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[Experiences at a sexologic clinic].
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Help with sexual difficulties.
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[Role of hormones in sexual dysfunctions, homosexuality, transsexualism and deviant sexual behavior: diagnostic and therapeutic consequences].
Hormones only play a minor role in sexual dysfunctions. They are clearly involved only in erectile dysfunction. Total testosterone is low in 8% of those patients, but only 32% of them are improved with androgen therapy. Free testosterone is also electively decreased in 30% and bioavailable (non SHBG bound) testosterone in 15%. However androgen-therapy is still less effective in these subgroups. Plain hyperprolactinemia is found in only 0,7% of the cases. Half of them result from a pituitary adenoma. The other endocrine dysfunctions are still scarcer. This data cannot justify a systematic determination of serum prolactin and testosterone in sexual dysfunctions. A cost effective hormonal screening is proposed, whereas the role of androgen-therapy in erectile dysfunction with or without hypogonadism is discussed. The hypothesis of an "inverted brain sexual differentiation" in homosexuality and for transsexualism, resulting from an abnormal antenatal endocrine milieu is reviewed. It cannot obviously explain by itself these conditions, but some amazing morphological findings in transsexual people do not permit to totally refute it. Lastly the role of androgens in paraphilia and parapaphilia related disorders seems limited to the arousal of an abnormal sexual behaviour previously scheduled by non hormonal mechanisms. However anti-androgens are in such cases one of the main effective treatment.
[Mass-hysteria with Koro-symptoms in Thailand].
Koro, a psychogenic anxiety syndrome interfering with genital body image and sexual functioning, has hitherto been described as occurring mainly in isolated cases of South Chinese males. The present communication reports an epidemic outbreak in November 1976 in Northeastern Thailand where within a few days at least 200 patients, most of them Thai and two-thirds males, were treated at local hospitals. Main presenting symptoms were acute anxiety, in some cases leading to fainting, (subjective) shrinking of the penis and impotency in men, shrinking and/or itching of the external genitals and frigidity in women; further complaints included initial nausea and dizziness, abdominal pains, headaches, facial numbness. All patients recovered after brief symptomatic intervention. Popular opinion and news media echoed the patients' paranoid projection of viewing the epidemic as caused by Vietnamese food and tobacco poisoning in a hideous assault against the sexual vitality and general health of the Thai people, in the context of a specific socio-cultural and politico-historical situation. It appears that an adequate interpretation of Koro and of analogous hysterical symptom formation would have to go beyond the hitherto applied psychoanalytic models by considering the specific sociodynamic factors involved in the pathogenesis of such phenomena.
Sex therapy: considerations in the selection of patients.
Sex therapy has proven helpful for many patients with sexual dysfunctions. In judging the appropriateness of this new treatment procedure the clinician should determine the following: that a sexual dysfunction exists, that a stable couple relationship exists, that there are no major marital, psychiatric or physical problems that are etiologically important or that would interfere with treatment, and that both partners are willing to engage in a treatment program.
[Sexual dysfunction is common during treatment with antidepressive agents].
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Sexual dysfunction in diabetic women.
This study examined sexual dysfunction in diabetic women. Eighty-one insulin-treated diabetic women were interviewed and administered standardized questionnaires. Using criteria derived from the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.) (DSM-III; American Psychiatric Association, Washington, D.C., 1980), 38 (47%) of the women were diagnosed with sexual dysfunction and 43 (53%) did not report sexual problems. The more frequently reported sexual problems were inhibited sexual excitement, inhibited sexual desire, and dyspareunia. Diabetic women with sexual dysfunction were more depressed, more stereotyped in their sex-role definitions, and less satisfied in their sexual relationships than those without sexual dysfunction. The two groups did not differ in metabolic control, insulin dose, duration of diabetes, or frequency of diabetic complications (e.g., neuropathy, etc.). Results suggest that diabetes may be associated with inhibited sexual excitement and dyspareunia in women. Both psychological and physiological concomitants of sexual dysfunction in diabetic women should be considered in diagnostic and treatment programs.
Female sexual dysfunction: anatomy, physiology, evaluation and treatment options.
It has been estimated that up to 76% of women, depending upon their age, have complaints of sexual dysfunction, including decreased libido, vaginal dryness, pain with intercourse, decreased genital sensation and difficulty or inability to achieve orgasm. Female sexual dysfunction is a significant problem that affects the quality of life of many women. This review addresses the etiologies and incidence of female sexual complaints, as well as new findings in the evaluation and treatment of female sexual dysfunction.
Clinical evaluation of female sexual function: effects of age and estrogen status on subjective and physiologic sexual responses.
INTRODUCTION: 30-50% of American women complain of sexual dysfunction. Aging, menopause, and a decline in circulating estrogen levels significantly increase the incidence of sexual complaints. Evaluation of physiologic components of the female sexual response has, in the past, been technically challenging and difficult to standardize. We describe methodology for evaluating physiologic and subjective components of the female sexual response in the clinical setting and determine the effects of age and estrogen status on them. METHODS: 48 women with complaints of sexual dysfunction were evaluated. Physiologic measurements include genital blood peak systolic velocity, vaginal pH, intravaginal pressure-volume changes (compliance), and genital vibratory perception thresholds. Measurements were recorded at baseline and following sexual stimulation. Baseline subjective sexual function was assessed using a Female Sexual Function Inventory. Age was then correlated with both physiologic and subjective sexual responses. RESULTS: Sexual stimulation resulted in increased mean genital blood peak systolic velocity, vaginal pressure-volume, and vaginal pH measurements (P < 0.05) in all women. Older women (ages 55-71 y) and menopausal women not on hormone replacement therapy had significantly lower physiologic response sexual complaints. Baseline subjective sexual function complaints included low arousal (67%), low desire (21%), difficulty achieving orgasm (92%), and pain or discomfort during and/or following intercourse (67%). CONCLUSIONS: Clinical evaluation of physiologic and subjective components of the female sexual response are possible using this comprehensive approach. Physiologic measurements were reproducible and easy to perform, and incidence and types of sexual complaints were assessed with the sexual function questionnaire. A comprehensive approach is necessary when evaluating female sexual dysfunction due to the significant emotional and relational factors that can contribute to the problem. This combined subjective/physiologic assessment may also prove useful when evaluating efficacy of pharmacotherapy in the future.
Sexual dysfunction in the peri- and postmenopause. Status of incidence, pharmacological treatment and possible risks. A secondary publication.
The frequency of female sexual dysfunction increases with age, and the menopausal transition has a negative effect on the sexuality. Pharmacological treatment options for female sexual dysfunction during the peri- and post-menopause include hormone therapy or sildenafil. A limited number of randomized, controlled trials have been conducted and evidence suggests that systemic hormone therapy with estrogen, estrogen/progesterone, estrogen/testosterone and tibolone have a positive impact on sexual dysfunction during the peri- and postmenopause. Further, there is evidence that treatment with local estrogen relieves vaginal dryness and dyspareunia. Recent knowledge on side effects related to hormone therapy necessitates careful evaluation of the indication for hormone therapy and the duration of postmenopausal hormone therapy should be as short as possible. Long-term side effects of testosterone have not yet been fully investigated. A positive effect of sildenafil has been observed in a limited group of women; those with arousal problems but with no desire problems. The results suggest an intensified focus on new pharmaceutical products for the treatment of female sexual dysfunction in the postmenopause. For the time being the effect of testosterone therapy and tibolone on female sexual dysfunction is being investigated. Sexual dysfunction in women (Female Sexual Dysfunction, FSD) is multi-factorial and influenced by physiological, psychological, social and emotional factors. FSD is defined in four diagnostic groups: desire-, arousal-, orgasm- and pain problems. Recently, it has been suggested that the woman herself should assess the dysfunction as distressful to be diagnosed as having a sexual dysfunction [1]. There are only a limited number of well-conducted population surveys on the prevalence of FSD. Further, relatively few randomized, controlled trials of pharmacological treatment of FSD have been carried out.
Differential patterns of arousal in sexually functional and dysfunctional women: physiological and subjective components of sexual response.
Physiological and subjective patterns of sexual arousal were compared for sexually functional and dysfunctional women. Previous studies revealed seemingly contradictory findings: Some found significant group differences on physiological but not on subjective responses to erotic stimuli, whereas others found the opposite. To reconcile this discrepancy, subjects were presented with edited versions of the three erotic videotapes used in previous studies. Sexual arousal was measured physiologically with a vaginal photoplethysmograph, and subjectively with a self-report rating scale. Previous methodology was systematically replicated and extended by developing alternate physiological data collection and reduction techniques, employing alternate methods of subjective assessment, evaluating the arousal-eliciting capacity of the erotic stimuli, and designing scripts to reduce social demand. Results indicated that dysfunctional women exhibited significantly less physiological and subjectively experienced sexual arousal than functional women in all three stimulus conditions. Dysfunctional women also reported significantly less autonomic arousal. Results (i) replicate several seemingly contradictory findings in the literature, (ii) reconcile and provide evidence supporting an explanation for the apparent discrepancy, and (iii) reveal that subjective experience and genital vasocongestion are two primary components of sexual arousal that reliably discriminate dysfunctional from functional patterns of sexual response in women.
Sexual dysfunction.
Sexual dysfunction may adversely affect a woman's self-esteem and her overall sense of well-being. The obstetrician-gynecologist can play an important role by asking the patient about any problems with sexual function. Physiologic changes, disease, surgery, or medical therapy may result in sexual dysfunction. The physician should recognize the potential effects of these conditions on a patient's sexuality and provide the patient with appropriate education and counseling. Patients should also be advised about alternatives for sexual expression, particularly after pelvic surgery. Specific support groups of others facing similar conditions may also be helpful. If, after taking a history of the patient's psychologic status, relationship, and a sexual history, the physician does not see an obvious cause and course of treatment, the best choice may be referral to a marriage or relationship counselor or a sexual therapist, particularly if the problem is of a psychologic nature or of long duration. Counseling or referral can be helpful and rewarding for the patient, her partner, and the physician.
Biology of female sexual function.
Although the psychosocial and relationship aspects of female sexuality have been extensively investigated, studies concerning the anatomy, physiology and pathophysiology of female sexual function and dysfunction are limited. The paucity of biologic data may be attributed to a lack of reliable experimental models and tools for investigating female sexual function and to limited funding, which is critical for developing experimental approaches. Research efforts by several investigators in different laboratories have been establishing experimental models needed for investigating the physiologic mechanisms involved in the genital arousal response of sexual function. These experimental models have permitted assessment of genital hemodynamics, vaginal lubrication, regulation of genital smooth muscle contractility and signaling pathways, providing preliminary information about the role of neurotransmitters and sex steroid hormones in sexual function. Further research is needed to define the neurotransmitters responsible for vaginal smooth muscle relaxation and the role of sex steroid hormones and their receptors in modulating genital hemodynamics, smooth muscle contractility, and neurotransmitter receptor expression. Finally, a global and integral understanding of the biologic aspects of female sexual function requires investigation of the vascular, neurologic (central and peripheral), and structural components of this extremely complex physiologic process.
The complexities of female sexual arousal disorder: potential role of pharmacotherapy.
Identifying any role for pharmacotherapy in women's sexual arousal disorders requires an understanding of the components of sexual arousal. Furthermore, an analysis of female sexual arousal disorders necessitates distinguishing between the absence of physiological genital responding and lack of attention to, or dislike of, any physiological responding. Pharmacologically enhancing a suboptimal physiological vasocongestive response is possible. Current studies involve both medications that magnify the affects of a natural neurotransmitter of genital sexual arousal (nitric oxide), and those that act independently of the natural mechanism. Enhancing attention to genital engorgement by pharmacological means is at present theoretical. Similarly, non-hormonal pharmacological means of facilitating pleasure from the arousal-associated genital congestion awaits scientific study. When a deficiency of estrogen or androgen is involved in the lack of pleasure from massaging vulval structures and/or involved in their suboptimal engorgement, their replacement can be beneficial. Scientific study of physiological androgen replacement therapy is only just beginning.
A new combination treatment for premature ejaculation: a sex therapist's perspective.
This article describes the diagnosis and treatment of premature ejaculation (PE) from a sex therapist's perspective and proposes that combination therapy integrating sex therapy and sexual pharmaceuticals is frequently the best treatment approach. Failure to appreciate the multimodal etiology and pathophysiology of PE makes the condition more difficult to diagnose and treat. Many physicians have tried pharmacologic approaches, but are limited to providing topical anesthetics or suggesting off-label uses of antidepressant and erectile dysfunction medications, because no medication is currently indicated specifically for PE. Furthermore, patients frequently relapse after discontinuation of the pharmaceutical. Sex therapists appreciate the multidimensional nature of PE for the patient and partner, but few patients seek out this approach, which is labor-intensive and often lacking long-term follow-up success. Most men with PE are not receiving treatment, secondary to their embarrassment about discussing their condition and a lack of clinician inquiry about sexual dysfunction. Even for those who do engage in discussion, diagnoses may be inconsistent, because a universally accepted definition of the condition and diagnostic criteria are nonexistent. Men with PE experience anxiety and lack sexual self-confidence; subsequently, their sexual and overall relationship frequently suffer. Because PE involves psychosocial and physiologic factors, treatment that addresses both should yield the best balance of function. There is interest in new agents designed specifically for PE to provide an improved pharmacotherapeutic opportunity. Yet, a combination treatment integrating pharmaceuticals and sex therapy would provide an optimized approach. Besides increasing coital latency directly, sexual pharmaceuticals could be used to provide greater opportunity for men to recognize their premonitory sensations to ejaculation more readily, facilitating a "choice point", which is key to facilitating behavioral change and learning. Such a combination approach would result in prolonged ejaculatory latency, improved treatment satisfaction, and superior long-term outcome.
The role of androgens in hormone replacement therapy.
In recent years, increased attention to women's sexual health has propelled basic scientific research and clinical trials investigating treatment paradigms for improving sexual well-being. As the prevalence of female sexual dysfunction has become manifest, knowledge of the intricate pathophysiological role of androgens in maintaining sexual function has fostered a clearer understanding of the effect of age on androgen status, the role of androgens in the postmenopausal ovary, and aetiological mechanisms of androgen insufficiency in premenopausal and postmenopausal women. Understanding the long-term safety and efficacy of physiological androgen replacement and the development of sensitive testosterone assays for specific use in women will better characterise women who are most likely to respond to androgen therapy and, thereby, optimise their quality of life.
A clinical update on female androgen insufficiency--testosterone testing and treatment in women presenting with low sexual desire.
The diagnosis of female androgen deficiency syndrome is suggested by complaints of a diminished sense of well being, persistent unexplained fatigue and decreased sexual desire, sexual receptivity and pleasure in a woman who is oestrogen-replete and in whom no other significant contributing factors can be identified. The diagnosis is supported by the finding of low circulating concentrations of free testosterone. Barriers to its recognition include the non-specificity of the symptoms and methodological problems due to insensitive testosterone assays. Barriers to its treatment include the unavailability of satisfactory forms of testosterone for administration to women and lack of data regarding long-term safety. Although several conditions lead to clear-cut androgen deficiency, such as hypopituitarism, adrenal and ovarian insufficiency, glucocorticoid therapy and use of oral contraceptives and oral oestrogens, it is important for clinicians to recognise that in normal women, androgen levels decline by 50% from the early 20s to the mid 40s, and hence age-related androgen insufficiency may occur in women in their late 30s and 40s, as well as postmenopausally. Satisfactory measurements of free testosterone requires a sensitive and reliable assay for total testosterone, and quantitation of sex hormone binding globulin, from which free testosterone is readily calculated. Adverse effects of testosterone treatment are few if replacement is monitored to achieve physiological circulating testosterone concentrations. Currently, available methods include testosterone implants and testosterone creams, and transdermal patches and sprays are in development.