|
Knowledge about sexual function is important for contemporary psychiatric
physicians for several reasons. The most important reason is that
sexuality is an important part of our patients’ lives. Intimate
sexual activity can serve as a vehicle for a sense of emotional
connection to another person, and intimate relationships may serve
as a buffer against the emotional impact of life stress. Many patients
suffer from a decreased sense of competence because they are personally
aware of psychological impairment. The presence of sexual impairment
may further undermine their sense of personal competence and put
an added burden on intimate relationships that may be already stressed
by psychiatric difficulties.
Recent information indicates that sexual dysfunction is highly
prevalent in the general population and is highly comorbid with
many psychiatric syndromes. Also, many commonly prescribed psychiatric
drugs have sexual side effects. In some cases, these side effects
may become an unspoken cause of treatment noncompliance.
The diagnosis and treatment of sexual disorders clearly falls within
the purview of psychiatry. Human sexuality is influenced by a myriad
of physical, psychological, interpersonal, and cultural factors;
psychiatry is the only specialty mandating that psychosocial and
biological factors must be integrated in both diagnostic understanding
and treatment planning (1). The treatment of sexual disorders involves
both an understanding of the patient’s subjective experience
of sexuality and the biological substrate of sexual behaviour.
This paper reviews the current information on female sexual dysfunction
that is of interest to a general psychiatric audience. The review
focuses on the prevalence of sexual dysfunction, the comorbidity
of sexual disorders with other psychiatric syndromes, sexual side
effects of psychiatric drugs, management of these side effects,
and current research concerning the pharmacologic treatment of female
sexual dysfunction.
To put evaluation and treatment of sexual disorders in historical
context, it is important to realize that much of the scientific
study of human sexuality has occurred in the last 40 years. Prior
to 1980, the only official categorization for sexual disorders in
the DSM of the American Psychiatric Association was the term “genitourinary
disorder.” The publication of Human Sexual Response in 1966
(2) and of Human Sexual Inadequacy in 1970 (3) stimulated interest
in the diagnosis and treatment of human sexual problems. By 1980,
the DSM included categories for the diagnoses of disorders of sexual
desire, sexual arousal, and orgasm. In 1994, the DSM-IV first included
a category for drug-induced sexual dysfunction (4).
Knowledge of female sexuality has consistently lagged behind our
knowledge of male sexuality. Data concerning the sexual side effects
of drugs were first identified in male patients and subsequently
reported in female patients (5). For example, the first case report
of antidepressant-induced orgasm disorder in a female patient was
reported by Wyatt in 1971 (6). A case series documenting antipsychotic-induced
sexual dysfunction in both sexes was reported in 1976 (7). The success
of sildenafil as a treatment for male erectile disorder sparked
interest in pharmacologic treatments for female sexual disorders.
This has led to several clinical trials of pharmacologic treatments
for female sexual dysfunction (8,9), the development of new assessment
tools (10,11), increased interest in assessing biological contributors
to female sexual dysfunction (12,13), and refinement in our diagnostic
understanding of female sexuality (14,15). Widespread interest in
the treatment of female sexual disorder is quite recent, as is documented
by the fact that the first international consensus meeting on diagnosis
of female sexual disorders was convened in 1999 (16), and the first
international society for the study of female sexuality (International
Society for Study of Women’s Sexual Health) was incorporated
in 2001, in Boston.
Recent population surveys have indicated that female sexual disorders
are highly prevalent in several Western countries. Comparison between
countries is problematic because different definitions and methodologies
are employed in different surveys. The National Health and Social
Life Survey was conducted in 1992 and involved personal interviews
with a probability sample of the US population between the ages
of 18 to 59 years (17,18). This survey found that 43% of women had
had significant sexual complaints in the preceding year.
The most common concern was lack of sexual interest (reported by
33% of women), followed by difficulty reaching orgasm (24%) and
problems with lubrication (19%). In the UK, Dunn and others (19,20)
surveyed a stratified random sample of 4 general practices. Because
95% of the population are registered with a general practitioner,
the registers can be used as sampling frames for a population study.
Sexual questionnaires were mailed to the study sample, and 44% replied
to the survey. Two-fifths of the women in this survey reported a
current sexual problem. The most common complaints were difficulty
achieving orgasm and vaginal dryness. The survey did not directly
inquire about sexual libido. Fugl-Meyer (21) reported a survey of
sexual function in a representative sample of Swedish women, aged
18 to 74 years. Forty-eight percent had a sexual dysfunction, defined
according to DSM-IV criteria. The most common problem was hypoactive
sexual desire disorder, followed by orgasmic and arousal disorders.
|
|
A history of sexual abuse was closely associated with orgasmic
difficulties, and most sexual difficulties increased with increasing
age. It is important to note that most surveys find considerable
overlap between different sexual disorders; that is, women complaining
of low libido frequently also have difficulty becoming sexually
aroused or reaching orgasm (21,22).
Population surveys indicate a high concordance of female sexual
dysfunction and marital discord and symptoms of anxiety and depression
(20). An Icelandic population survey found that 57% of patients
with a lifetime prevalence of a psychosexual disorder had a lifetime
prevalence of another psychiatric disorder. The most common lifetime
diagnoses associated with sexual disorders were anxiety disorders
and dysthymia (23).
Studies of sexual function in psychiatric patients suggest that
sexual disorders are more common in patients diagnosed with depression,
schizophrenia, anorexia, and anxiety disorders. Interestingly, sexual
activity and libido are reported to increase in manic episodes (24).
Several clinical investigators have reported that patients with
a diagnosis of schizophrenia have symptoms of hypoactive sexual
desire disorder (25–29). The decreased libido is not necessarily
a result of treatment with neuroleptic agents, because one investigator
reported that libido increased when patients were given neuroleptic
agents (28). Anorexia nervosa (AN) has been reported to be associated
with sexual impairment corresponding either to sexual aversion disorder
or hypoactive sexual desire disorder (30–32). Interestingly,
the degree of caloric intake has been found to be related to a decreased
frequency of masturbation in patients with AN, and an increased
level of sexual drive has been reported to correlate with weight
gain in patients with AN. Patients with bulimia nervosa (BN) are
more likely to have engaged in coitus than are patients with anorexia.
Studies have also found high rates of hypoactive sexual desire disorder
in women with obsessive–compulsive disorder (OCD) and panic
disorder (33).
Clinicians have recognized for several decades that diminished
sexual interest is part of the symptomatic presentation of depressive
disorders. Mathew and Weinman reported that diminished libido was
common in a series of patients with major depressive disorder (MDD)
(34). More recently, Kennedy investigated sexual function in 55
male and 79 female patients with untreated MDD (35). Fifty percent
of the female patients reported a marked decrease in libido with
the onset of MDD. Fifty percent of the women also reported decreased
sexual arousal. Fifteen percent reported difficulty achieving orgasm.
Problems with desire were associated with a greater number of depressive
episodes. However, both of these reports are limited by the absence
of control groups. Kivela and Pahkala studied depressive symptomatology
in elderly citizens of Ahtari, Finland (36,37). In women between
the ages of 60 and 69 years, loss of libido was significantly more
common in those with depression, although a large number of women
without depression in this age group reported loss of libido. In
women over age 70 years, loss of libido was quite common in those
both with and without depression and was not significantly more
common in the women with depression. There is also evidence that
women without depression who have a complaint of low libido have
a greater lifetime incidence of affective disorder. In 1986, Schreiner-Engel
and Schiavi examined couples with a primary complaint of hypoactive
sexual desire disorder who did not suffer from depression (38).
Patients and control subjects without hypoactive sexual desire disorder
were administered the Schedule for Affective Disorders and Schizophrenia-Lifetime
Version (SADS-L), and it was found that patients with a current
diagnosis of hypoactive sexual desire disorder had an increased
lifetime prevalence of affective disorder. The authors hypothesized
that there may be a common biological etiology to both affective
disorder and hypoactive sexual desire disorder.
Case reports, clinical series, and controlled studies suggest that
a wide variety of commonly prescribed psychiatric drugs may adversely
affect female sexual function. Double-blind studies undertaken as
early as 1986 and 1987 indicated that monoamine oxidase inhibitors
(MAOIs), benzodiazepines, and tricylcic antidepressants (TCAs) were
associated with orgasmic delay (39). However, the effect of these
agents on sexual function was not appreciated by most psychiatrists
until these drugs had been in clinical use for several years. The
reason for the delayed recognition of sexual side effects is probably
that most patients do not report sexual side effects unless directly
asked by their physicians (40). The most common side effects are
delayed orgasm and decreased libido, although decreased lubrication
may be associated with sertraline use (41). Psychiatric drugs associated
with sexual side effects include the MAOIs, TCAs, selective serotonin
reuptake inhibitors (SSRIs), and antipsychotic agents that elevate
prolactin. Whether lithium carbonate and anticonvulsants are associated
with sexual problems is less clear (42).
|
