Acknowledgements: The program (click the picture above) and this coverage would not have been possible without the outstanding contribution of the Boston University School of Medicine Office of Continuing Medical Education; we owe lots of thanks for them.

The research work done by Drs Irwin Goldstein and Jennifer Berman are integral to this course and to the entire field of female sexual dysfunction.

DSMIV Female Sexual Dysfunction Classification (FSD)

The American Psychiatric Association in their recent edition of the DSM IV describes FSD as:
"persistent or recurrent inability to attain or maintain until completion of sexual activity, an adequate lubrication-swelling response of sexual excitement."

Proposed FSD Classification

There's some very major areas of disagreement and conflict, which need to be resolved. There has been a lot of discussion about how much sexual desire problems, lack of desire, is that a dysfunction and how do we define it, what are the characteristics of low desire in a woman, is lack of orgasm a dysfunction in women and how do these different sexual problems, specific problems relate to one another and does a woman have to have 1, 2 or 3 of these problems before we say she's dysfunctional.

The current consensus of classification seems to be: a disorder of desire or libido; arousal disorder, which includes problems with lubrication, sensation, and orgasm; as well as pelvic pain disorder, which may or may not be psychologically based. Women can fall into any one of those or combinations of different ones. Most women have primary arousal disorders, meaning they have difficulty or are unable to become sexually aroused.

Functional Neurovascular Anatomy

The female has two corporal bodies that lie on each side of the clitoris. During sexual arousal these bodies are engorged, the mechanism being almost the equivalent of the erection in the male.

In further studies, the group in the Boston University School of Medicine is attempting to redefine the anatomy, to get an understanding of where the nerve, and the blood vessels are that are pertinent or vital to normal sexual function in women.

Functional End Organ Anatomy

The structure of the clitoris is very much like the penis. Both are made of erectile tissue, but there is more to the clitoris than meets the eye. Only this year new research based on rare autopsies of young women, is challenging earlier understanding of the clitoris. It appears to be a much bigger internal organ than previously thought, wrapping around the outside of the vagina up to 3 ½ inches in a pyramid of tissue whose sole function is to give sexual pleasure, then reaching back into the body. When the vagina responds to sexual stimulation, its smooth muscle relaxes dilating the vaginal walls and increasing blood flow which brings lubrication to the area.

The clitoris is also much closer to the urethra than doctors had thought. In fact, the clitoris surrounds this tube on three sides, making it vulnerable to damage when doctors operate the tube.

Regulation of Smooth Muscle Contractility: Cell Structure Studies

The study published in the latest issue of the International Journal of Impotence Research developed a New Zealand White rabbit clitoral corpus cavernosum smooth muscle cell culture. These smooth muscle cells retain their biochemical and functional integrity. According to the authors of the study (from Department of Urology, Boston University School of Medicine), this in-vitro cell culture system may facilitate studies aimed at understanding the molecular basis of female sexual function.

Physiology

There is limited understanding of the physiology of the female sexual response.

Estrogen and Testosterone in Female Sexual Dysfunction

There is increasing awareness that many women experience symptoms of androgen deficiency after either natural or surgical menopause. The predominant complaint of affected women is less sexual desire. Many women experiencing the clinical symptoms of androgen deficiency and low free testosterone levels respond well to testosterone replacement therapy. However, some women also have additional psycho-social issues complicating their symptomatology and these must be addressed either before or concurrently with androgen replacement.

Effects of Central/Peripheral Nervous System Disease on Female Sexual Function

Central/Peripheral nervous system diseases such as multiple sclerosis have been associated with sexual dysfunctions, both among women and men.

Effects of Psychiatric Disease on Female Sexual Function

Impaired sexual function has been noted to occur in various psychiatric illnesses. In affective disorders, disturbances of libido, erection and orgasm have been reported. Disordered sexual behavior has also been noted in patients with schizophrenia and anorexia nervosa. Clinical speculation suggests that anxiety disorders may also be associated with a higher prevalence of sexual problems.

The medication used for psychiatric disorders can further attenuate the problems of sexual dysfunction; this has been found to be true particularly with serotonin reuptake inhibitors like Prozac and Zoloft.

Arteriogram Studies in Women with Peripheral Vascular Disease

The first phase of the female sexual response, associated with neurotransmitter-mediated vascular smooth muscle relaxation, results in increased vaginal lubrication, wall engorgement and luminal diameter as well as increased clitoral length and diameter. Specific physiologic impairments of vasculogenic female sexual dysfunction include vaginal engorgement and clitoral erectile insufficiency syndromes. These syndromes exist when during sexual stimulation abnormal arterial circulation into the vagina or clitoris, usually from atherosclerotic vascular disease, interferes with normal vascular physiologic processes. Clinical symptoms may include delayed vaginal engorgement, diminished vaginal lubrication, pain or discomfort with intercourse, diminished vaginal sensation, diminished vaginal orgasm, diminished clitoral sensation or diminished clitoral orgasm. An animal model of this syndrome, with significant physiologic responses between the control and the atherosclerotic pelvic nerve stimulated hemodynamic responses, was discussed. Non-atherosclerotic, traumatic vascular disease of the ilio-hypogastric-pudendal arterial bed from pelvic fractures or blunt perineal trauma may also result in diminished vaginal/clitoral arterial blood flow following sexual stimulation. Diagnostic studies assessing the hemodynamic integrity of the ilio-hypogastric-pudendal arterial bed to the vagina and clitoris and new oral/topical pharmacologic strategies for enhancing vaginal/clitoral blood flow in patients with vasculogenic female sexual dysfunction were discussed. There is a growing body of evidence that women with sexual dysfunction will commonly have physiologic abnormalities, such as vasculogenic female sexual dysfunction, contributing to their overall sexual health problems.