Female Sexual Health

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Introduction

Sexual health term was first offered by WHO in 1975 since that time the definition of sexual health s still developing. Sexual health is a condition of well- being that allows both male and female to fully participate and enjoy during 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.

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 unware they have a problem or dysfunction with their sexual activity. The sexual dysfunction refers to different disorders; loss of desire, orgasm disorders, arousal disorder, dyspareunia, or vaginismus, or overlapping of more than one disorders.

Sexual Response Cycle

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:

• The excitement phase

It is the initial response when female first aroused it is like I want to have a 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, 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.

• The plateau phase

The blood flow and heart rate will continue to increase, clitoris will be more sensitive, the increase in the muscle tension of the body reach to hands, feet, face, and other areas. There will be expansion of the upper 2/3 of the vagina and tightness around the lower third to can grap the penis (pubovaginalis  is the responsible for this action) the uterus will be fully elevated, vagina will expand and darkness of it is wall will be noted. The Bartholin glands produce additional lubrication in and around the vagina.

• The orgasm phase

Defined as the maximum sexual sensation can be reached. It is a rhythmic, involuntary contraction of muscles of the PFM around uterus, vagina, and muscles all over the body. This  followed by release of built-up muscle tension

• 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 majoa, minora, vaginal, uterus , all return to the normal resting position, and the respiration return to the level of  prearousal phase.

This classification according to William Masters and Virginia Johnson in 1966 it was based on the physical changes and neglected the emotional/ psychological changes, later on Helen Kaplan in 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 mid-20th century is defined it is not necessay to be a spontaneous drive and it unconscious and it happens when there is arousal response.

Sexual Dysfunction

• Post partum sexual dysfunction, dyspareunia, vaginal dryness. There was a ystematic review : perneal trauma / episitomy increase risk of dysfunction in first year post partum it reaches about 83% at 3 months after childbirth and declines to 64% at 6 months.  
• Decrease the sexual desire, it is more common near pre-menopause and post menopausal women because of hormonal changes and decline in estrogen, 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 need 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 to be aroused or maintain arousal phase (impairment in response of genitalia to sexual stimuli)
• Orgasmic dysfunction, a delay or absence of orgasm after arousal phase and ongoing stimuli.

Management

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

Medical management

Hormonal treatment for sexual arousal disorders and hyposexual dysfunction:

• 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:

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