
experience pleasure at all anymore, just pain. I’m not happy like this. Is it
really not possible to do something to get us back to how we were before?”
Thomas
WHAT ARE THE MEDICAL
DEFINITIONS OF PAIN DURING INTERCOURSE?
The International Consensus on
Female Sexual Disorders classifications are:
- Dyspareunia: a recurring
or persistent pain associated with sexual intercourse
- Vaginismus: a recurring or
persistent involuntary spasm of the muscles surrounding the vagina, rendering
penetration either impossible or very painful (see next)
Basson, R., Bertian, J., Burnett,
A. Graziottin A. et Al.
Report of the International Consensus Development
Conference on Female Sexual Dysfunction: Definitions and Classifications.
J.Urol, March 2000; 163:888-93
PART 1 DYSPAREUNIA
WHAT ARE THE CAUSES OF DYSPAREUNIA, I.E. PAINFUL
INTERCOURSE, IN THE PERI-MENOPAUSE?
Dyspareunia
maybe perceived:
- in the introital area (introital or superficial dyspareunia)
- at mid-vagina (mid-vaginal dyspareunia)
- and/ or deep in the pelvis (deep dyspareunia).
Introital and mid-vaginal dyspareuniamay occur or worsen from the
peri-menopause onwards due to the following conditions:
- A hormonal etiology, which tops the list of factors as vaginal
dryness is related to progressive (in pre-menopause) or definitive loss (in
post-menopause) of an adequate concentration of vaginal oestrogen
- The reduction
of estrogen production may be gradual, in the natural menopause, or abrupt,
when ovaries are surgically removed(“an intervention called
“ovariectomy”). Chemotherapy and/or pelvic radiotherapy, for the
treatment of different tumors, may as well cause a premature menopause. lIt
is important to mention that vaginal oestrogen concentration may be
insufficient despite periods still being present, during the premenopausal
years.
- However, the hormones that are most responsible for female sexual excitement are
androgens,
that is, the male hormones, produced in very small quantities in the female
body, by the ovaries themselves and the adrenal glands. Androgens production is
reduced by ore than 50% when ovaries are surgically removed.It may caused the
so called “Female Androgen Deficiency Syndrome
____________________________________________
TAB 1 Symptoms suggestive of the ”Female Androgen Deficiency
Syndrome"
- loss of libido
- arousal difficulties
- clitoral orgasmic
difficulties
- loss of assertiveness
- loss of vital energy
- loss of pubic hair
- reduced muscle mass
- changes in body image due to the increase in centripetal fat
____________________________________________
Modified
from Sands R. Studd J. Exogenous androgens in postmenopausal women AmJ.Med.98
(1a):76-79,1995
- A
reduction in the production of these hormones due to menopause causes a drastic
reduction in sexual desire, thus less lubrication, when estrogen are reduced
and less clitoral congestion, when androgens are reduced. Data from the
Yale Midlife Study indicated that 77% of menopausal women reported loss of sex
drive, 58% had vaginal dryness and 39% suffered from dyspareunia.
Sarrel PM Sexuality and menopause. Obstet. Gynecol.
75: 26-30, 1990
Sherwin BB Gelfand MM Brender W Androgen
enhances sexual motivation in females: a prospective, cross-over study of sex
steroid administration in surgical menopause Psychosm.Med. 47:339-51, 1987
Vaginitis and Vulvitis may be frequent co-factors of recently acquired dyspareunia
also in the peri-menopausal years they may be secondary to:
1) Modifications of the normal vaginal “ecosystem”
2) Infections from germs arriving fron the colon
3) Infections from Sexually Trasmitted Diseases (STD)
- Lactobacilli, are microscopic bacteria who are normal protective inhabitants of the vagina
in the fertile age. They
are in perfect shape and number when the vagina has normal level o estrogens,
which garantees a pH of around 4.
- Lactobacilli indeed require a vaginal pH of around 4. The pH is the degree of acidity of
our vagina. It normally ranges between 3.8-4.2
- Gardnerellais a germ normally present in the vaginal
“ecosystem”, that includes the billions of microscopic bacteria normally
living in our vagina. Usually Gardnerella is a small tribe, so to say, because
its proliferation is controlled by the abovementioned normal inhabitants,
called Lactobacilli.
- Gardnerella proliferates at a pH above 5,
when the vagina is deprived of the majority of the Lactobacilli, due to the
loss of oestrogens and consequent increased vaginal pH. The consequences of
this increase, called “vaginosis” are leakage of whitish liquid and irritation
of the introital part of the vagina, favouring vaginitis.
- In the postmenopause, if
the woman does not use an Hormonal Replacement Therapy (HRT) at least topical,
ie when estrogens are directly applied topically to the vagina, the pH
raises to 5, 6, 7. The normal ecosystem, say the normal bacterial tribes,
disappear
- Three
problems may arise:
- the proliferation of vaginal bacteria usually present as minorities, like Gardnerella, Ureaplasma etc;
- the arrival of germs normally living in the colon: the Escherichia coli,
Enterococcus foecalisetc.
- increased vulnerability to Sexually Transmitted Diseases (that may be contracted at
any age, when intercourse with a new partner is not protected by condom
use)
No more protected by the Lactobacilli, the vagina is easily colonized by those
germs, causing unpleasant recurrent vaginitis and
cystitis, infections of the bladder.
- Vulvar
Dystrophy, ie an aging of the external female genitalia, due to both the
negative effect of aging per se and the loss of sexual hormones
after the menopause.
- It is increasingly credited to be a full thickness disorder with a progressive
reduction of all the tissue components.
- The labia become thinner, skin and mucosa become more subtle,
fragile, and pale, due to the reduction of vessels; pubic hair are whitening
and lost
- Vulvar Dystrophy is probably due to a genetic vulnerability accelerating hormone
receptor loss, which diminishes the positive protective effect hormones usually
have on all the vulvar components.
- It has been proved that there is an age dependent reduction of more than 50% of
the cavemosal smooth muscle components from the first to the sixth decade of
life, this being the basis of the increasingly reported difficulty in
getting genitally aroused (“my clitoris is dead”) up to orgasm,
which becomes progressively less intense and more difficult or impossible to
reach.
- Thus intercourse may be more painful due to lack of lubrication and
vulvar congestion.
- Iatrogenic factors, i.e. problems caused as side effects of medical or surgical
treatment, may precipitate and/or worsen pain during intercourse:
- overzealous
colporraphies (“Plastic of the vagina when a prolapse, ie a descensus of the
vaginal wall and/or of the uterus, in is play) and other pelvic surgeries may
be responsible for an anatomical narrowing of the introital area of the
vagina that may be incompatible with intercourse.
- Questions about ongoing sexual activity should always be asked before every type
of pelvic surgery, even in elderly patients, without the assumption that the
lady is too old to have sex.
- Always tell your physician if you are sexually active.
- If he/she, doesn’t ask, you’d better tell, so that he/she can
include this critically important information in your medical record
- Radiotherapy
and/or radical surgery for cervical cancer may also cause reduced vaginal
receptivity because of the shortening and retraction of the vagina .
- Last, but not least, as post-menopausal and elderly women are usually on multi-pharmacological treatment, sexual side-effects
of drugs contributing to dyspareunia through libido and arousal disorders
should be considered
Muscular factors –
namely a defensive coontraction, leading to a tightening of the pelvic floor –
may become relevant when the persistence of pain causes a secondary defensive
contraction of the levator ani.
This may become an added cause of mid-vaginal dyspareunia and/or post-coital
cystitis .
Pain is
the most powerful reflex inhibitor of perivaginal arousal, increasing the vulnerability due
to the lack of the protective effect of oestrogen, thus further increasing the
mechanical trauma of intercourse without lubrication.
Vascular factors, i.e. smoking, artherosclerosis, hypertension and dismetabolic
disorders like diabetes with microangiopathy (and neuropathy) may all contribute to
genital arousal disorders, with vaginal dryness leading to dyspareunia.
Pain related
disorders indicate a specific pathology within the pain system. When
there is a chronic, persistently increased pain input from the introital
vaginal area, there is a proven increase in pain fibres , and a systemic
lowering of the pain threshold.
This addresses a shift from the so called
“nociceptive pain” when pain “simply” indicates an ongoing damage with tissue
inflammation, to the so called “neuropathic pain” when pain is “produced”
and/or exacerbated within the pain system.
Meana
M, Binik YM, Khalife S, Cohen D. Dyspareunia: sexual dysfunction or pain
syndrome? J Nerv Ment Dis 185(9): 561-9; Sep 1997
Meana
M, Binik YM, Khalife S, Cohen DR Biopsychosocial profile of women with
dyspareunia Obstet Gynecol 90(4 Pt 1): 583-9; Oct 1997
Bergeron
S Khalifé S Pagidas K Meana M Amsel R Binik YM A randomized comaptison of group
cognitive-behavioural therapy, surface electromyographic bioffedback and
vestibulectomy in the tratment of dyspareunia resulting from VVS Pain 91(3)
297-306,2001
Least frequent
biological factors are neurological diseases
including pudendal nerve entrapment syndrome, leading to dyspareunia, which may
appear many years after coccygeal–sacral physical trauma or pelvic surgery;
Sjogren’s Syndrome, an auto-immunitary disease
where antibodies attack components of the exocrine gland system;
physical genital trauma and/or sexual abuse.
Deep Dyspareunia (i.e. pain deep in the
pelvis) may be more frequently caused by:
- Pelvic endometriosis.
Deep dyspareunia being the emerging symptom, recurring in
cases of cyclic HRT in women with previous endometriosis, and with a conserved
uterus, low dose continuous combined HRT should be the first choice to avoid
bleeding and recurrence of pain.
- Pelvic inflammatory disease PID: a condition where germs typical of a Sexually Trasmitted
Disease go up to the uterus and tubes, and spreads inside the pelvis. Once
considered a disease of youth, nowadays women of all ages may be exposed to
PID when they have unprotected sex with new partners.
- Pelvic varicocle(5),
which is increasingly diagnosed as a cause of deep dyspareunia.
- Levator ani myalgia: deep pelvic pain may also be secondary to trigger point stimulation
at the levator ani level, when the muscle is intensely myalgic (5,21-23).
Graziottin A.
Dyspareunia: clinical approach J. Sex Marital Therapy 27: 534-538,2001
Sands R. Stud J.
Exogenous Androgens in post-menopausal women AmJ.Med.98(1A):76-79,1995
Graziottin A.,
Castoldi E., Montorsi F., Salonia A., Maga T. Vulvodynia: The Challenge of
unexplained genital pain J. Sex Marital Therapy 27: 567-576,2001
Meana M, Binik YM, Khalife S, Cohen D. Dyspareunia: sexual dysfunction
or pain syndrome? J Nerv Ment
Dis 185(9): 561-9; Sep 1997
Meana M, Binik YM,
Khalife S, Cohen DR Biopsychosocial profile of women with dyspareunia Obstet
Gynecol 90(4 Pt 1): 583-9; Oct 1997
Bergeron S Khalifé S
Pagidas K Meana M Amsel R Binik YM A randomized comaptison of group
cognitive-behavioural therapy, surface electromyographic bioffedback and
vestibulectomy in the tratment of dyspareunia resulting from VVS Pain 91(3)
297-306,2001
WHICH
QUESTIONS SHOULD YOU EXPECT YOUR GYNAECOLOGIST TO ASK SO HE/SHE CAN MAKE A
PRECISE DIAGNOSIS?
When did you
notice that intercourse was becoming painful? Have you always suffered from
pain during intercourse or is it only recently “acquired”?
- When dyspareunia is lifelong it is usually caused by
vaginismus and/or coexisting, lifelong female sexual disorders, like low
libido and/or arousal difficulties, of psychosexual etiology. In other word,
sexual difficulties, including pain at intercourse, that are present from the
very beginning of the sexual life usually are caused by sexual inhibitions,
lack of sexual education, frustration of attachment and love needs during
infancy, negative early sexual experiences, like harrassment or abuse… Only in
aminority of lifelong cases a biological factor is the leading etiology of the
complaint.
- Lifelong
dyspareunia may worsen around the menopause because of the loss of hormones
causing further pain up to a complete avoidance of sex.
If pain is
recently “acquired”, do you also suffer from vaginal dryness during
intercourse, and/or vaginitis, and/or cystitis-like symptoms 24 – 72 hours
after intercourse?
- All these
factors must be considered and can be due to a loss of hormones, an altered
vaginal ecosystem and a tightened pelvic floor (see the paragraph on the causes
of dyspareunia).
Do you always
feel pain during intercourse or is it limited to some situations?
The quality of
the relationship concerned, frustrated intimacy needs, potential conflicts,
areas of disappointment and/or anger can all contribute to situational
dyspareunia. Dennestein et Al, in their 8 year study on women during the
menopausal transition, found that “feelings for a
partner” and a “partner’s health and
sexual problems” were the strongest predictors of sexual changes
across the menopause.
Dennerstein L. Lehert P . Burger H. Garamszegi C. Dudley EC Menoapuse and
sexual functioning in Studd J. (ed) The management of the menopause The
millennium review, Parthenon Publishing , New York, 203-210, 2000
If you avoid
intercourse, is your sexual experience still pleasurable and satisfying or not?
How is your sexual drive? Is arousal easy? Do you usually reach clitoral
orgasm? Do you notice a lack of lubrication when you try intercourse?
These questions
will help to understand the quality of sexual response besides intercourse. The
presence of a dysfunctional sexual response may suggest a mixed etiology,
biological and psychosexual
How intense is the pain you feel?
Focusing on the
intensity and characteristics of pain is a relatively new approach in
addressing dyspareunia issues. Traditional methods of measuring pain may be
used. A lowered sense of pain threshold is an increasingly recognised aspect of
this disease.
Do you feel pain before, during or after the intercourse?
Pain before
intercourse suggests a phobic attitude towards penetration and/or the presence
of chronic vulvar vestibulitis, when pain persists even without further
itercourses.
Pain during
intercourse is the most frequently reported. This information, along with “
where does it hurt?”, proves to be the most predictive of the
organicity of pain, ie of a physical,biological cause of it.
Pain after intercourse also suggests vestibulitis because of worsening of
post-coital irritation in the peri-post-menopause.
Where does it
hurt? At the beginning, in the middle or deep in the vagina?
Meana et Al noted that location of pain and its onset within an episode of
intercourse were the strongest predictors of presence and type of organicity.
With this
information the gynecologist should be able to make an appropriate differential
diagnosis, ie to recognize the cause(s) that may contribute to the current
dyspareunia and to address them in the most effective individually tailored
treatment
Graziottin
A. Dyspareunia. J. Sex Marital Therapy 27: 534-538,2001
Graziottin A. Loss of libido in the post-menopause Menopausal Medicine, 8(1):9-12,2000
GYNAECOLOGIST’S PAIN MAP
During a thorough physical
examination your gynaecologist will ask the critical question “
where does it hurt?”. While gently and
competently exploring all the possible sources of pain, the physician will be
able to build up a careful “pain map” based on solid anatomy and
logical physiopathology. The creation of this map will help create a
positive and trusting doctor-patient relationship, as it will prove that the “
pain is not in your mind!”.
This type of examination
may reveal and/or confirm:
- acute pain at
5 and 7 if the entrance of the vagina is considered as a clock face. This is
evidence of vestibulitis
- tender points, when pain is elicited
at the gentle pressure on the insertion of perivaginal
muscle on the ischiatic spine, and/or trigger points that is points
from which pain irradiates when touched; Tender point could be elicited as well
on retracted scars, and/or on superficial myalgic, ie painful, perineal
muscles.
- a congested,painful clitoris in cases of associated clitoralgia
- a dry, dystrophic vagina. This is more common with age if HRT is not carried out locally.The
gynecologist should always evaluate the vaginal pH , ie the grade of
local acidity, with a simple coloured stick applied to the vagina for 10-15’’.
Without sexual hormones the pH raises, easing negative modifications of the
vaginal ecosystem that becomes more vulnerable even to banal infection
- a narrow introitus,
i.e. entrance of the vagina, after surgery. Retraction, pain, mucocutaneous and
myofascial trigger points that may affect the vaginal anatomical outcome, and
the pelvic floor muscles’ defensive hypertonus are all frequent co-factors in
introital and mid-vaginal dyspareunia after perineal surgery.
- spasm of the
peri-vaginal muscles with tender and/or trigger points in the mid-vagina.
Trigger points on the
levator ani may cause deep pelvic pain and mimic deep dyspareunia.
- acute provoked pain with
bimanual deep exploration. Posterior pain maybe suggestive of endometriosis, of
which deep dyspareunia may be the emerging symptom, recurring in cases of
cyclic HRT.
- lateral, deep pelvic
pain may be more frequently caused by Pelvic Inflammatory Desease (PID), caused
by Sexually Transmitted Diseases that infected uterus, tubes and spread within
the pelvis.
- Anterior pain is
more frequently present when dyspareunia is associated with post-coital urgency
and frequency.
Graziottin A. Dyspareunia. J. Sex Marital Therapy 27: 534-538,2001
Graziottin A. Loss of libido in the post-menopause Menopausal Medicine, 8(1):9-12,2000
CAN I REALLY BE CURED FROM DYSPAREUNIA?
YES, IF THE DIAGNOSIS IS CORRECTLY MADE, ADDRESSING ALL POTENTIALLY CONTRIBUTING
FACTORS!!!
Many
women who suffer from dyspareunia are often extremely frustrated in not
being able to find an adequate answer to their problem, so far as to think that
there is no solution. Far too often, as already stated, the pain is said to be
purely “psychological”, therefore not even worthy of a clinical evaluation.
To cure dyspareunia what is it necessary to do?
It is necessary to consult a gynaecologist, who is able to:
- Recognise the problem
- Evaluate the severity so as to make a correct prognosis
- Diagnose all the factors that may predispose, precipitate and/or maintain the problem
- Suggest an adequate therapy accordingly
An integrated diagnosis
between medical and psychosexual factors is preliminary to the effective
treatment.
Always consult your physician, who will evaluate if there is an
indication for one or more of the following treatments:
- Topical hormonal treatment, which is the first choice to reduce pain caused by
inadequate genital arousal, particularly during and after the menopause.
a) Vaginal oestrogen may offer a rapid relief
when dyspareunia is more dependent on vaginal dystrophy. Topical oestrogen may
be the first line treatment in women who cannot, or do not want, a systemic HRT
(hormone replacement therapy). They should be prescribed even in the pre-menopause
or during systemic HRT when symptoms and/or signs of vaginal dystrophy are
present. 17 beta estradiol vaginal tablets may significantly improve atrophic
vaginitis and related symptoms with a better compliance profile than the more
powerful conjugated equine oestrogen vaginal cream, because they are as
effective but do not cause leakage.
Rioux JE.Devlin MC
Gelfand MM et Al 17 beta estradiol vaginal tablets versus conjugated equine
estrogen vaginal cream to relieve menoapusal atrophic vaginitis Menopause 7 (3)
156-61, 2000
b)Testosterone Propionate powder
in Vaseline jelly is to be applied to the external genitalia, daily or every
other day, in very very small quantities. This local treatment is effective in
increasing the clitoral arousal, sensitivity and responsiveness. The same
therapy applied to the vulva will relieve entry dyspareunia.
- Systemic HRT, i.e. when taken
spreads around the whole body, is indicated in cases of sexual co-morbidity,
when loss of libido and poor arousal due to the menopause and/or when other
menopausal symptoms are complained of. This type of HRT can be taken either as
oral patches, injections, nasal spray, transdermal gel or subcutaneous
implants.
The
desire of the woman to maintain a good sexuality, or improving a fading one,
should be considered for the optimal HRT choice.
Two recent
papers on both tibolone and oral HRT containing estradiol and norestisterone
(NETA), suggest a significant positive effect on muscle tone and motor
competence. The androgenic activity of these components This is also beneficial
from the sexual point of view, both for the increased genital well-being, that
improves the vital energy and sense of fitness, and specifically for the
condition of the pelvic floor, so important in the female sexual function
(although specific studies on these special aspects have not been performed so
far).
Systemic
and local HRT is to be considered to reduce dyspareunia and improve the quality
of life and overall sexuality of patients treated for genital cancer, with the
exception of adenocarcinomata of the endometrium and of the cervix.
- Rehabilitation of the pelvic floor muscles,
that contract in chronic coital pain, is of specific
importance in the treatment of dyspareunia
Stretching and relaxation of
contracted muscles, self-massage with medicated oil (Saint John’s wart) or
electromyographic biofeedback, when available, may all relieve the muscle
tension, reducing mid-vaginal dyspareunia and limiting the source of referred
pain
Glazer
HI Rodke G. Sewncionis C Hetz R Young AW treatment on vulvar vestibulitis
syndrome with electromyographic biofeedback of pelvic floor musculature J.Reprod.Med.
40 (4) 283-290,1995
McKay
E Kaufman RH Doctor U Berkova Z. Glazer H Treating vulvar vestibulitis with
electromyographic feedback of pelvic floor musculature J.Reprod.Med. 46:337-42,
2001
- Electroanalgesia, a more specific treatment, should be
recommended when introital hyperalgesia, i.e. chronic sensitivity to pain, is due to Vulvar
Vestibulitis Syndrome (VVS).
- Antalgic
treatment, with a systemic and local treatment is reserved for the treatment of
severe dyspareunia, usually associated with VVS or neurological pain, when all
previous treatment have failed. Presacral anethetic block of the ganglion impar
has recently been proposed as an effective second line treatment also when all
previous treatment have failed.
Graziottin A. Vincenti E Paper
presented as Podium Session at the meeting of the International Society for the
Study of Women’s Sexual Health (ISSWSH), Proceedings of the Vancouver meeting,
October 10-13, pag 51 (abstract)
- Coexistent general medical conditions(vascular,
dismetabolic, neurological, immunitary)
should also be addressed as well to reduce the multi-systemic
etiology of dyspareunia
- PSYCHOSEXUAL THERAPY should be recommended when the etiology
of pain is more dependent on psychosexual or contextual factors, particularly when
negative couple dynamics are in play
Clulow C
(ed) Adult attachment and couple psychotherapy Brunner Routledge, Hove (UK)
2001
References:
Andrews WC
Approaches to taking a sexual history, in Bachmann GA (ed) Menopause and Female
sexuality J. Womens’ Health & Gender-Based Medicine 9(S1) S25-S32, 2000
Barlow DH, Cardozo L, Francis RM et al Urogenital ageing and its effect on sexual
health in older British women Br J Obstet Gynaecol 104: 87-91; 1997
Basson
R. Berman J. Burnett A. Derogatis L. et Al. Report of the International
Consensus Development Conference on female sexual dysfunction :
definition and classification J.Urol, 163 :889-93,2000
Basson R. The female sexual response: a different model J.Sex Mar.Therapy,
26:51-65,2000
Bergeron S Khalifé S Pagidas K Meana M Amsel R Binik YM A randomized comaptison of group
cognitive-behavioural therapy, surface electromyographic bioffedback and
vestibulectomy in the tratment of dyspareunia resulting from VVS Pain 91(3)
297-306,2001
Bergeron S, Binik YM, Khalife S, Pagidas K Vulvar vestibulitis syndrome: a critical
review (80 refs) Clin J Pain 13(1): 27-42; Mar 1997
Bohm.Starke N. Hilliges M. Brodda-Jansen G. Rylander E. Torebjork Psychophysical evidence
of nociceptor sensitization in vulvar vestibulitis syndrome Pain 94: 177-183,
2001
Bohm-Starke N. Hilliges M. Falconer C. Rylander E Increased intraepithelial innervation in
women with vulvar vestibulitis syndrome Gynecol. Obstet.Invest. 46:256-260, 1998
Bonica JJ Definitions and taxonomy of pain In J Bonica (ed)The Management of Pain.
Philadelphia: Lea & Febiger. 2: 18-27; 1990
Caillouette JC Sharp CE. Zimmermann GJ Roy S Vaginal pH as a marker for bacterial
pathogens and menopausal status Am.J.Obstet.Gynecol. 176:1270-1277,1997
Clulow C (ed) Adult attachment and couple psychotherapy Brunner Routledge, Hove (UK)
2001
De Lancey JO, Sampselle CM, Punch MR Kegel dyspareunia: levator ani myalgia caused
by overexertion Obstet Gynecol 82: 658-9; 1993
Dennerstein
L. Lehert P . Burger H. Garamszegi
C. Dudley EC Menoapuse and sexual functioning in Studd J. (ed) The management
of the menopause The millennium review, Parthenon Publishing , New York,
203-210
Diagnostic and statistical manual of mental disorders (4th ed. ) American Psychiatric
Association (ed) Washington DC 1994
Goldstein I, Berman JR Vasculogenic female sexual dysfunction: vaginal engorgement and
clitoral erectile insufficiency syndromes Int J Impotence Res 10: S84-S90; 1998
Graziottin A. Clinical Approach to Dyspareunia: J.Sex Marital Therapy 27:489-501, 2001
Graziottin A. Loss of libido in the postmenopause Menopausal Medicine, 8(1):9-12, 2000
Graziottin A. Maraschiello T. Farmaci e Sessualità Airon ed. Milano, 2002
Graziottin A. Sexual function in women with gynecologic cancer: a review It.J.Gynec.Obstet.2:61-68,
2001
Graziottin A. Vincenti E. Anthalgic treatment of intractable pain due to vulvar
vestibulitis syndrome: preliminary results with oral gabapentin and anethetic
block of ganglion impar (abstract) Proceedings of the Congress of the
International Society for the Study of Women’s Sexual Health (ISSWSH),
Vancouver, October 10-14, 2002, pag 51
Gruber CJ.Tschugguel W Schneeberg C. Huber JC Production and action of estrogens NEJM
346:340-352, 2002
Hagedorn M. Buxmeyer B. Schmitt Y Bauknecht T. Survey of lichen sclerosus in women and
men Arch. Gynecol. Obstet.266:86-91,2002
Lauman EO, Gagnon JH, Michaci RT, Michaels S Sexual dysfunction in the United States:
prevalence and predictors JAMA 10; 281 (6): 537-42; 1999
Levin RJ The mechanism of human female sexual arousal Ann Rev Sex Res 3: 1-48;1992
Levin RJ Measuring the menopausal genital changes- a critical account of laboratory
procedures past and for the future in Graziottin A (ed) Menopause and Sexuality
,Menopause Review, IV (4):49-57,1999
Madelska K. Cummings S Tibolone for post-menopausal women: systematic review of
randomized trials J.Clin.Endocrinol.Metabolism 87 (1):16-23,2002
Meana M, Binik YM, Khalife S, Cohen D. Dyspareunia: sexual dysfunction or pain
syndrome? J Nerv Ment Dis 185(9): 561-9; Sep 1997
Meana M, Binik YM, Khalife S, Cohen DR Biopsychosocial profile of women with
dyspareunia Obstet Gynecol 90(4 Pt 1): 583-9; Oct 1997
Mulherin
DM, Sheeran TP, Kumararatne DS et al Sjogren’s syndrome in women presenting
with chronic dyspareunia Br J Obstet Gynaecol 104: 1019-1023; Sep 1997
Notelovitz
M. A practical approach to postmenopausal hormone therapy Ob/Gyn, Special ed. MacMahon, New York, April
2002
O’Connell
HE Hutson JM Anderson CR Plenter RJ Anatomical relationship between urethra and
clitoris J.Urol. 159:1892-7,1998
Pukall CF.Binik YM. Khalifé S. Amsel R. Abbott FV. Vestibular tactile and pain
threshold in women with vulvar vestibulitis Pain 96 (1-2): 163-175, march 2002
Rioux JE.Devlin MC Gelfand MM et Al 17 beta estradiol vaginal tablets versus
conjugated equine estrogen vaginal cream to relieve menoapusal atrophic
vaginitis Menopause 7 (3) 156-61, 2000
Schindler AE Hormone Replacement Therapy (HRT) in women after genital cancer Mturitas 41
Suppl.1 S 105-111, 2002
Shifren JL Glenn D Braunstein MD et Al Transdermal testosterone treatment in women with
impaired sexual function after oophorectomy NEJM 343 (10):682-8,2000
Tarcan T. Park.K Goldstein I Maio G Fassina A. Krane RJ histomorphometric analysis of
age related structural changes in human clitoral cavernosal tissue J.Urol
161:940-4,1999
Thompson JM Tension myalgia as a diagnosis at the Mayo Clinic and its relationship to
fibrositis, fibromyalgia and myofascial pain syndrome Mayo Clin Proc 65:
1237-48; 1990
Wesselmann U, Burnett AL, Heinberg LJ The urogenital and rectal pain syndromes (Review)
(282 refs) Pain 73(3): 269-94; 1997
World Health Organization: ICD 10.International Statistical Classification of
Diseases and Related Health Problems, Geneva, World Health Organization, 1992
WHAT ARE THE MEDICAL DEFINITIONS OF PAIN DURING INTERCOURSE?
The International Consensus on Female Sexual Disorders classifications are:
- Dyspareunia: a recurring or
persistent pain associated with sexual intercourse
- Vaginismus: a recurring
or persistent involuntary spasm of the muscles surrounding the vagina,
rendering penetration either impossible or very painful
PART 2 VAGINISMUS
WHAT EXACTLY IS VAGINISMUS?
- Vaginismus refers to a recurring
or persistent involuntary spasm of the muscles surrounding the vagina.
- Due to the tension of
these muscles, the entrance of the vagina becomes so contracted that
penetration can be either impossible or very painful.
- Vaginismus is frequently
associated with a phobia of coitus, i.e. a terror of penetration, of various
intensities.
IF YOU HAVE VAGINISMUS, HAVE YOU ALWAYS HAD IT?
- Vaginismus can occur at the
beginning of a woman’s sex life (lifelong), i.e. primary vaginismus.
This can be the cause of unconsummated marriages.
- Vaginismus can appear after months
of years of normal sexual activity (acquired), i.e. secondary vaginismus.
Basson R., Bertian J., Burnett A., Graziottin A. et Al. Report of the International
Consensus Development Conference on Female Sexual Dysfunction: Definitions and
Classifications. J.Urol, March 2000; 163:888-93
THE BODY SPEAKS FOR ITSELF
The
accurate examination of the female body reveals many underlying biochemical
factors and inner equilibrium. For example:
- The female hormones – above all oestrogen – nourish all aspects of femininity, physical and
psychological. Furthermore, they keep the genital tissue healthy and reactive,
thus favouring a good lubrication and a rapid vaginal congestion that make
penetration pleasurable.
- A pre-menopausal woman with a regular menstrual cycle also enjoys the sensation of general well-being.
Oestrogen give the skin elasticity and luminosity. Above all they create the
characteristic “scent of a woman” typical in the fertile age.
- The reduction of
androgens from the female body during menopause not only drastically
reduces sexual desire, vital energy and positivity, but also can be accompanied
by loss of pubic hair and a reduction of muscle mass and strength, leading to
the so called “Female Androgen Deficiency Syndrome”.
- An unwelcome change in
the in the woman’s body shape, with an accumulation of fat on the waist and
stomach is another “side-effect” and sign of androgen depletion.
- The accurate examination
of the physical attitude, and of the woman’s behavior may as well disclose if
there is a sexual problem, particularly when primary vaginismus is in play.
Are there signs of
tension, besides the peri-vaginal muscles, that can be recognised with
vaginismus?
- Certainly. A clenched
mouth, with tense facial muscles and the eyes wide apart are
all frequent characteristics associated with women who suffer from painful
sexual intercourse, due to lifelong, severe vaginismus as if she is afraid of “letting
herself go” in every sense. Interestingly, a clenched mouth is often
associated with perivaginal spasms, as if unconsciously, the woman is closing
every opening to the world of sexual intimacy.
- As well as in the
muscles that surround the vagina and mouth, two other real points where tension
may accumulate are the cervical column and the lumbar. This
explains the increasing rigidity of the spine and the tenseness of the
paravertebral muscles in many vaginismic women, thus affecting posture.
Why does muscle tension interfere with sexual behaviour?
The more rigid the body
is, the higher the levels of anxiety and stress that are “enemies” of
sexual desire and excitement. Furthermore, cervical tension limits the ability
to “let go”, that is necessary to achieve sexual pleasure. Mobility and
physical relaxation are “friends” of erotic pleasure, especially when it comes
to penetration.
How can difficulty in breathing interfere with sexuality?
- Emotional tension tends
to make itself seen in the way we breathe. In times of acute anxiety, the
breath becomes short and superficial, almost to the point of feeling that you
are suffocating. This very unplesant sensation is often referred to when
vaginismic women express their feeling at every coital attempt, in spite of a
loving relationship with their partner. The terror of being penetrated is
referred to as overwhelming.
- When this tension
becomes permanent, as with certain sexual disturbances, changes in the rhythm
and depth of breath can become chronic. A bad quality of breathing inhibits our
ability to listen to our sensations and emotions, as well as sexual ones, as
the Orientals know well, preventing us from feeling, at depth, the pleasures of
the body.
Is this a psychological or physical problem?
Both. Signs of
tension, respiratory and muscular, arrive at the brain before those of
pleasure. Erotic stimulants, coming from the skin and genitals, in these cases
become blocked at the level of the spinal cord. Therefore, even if a woman has
a fantastic lover, all the sensations of physical pleasure become blocked in
the periphery and never arrive at the brain. This is the reason why, if
vaginismus is to be treated effectively, all these aspects are to be
considered.
And the clinical evaluation?
Apart from making note of these
signs of tension, a gynaecologist should evaluate during the visit the
grade of severity of vaginismus, thus creating a sort of “staging” of the problem,
that is a prognostic evaluation in which the following must be considered:
- the level of perivaginal muscle tension
- the grade of phobia
- the presence, or not, of other associated pathological problems - either physical
or psychological - (disturbances of sexual desire and excitement, particularly)
- the motive for a solution
- the woman’s relational situation (i.e. single or in a relationship)
- the quality of that relationship
- the presence of eventual associated male problems
- the number of years since the problem was discovered to the point of asking for
help.
After this evaluation, the doctor
is able to choose the best therapeutic strategy.
WHAT ARE THE MAIN CAUSES OF PRIMARY VAGINISMUS?
The causes can be physical and/or psychological. Frequently both.
- The psychological causes of lifelong
vaginismus are usually associated with fear of penetration due to lack
of sexual education, religion-related inhibitions, negative information about
intensity of pain at the first intercourse, or about the loss of blood, and/or
about the risk of getting pregnant , when no information about contraception
was available
- The physical causes of lifelong vaginismus
are rare, but are usually associated to a particularly fibrous and rigid hymen.
WHAT IS THE HYMEN EXACTLY?
- The hymen is a membrane
at the entrance of the vagina, that tears with the first experience of sexual
penetration.
- In rare cases the hymen
is so rigid and fibrous that normal penetration is made impossible and it
requires a simple medical intervention under local anaesthetic to break it.
- Repetitive attempts by
the partner to penetrate in the case of a rigid hymen, can cause the woman to
“defend herself” from the pain, thus leading to vaginismus.
WHAT ARE THE OTHER PHYSICAL CAUSES OF VAGINISMUS?
- Physical factors are more common causes of secondary vaginismus.
- This is the case when
changes in the genital and pelvic area (frequently due to ageing) leading to dyspareunia,
create a defensive spasm of the peri-vaginal muscles. This can lead to myalgia,
that is when the muscle tension causes pain.
- In these cases, the
spasms of the elevator muscles, making penetration painful or impossible, can
appear after many years of more or less normal sexual activity.
- The memory of previous
pain can cause spasms, even after the original physical problem has been
resolved.
WHY YOU SHOULD NOT BE AFRAID TO CONFRONT THE PROBLEM NOW!
- Pain is rarely purely psychogenic.
- Pain during intercourse makes no exception. As with all pain syndromes, it usually has one or more
multiple biological factors.
- Pain during intercourse
deserves careful clinical attention, as it is the common emerging symptom of a
variety of medical conditions that should be recognised and treated
accordingly.
- Psychosexual factors,
mostly low libido, life-long or recently acquired because of the persisting
pain, and arousal disorders due to the inhibitory effect of pain, should be
addressed in parallel, in order to give a comprehensive, integrated and more
effective treatment.
- Psycho-dynamic issues,
both personal and/or related to couple relationships should also be adequately
addressed if present.
WHAT IS THE MOST EFFECTIVE TREATMENT OF VAGINISMUS?
It is a behavioural psychosexual therapy: after having excluded (or treated)
concomitant biological factors, the therapy will address:
- the lack of sexual education, with proper information
- an improved knowledge and awareness of the genitals, of the internal part of the
body, of the possibility to command the muscles that, when contracted, “close”
the introital area of the vagina: “Where’s a wall,
there’s a door and a way”
- the woman will learn to voluntarily relax the pelvic floor, to pay attention to
different levels of muscle tension, to integrate breathing with progressive
physical relaxation, to become familiar with the sensations that she may
perceive in her genitals
- when the phobic component is very high, with a general alert arousal (ie excess of
anxiety and fear) the physician may suggest anxiolytic and antidepressant to
reduce the panic attack at the sole idea of being penetrated , thus easing the
progression of the treatment
- when the woman is able to command her muscles, progressive molds or dilatators will
be used to help her to become familiar and confident with new sensations and
possibilities
- in parallel, a short psychotherapy will address fears and psychosexual issues
and/or couple negative interactions
- when a male problem is in play (one third of vaginismic patient have a partner
suffering from situational Erectile Deficit and /or very premature ejaculation)
it should be properly addressed by the andrologist working in the team of the
Sexual Medicine Center
On a positive note, what are the results?
With
a suitable therapy, the success rate is 94% in the cases of isolated
vaginismus, and 82% if both members of the couple have sexual problems, the
probability of a successful treatment being higher when the couple seeks for
help soon after discovering such problem. The prognosis is more reserved when
the woman ask for help many years later, when even the sex drive and any kind
of intimacy have already disappeared.
So why not confront the problem immediately?
REFERENCES
Andrews WC Approaches to taking a sexual history, in Bachmann GA (ed) Menopause and Female
sexuality J. Womens’ Health & Gender-Based Medicine 9(S1) S25-S32, 2000
Barlow
DH, Cardozo L, Francis RM et al Urogenital ageing and its effect on sexual
health in older British women Br J Obstet Gynaecol 104: 87-91; 1997
Basson
R. Berman J. Burnett A. Derogatis L. et Al. Report of the International
Consensus Development Conference on female sexual dysfunction :
definition and classification J.Urol, 163 :889-93,2000
Basson R. The female sexual response: a different model J.Sex Mar.Therapy,
26:51-65,2000
Bergeron S Khalifé S Pagidas K Meana M Amsel R Binik YM A randomized comaptison of group
cognitive-behavioural therapy, surface electromyographic bioffedback and
vestibulectomy in the tratment of dyspareunia resulting from VVS Pain 91(3)
297-306,2001
Bergeron
S, Binik YM, Khalife S, Pagidas K Vulvar vestibulitis syndrome: a critical
review (80 refs) Clin J Pain 13(1): 27-42; Mar 1997
Bohm.Starke N. Hilliges M. Brodda-Jansen G. Rylander E. Torebjork Psychophysical evidence
of nociceptor sensitization in vulvar vestibulitis syndrome Pain 94: 177-183,
2001
Bohm-Starke N. Hilliges M. Falconer C. Rylander E Increased intraepithelial innervation in
women with vulvar vestibulitis syndrome Gynecol. Obstet.Invest. 46:256-260, 1998
Bonica JJ Definitions and taxonomy of pain In J Bonica (ed)The Management of Pain.
Philadelphia: Lea & Febiger. 2: 18-27; 1990
Caillouette JC Sharp CE. Zimmermann GJ Roy S Vaginal pH as a marker for bacterial
pathogens and menopausal status Am.J.Obstet.Gynecol. 176:1270-1277,1997
Clulow C (ed) Adult attachment and couple psychotherapy Brunner Routledge, Hove (UK)
2001
De Lancey JO, Sampselle CM, Punch MR Kegel dyspareunia: levator ani myalgia caused
by overexertion Obstet Gynecol 82: 658-9; 1993
Dennerstein L. Lehert P . Burger H. Garamszegi
C. Dudley EC Menoapuse and sexual functioning in Studd J. (ed) The management
of the menopause The millennium review, Parthenon Publishing , New York,
203-210
Diagnostic
and statistical manual of mental disorders (4th ed. ) American Psychiatric
Association (ed) Washington DC 1994
Goldstein
I, Berman JR Vasculogenic female sexual dysfunction: vaginal engorgement and
clitoral erectile insufficiency syndromes Int J Impotence Res 10: S84-S90; 1998
Graziottin
A. Castoldi E. Montorsi F. Salonia A. Maga T. Vulvodynia: the challenge of
“unexplained” genital pain J.Sex.MaritalTher. 27:567-576,2001
Graziottin A. Clinical Approach to Dyspareunia. J.Sex Marital Therapy 27: 489-501, 2001
Graziottin A. Loss of libido in the postmenopause Menopausal Medicine, 8(1):9-12, 2000
Graziottin A. Maraschiello T. Farmaci e Sessualità Airon ed. Milano, 2002
Graziottin A. Sexual function in women with gynecologic cancer: a review
It.J.Gynec.Obstet.2:61-68, 2001
Graziottin A. Vincenti E. Anthalgic treatment of intractable pain due to vulvar
vestibulitis syndrome: preliminary results with oral gabapentin and anethetic
block of ganglion impar (abstract) Proceedings of the Congress of the
International Society for the Study of Women’s Sexual Health (ISSWSH),
Vancouver, October 10-14, 2002, pag 51
Gruber CJ.Tschugguel W Schneeberg C. Huber JC Production and action of estrogens NEJM
346:340-352, 2002
Hagedorn M. Buxmeyer B. Schmitt Y Bauknecht T. Survey of lichen sclerosus in women and
men Arch. Gynecol. Obstet.266:86-91,2002
Lauman EO, Gagnon JH, Michaci RT, Michaels S Sexual dysfunction in the United States:
prevalence and predictors JAMA 10; 281 (6): 537-42; 1999
Leiblum SR vaginismus: a most perplexing problem. In SR Leiblum & Ray Rosen (Edr)
Principles and practice of sex Therapy (3rd ed) New York: Guilford Press
Levin RJ The mechanism of human female sexual arousal Ann Rev Sex Res 3: 1-48;1992
Levin RJ Measuring the menopausal genital changes- a critical account of laboratory
procedures past and for the future in Graziottin A (ed) Menopause and Sexuality
,Menopause Review, IV (4):49-57,1999
Madelska K. Cummings S Tibolone for post-menopausal women: systematic review of
randomized trials J.Clin.Endocrinol.Metabolism 87 (1):16-23,2002
Meana M, Binik YM, Khalife S, Cohen D. Dyspareunia: sexual dysfunction or pain
syndrome? J Nerv Ment Dis 185(9): 561-9; Sep 1997
Meana M, Binik YM, Khalife S, Cohen DR Biopsychosocial profile of women with
dyspareunia Obstet Gynecol 90(4 Pt 1): 583-9; Oct 1997
Mulherin DM, Sheeran TP, Kumararatne DS et al Sjogren’s syndrome in women presenting
with chronic dyspareunia Br J Obstet Gynaecol 104: 1019-1023; Sep 1997
Notelovitz M. A practical approach to postmenopausal hormone therapy Ob/Gyn, Special ed.
MacMahon, New York, April 2002
O’Connell HE Hutson JM Anderson CR Plenter RJ Anatomical relationship between urethra and
clitoris J.Urol. 159:1892-7,1998
Pukall CF.Binik YM. Khalifé S. Amsel R. Abbott FV. Vestibular tactile and pain
threshold in women with vulvar vestibulitis Pain 96 (1-2): 163-175, march 2002
Rioux JE.Devlin MC Gelfand MM et Al 17 beta estradiol vaginal tablets versus
conjugated equine estrogen vaginal cream to relieve menoapusal atrophic
vaginitis Menopause 7 (3) 156-61, 2000
Sands R. Studd J. Exogenous androgens in postmenopausal women AmJ.Med.98
(1a):76-79,1995
Sarrel PM Sexuality and menopause. Obstet. Gynecol. 75: 26-30, 1990
Schindler AE Hormone Replacement Therapy (HRT) in women after genital cancer Mturitas 41
Suppl. 1 S 105-111, 2002
Shafik A Pudendal canal syndrome as a cause of vulvodynia and its treatment by
pudendal nerve decompression Eur J Obstet Gynecol Reprod Biol 80(2): 215-20;
1998
Sherwin BB Gelfand MM Brender W Androgen enhances sexual motivation in females: a
prospective, cross-over study of sex steroid administration in surgical
menopause Psychosm.Med. 47:339-51, 1987
Shifren JL Glenn D Braunstein MD et Al Transdermal testosterone treatment in women with
impaired sexual function after oophorectomy NEJM 343 (10):682-8,2000
Tarcan T. Park.K Goldstein I Maio G Fassina A. Krane RJ histomorphometric analysis of
age related structural changes in human clitoral cavernosal tissue J.Urol
161:940-4,1999
Thompson JM Tension myalgia as a diagnosis at the Mayo Clinic and its relationship to
fibrositis, fibromyalgia and myofascial pain syndrome Mayo Clin Proc 65:
1237-48; 1990
Wesselmann U, Burnett AL, Heinberg LJ The urogenital and rectal pain syndromes (Review)
(282 refs) Pain 73(3): 269-94; 1997
World Health Organization: ICD 10.International Statistical Classification of
Diseases and Related Health Problems, Geneva, World Health Organization, 1992
Copyright © Alessandra Graziottin 2002
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