Female Sexual Health

Original Editor - Khloud Shreif

Top Contributors - Khloud Shreif, Lucinda hampton and Kim Jackson  

Introduction[edit | edit source]

Sexual health is a condition of well-being that allows both males and females to fully participate in and enjoy sexual activity. It is hormonal dependant and can be affected by physical, mental, emotional, social, or hormonal factors. For some women, it is an important method to conceive her baby. Sexual health as a term was first used by WHO in 1975. Since that time the definition of sexual health continues to develop

In some countries there are still women who feel shame to talk about their sexual health and their associated sexual dysfunction to their health care professionals or may be unaware they have a problem or dysfunction with their sexual activity. Sexual dysfunction refers to different disorders; loss of desire, orgasm disorders, arousal disorder, dyspareunia, vaginismus, or overlapping of more than one disorder.

Sexual Response Cycle[edit | edit source]

The sexual response cycle is the physical, psychological, and emotional body response when one is aroused or involved in sexual activity, it is divided into 4 stages:

  1. The excitement phase: It is the initial response when a female is first aroused it is like I want to have sex. There will be an increase in the heart rate, respiratory rate, and blood pressure, resulting in vasocongestion (engorgement of blood vessels), as well as, an increase in muscle tension that is called myotonia. Because of the vasocongestion the nipples will harden and there will be an increase in the breast volume, the clitoris will increase in length swell, labia majora, minora, and uterus will also be engorgement because of the increase in the blood supply.
  2. The plateau phase: The blood flow and heart rate will continue to increase, the clitoris will be more sensitive, and the increase in the muscle tension of the body reaches to the hands, feet, face, and other areas. There will be an expansion of the upper 2/3 of the vagina and tightness around the lower third to can grab the penis (pubovaginalis is responsible for this action) the uterus will be fully elevated, the vagina will expand and the darkness of its wall will be noted. The Bartholin glands produce additional lubrication in and around the vagina.
  3. The orgasm phase: Defined as the maximum sexual sensation can be reached. It is a rhythmic, involuntary contraction of muscles of the PFM around the uterus, vagina, and muscles all over the body. This  followed by the release of built-up muscle tension
  4. The resolution phase, marked by a return to baseline: Relaxation of the muscles, blood pressure returns to it is normal level, decrease in the blood flow to the genital organs, clitoris, labia majora, minora, vaginal, uterus, all return to the normal resting position, and the respiration return to the level of pre arousal phase[1].

This classification according to William Masters and Virginia Johnson 1966 was based on physical changes and neglected the emotional/ psychological changes[2], later on, Helen Kaplan 1979 proposed a model and added desire, excitement, and orgasm.

Desire phase, it is the cognitive and emotional state, defined as the interest and enjoyment to be aroused and wanted to have sex. In the mid-20th century is defined it is not necessary to be a spontaneous drive it is unconscious and it happens when there is an arousal response[1].

Sexual Dysfunction[edit | edit source]

  • Pelvic Floor Functions.png
    Post Partum sexual dysfunction, dyspareunia, vaginal dryness. There was a systematic review: perineal trauma / episiotomy increases risk of dysfunction in the first year postpartum it reaches about 83% at 3 months after childbirth and declines to 64% at 6 months[3].  
  • Decrease sexual desire, it is more common near pre-menopause and post-menopausal women because of hormonal changes and decline in estrogen, and progesterone levels.
  • Painful sex/ dyspareunia, recurrent, persistent pain during or after having sex, it may be due to loss of lubricants or muscular origin. This muscular cause it may be superficial she will have pain on entry or deep dyspareunia that will be more related to levator anii muscles.
  • Vaginismus, involuntary muscle spasm/ contraction around the lower third of the vagina, the NHS defined it as an automatic reaction of the body to due to a fear of some or all types of vaginal penetration, it may be a fear of pelvic examination, during intercourse, or both. This usually needs a combination of cognitive, behavioral psychotherapy, and physical therapy intervention.
  • Arousal disorders, a decrease or absence of sexual interest, her desire may be intact but she will face difficulty being aroused or maintaining arousal phase (impairment in response of genitalia to sexual stimuli)
  • Orgasmic dysfunction, a delay or absence of orgasm after arousal phase and ongoing stimuli[4][5].


Management[edit | edit source]

Management of female sexual dysfunction will be a combination of cognitive behavior therapy[7], psychotherapy, sometimes she will need support from her partner[8] it is important to understand her fear and her problem in addition to medication and pelvic floor rehabilitation.

Medical management[edit | edit source]

Hormonal treatment for sexual arousal disorders and hyposexual dysfunction[5]:

  • Hormone replacement with systemic or vaginal estrogen, estrogen will help women post-menopause and near menopause but it helps more with vaginal atrophy changes than sexual dysfunction at this age.
  • Androgen supplementation, it plays an important role in the management of desire disorders in women.
  • Tibolone, a selective estrogen receptor modulator (SERM)  

Ospemifene (SERM)

Nonhormonal treatment for sexual arousal disorders and hyposexual dysfunction[5]:

  •  Flibanserin
  • Sildenafil
  • Herbal therapy, such as ginkgo biloba extract (GBE) or ArginMax
  • Eros-clitoral device[9].

Physical therapy management[edit | edit source]

Yoga pose.jpg

The physical therapy program will rely on the assessment, and internal and external pelvic examination, every woman needs a unique program according to her requirements and complaints. The program will depend on relaxation techniques, deep breathing techniques, stretching nearby tight muscles, stretching and release of pelvic floor muscles (superficial layer, deep layer, or both), internal and external soft tissue mobilization, or yoga as in dyspareunia, vaginismus, or hyperactive pelvic floor muscles (PFM).

Appropriate Kegel exercise program, strengthening program, sensory training, clitoris stimulation in hypoactive PFM conditions. Transcutaneous electrical nerve stimulation TENS, biofeedback, interferential therapy, sex toys can be used for rehabilitation[10].

References[edit | edit source]

  1. 1.0 1.1 Rowland DL, Gutierrez BR. Human sexual response, phases of. The Sage encyclopedia of abnormal and clinical psychology. Sage. 2017:1705-6.
  2. Levin RJ. Critically revisiting aspects of the human sexual response cycle of Masters and Johnson: Correcting errors and suggesting modifications. Sexual and Relationship Therapy. 2008 Nov 1;23(4):393-9.
  3. Cattani L, De Maeyer L, Verbakel JY, Bosteels J, Deprest J. Predictors for sexual dysfunction in the first year postpartum: A systematic review and meta‐analysis. BJOG: An International Journal of Obstetrics & Gynaecology. 2022 Jun;129(7):1017-28
  4. Kingsberg SA, Janata JW. Female sexual disorders: assessment, diagnosis, and treatment. Urologic Clinics of North America. 2007 Nov 1;34(4):497-506.
  5. 5.0 5.1 5.2 Clayton AH, Juarez EM. Female sexual dysfunction. Medical Clinics. 2019 Jul 1;103(4):681-98.
  6. American Sexual Health Association. Understanding Female Sexual Dysfunction . Available from: http://www.youtube.com/watch?v=Z6mC16Q0ZL8[last accessed 3/10/2022]
  7. Thomas HN, Hamm M, Hess R, Borrero S, Thurston RC. Patient-centered outcomes and treatment preferences regarding sexual problems: a qualitative study among midlife women. The journal of sexual medicine. 2017 Aug 1;14(8):1011-7.
  8. Basson R. Women's sexual dysfunction: revised and expanded definitions. Cmaj. 2005 May 10;172(10):1327-33.
  9. Wilson SK, Delk 2nd JR, Billups KL. Treating symptoms of female sexual arousal disorder with the Eros-Clitoral Therapy Device. The Journal of Gender-specific Medicine: JGSM: the Official Journal of the Partnership for Women's Health at Columbia. 2001 Jan 1;4(2):54-8.
  10. Arnouk A, De E, Rehfuss A, Cappadocia C, Dickson S, Lian F. Physical, complementary, and alternative medicine in the treatment of pelvic floor disorders. Current urology reports. 2017 Jun;18(6):1-3.