Nineteen carbon sex steroids or hormones, produced primarily by the ovaries and adrenal glands, but also from other organs, such as skin and muscle. There are seven androgens, four of which can be routinely measured during blood testing: dehydroepiandrosterone (DHEA), androstenedione, testosterone, and dihydrotestosterone. Androgens induce genital and non-genital cells to synthesize specific proteins, such as growth factors and enzymes. These proteins affect genital tissue growth, maintain genital tissue structure, and play a critical role in genital tissue physiology, including engorgement and blood flow changes with sexual stimulation. Androgen-induced proteins also affect sexual desire, bone density, adipose tissue distribution, mood, energy, and wellbeing. In many cases, lack of androgens can be associated with genital atrophy and sexual health problems. See Androgen Therapy
Off-label (not yet FDA-approved for that use) systemic hormone treatment for women with sexual health issues, who are suspected to have androgen insufficiency syndrome and low levels of “unbound” or calculated free testosterone. Androgen therapy may include dehydroepiandrosterone (DHEA) treatment and/or testosterone treatment. The typical dose of testosterone is 10% of the recommended dose of testosterone gel that is FDA-approved for treatment of men with hypogonadism. Ideally, the dose of androgens delivered daily to women with sexual health concerns is designed to keep the blood levels of the various androgens in the mid to upper values of the normal range. Blood levels for DHEA and testosterone are typically checked every three months while on therapy, until stable values are achieved.
Data show that women with sexual health concerns, who have androgen insufficiency, significantly improve sexual function using androgen therapy. Potential adverse effects of androgen (DHEA and/or testosterone) therapy include facial hair growth (hirsutism) and acne. There is no evidence that exogenous testosterone increases the risk of endometrial cancer, endometriosis, breast cancer, cardiovascular concerns, sleep apnea or aggressiveness. Issues such as balding, voice deepening, and enlarged clitoris do not result when dosing used for women with sexual health problems is selected as 10% of the usual male dose for hypogonadism. See Androgen Therapy.
Absence of ejaculation during orgasm.
Inability to achieve an orgasm during conscious sexual activity although nocturnal emission may occur.
The enzyme that facilitates the conversion of testosterone to estradiol, and androstenedione to estrone. Having an active aromatase enzyme allows women to be treated by testosterone for low testosterone values and receive the benefit of diminished intensity of hot flushes and night sweats (an estrogen effect). As women age, the activity of the aromatase enzyme appears to diminish, so that testosterone conversion to estradiol is reduced. See Medical Androgen Therapy
The feelings and physical signs of sexual desire. Arousal may be sub-classified into three specific categories: subjective, genital, and combined. Subjective sexual arousal consists of feelings of sexual arousal, sexual excitement, and sexual pleasure derived from any type of sexual stimulation. It does not always strongly correlate with genital congestion. Genital sexual arousal consists of vulvar swelling or vaginal lubrication from any type of sexual stimulation, and sexual sensations from caressing genitalia. Combined genital and subjective arousal includes feelings of sexual arousal, sexual excitement, and sexual pleasure from any type of sexual stimulation, as well as genital sexual arousal, such as vulvar swelling or vaginal lubrication.
Shrinking in size of some part or organ of the body, usually caused by lack of hormone (androgens or estrogens) support, injury or reduced blood flow.
Situated at the bottom of the posterior parts of the labia minora, deep to the lowest inner portions of the clitoris (crus), and deep to the erectile tissue of the corpora spongiosa. The right and left greater (major) vestibular glands produce a clear, mucinous secretion during sexual arousal, designed to aid in physiologic vestibular lubrication. The main duct of each Bartholin’s gland opens at the lateral margin of the lower half of the vaginal opening, outside to the hymenal tissue of the vagina. The Bartholin’s glands may be the site of infection and cyst formation.
Records the sum of the “unbound” testosterone, as well as the loosely bound testosterone, to albumin. Sex steroid hormones, such as testosterone, may be tightly “bound” to sex hormone binding globulin (SHBG), loosely bound to albumin, or “unbound” to either protein, and physiologically available to enter the cell and direct protein synthesis. Bioavailable testosterone is considered more clinically useful than total testosterone, especially if SHBG is elevated. See Androgen Therapy
Produced commercially to be chemically exact duplicates of the hormones and their precursors naturally made (seven androgens, three estrogens, and one progesterone), that result in physiologic responses identical to hormones produced by the woman in her own body. One major reason why health care providers prefer bioidentical hormones for hormone therapy is that they can be measured scientifically and accurately with standard blood testing. Bioidentical hormones can be extracted and derived from a variety of different sources, such as soy or yams. Bioidentical hormones, such as testosterone, estradiol, and progesterone, are FDA-approved and are recommended, versus compounded products by compounding pharmacies. Compounded products are prepared by methods that are not inspected by the FDA, and concentrations of the hormones may vary within the solution (layering effect within the ointment or cream) or may vary from one pharmacist to another.
Use of a monitoring device that displays information about the operation of a bodily function that is not normally consciously controlled, such as heart rate or body temperature. Electromyographic (EMG) biofeedback monitors muscle activity, which is under conscious control. EMG provides the woman with visual and auditory feedback to relax and strengthen the pelvic floor muscles.
Breast Cancer Susceptibility Gene (BRCA)
The breast cancer receptor gene that shows increased risk of breast and ovarian cancer. The changes from normal in the BRCA1 or BRCA2 genes can be inherited from your mother or father. Genetic counseling is imperative, as having the BRCA gene does not mean you have cancer.
A blood test that measures the concentration of a protein that indicates new inflammation. Recent studies have suggested that inflammation is important in the process in which fatty deposits build up in the lining of arteries, or atherosclerosis. C-reactive protein levels, using the very high sensitivity assay called “hs-CRP,” may assess for cardiovascular disease risk. Researchers are finding that hs-CRP levels can predict recurrent cardiovascular disease, stroke, and death. If the hs-CRP level is lower than 1.0 mg/L, a person has a low risk of developing cardiovascular disease. If hs-CRP is between 1.0 and 3.0 mg/L, a person has an average risk. If hs-CRP is higher than 3.0 mg/L, a person is at high risk.
Since blood flow is an important biologic aspect of sexual arousal, elevated C-reactive protein levels may predict individuals with impaired blood flow and sexual dysfunction. Using this hypothesis, C-reactive protein levels were measured in women at risk for blood vessel inflammation, that is, women with metabolic syndrome. Compared to women without metabolic syndrome, it has been found that women with metabolic syndrome have lower sexual function scores, lower sexual satisfaction, and higher levels of C-reactive protein. Strategies to lower elevated C-reactive protein levels include diet, exercise, and statins or drugs that are very effective in reducing cholesterol.
Erectile structure approximately five inches (thirteen centimeters) in length, of which only a small segment, the glans clitoris, is noticeable from the vestibule surface. The shaft or body of the clitoris is comprised of two paired erectile chambers passing upwards, underneath the vulva towards the pubic bone, and continuing as separate right and left clitoral curae, straddling the urethra and vagina. During sexual arousal, clitoral blood flow increases, and clitoral smooth muscle relaxes. The result is that the engorged portion of the clitoris not attached to the pelvic bone, the clitoris shaft, changes its angle to the vulva from thirty degrees at baseline to more than ninety degrees during sexual arousal. The increased angle improves opportunity for clitoral glans contact during sexual activity.
Undue delay in reaching ejaculation during sexual activity.
One of seven androgen and their precursors in a woman’s body. DHEA is the first of the androgen precursors, synthesized primarily in the adrenal gland. DHEA has multiple actions including helping arterial blood vessels relax. It ultimately converts to testosterone. DHEA treatment has been shown to improve sexual desire, arousal, lubrication, orgasm, and satisfaction in women with sexual dysfunction. There are no FDA-approved DHEA products, however, bioidentical DHEA is commonly purchased at health food stores. See Androgen Therapy
Promotes the craving or desire for continued sexual activity once sexual stimulation has started. Dopamine neurotransmitter systems appear to play a role in central sexual arousal, sexual excitation, sexual mood, and sexual motivation. Treatment with dopaminergic agonist drugs (agents that act like dopamine) has resulted in an increase in sexual desire and improvement in orgasm in a number of women with sexual dysfunction.
A sexual pain disorder, defined as a recurrent and persistent genital pain, experienced in varying genital locations. Pre-menopausal dyspareunia can be secondary to vulvar vestibulitis syndrome. Other causes include vestibular dermatologic conditions such as lichen sclerosis or lichen planus, or fungal infections of the clitoris or labia. Deep dyspareunia is associated with pelvic pathology such as endometriosis and chronic pelvic pain, associated with pelvic floor disorders. Other conditions include Bartholin cysts, fibroepitheliomas of the frenulum, interstitial cystitis, and sexually transmitted diseases such as herpes or human papilomavirus. Post-menopausal dyspareunia is usually due to vaginal atrophy and reduced lubrication, secondary to low estradiol blood levels. Genital pain is a multi-dimensional physical and psychologic health concern.
Recurrent of persistent genital pain induced by non-coital sexual stimulation.
Electroconvulsive Therapy (ECT)
A treatment in which a brief application of electric stimulus is used to produce a generalized seizure. As a treatment for severe depression and suicidal intent, ECT has a higher success rate than any other form of treatment and can be life-saving. Recurrent ECT has potential as a treatment strategy for some women with persistent sexual arousal syndrome, depression, and suicidal intent, although much more research is needed.
European Medicines Agency, a regulatory body for pharmaceutical and device products in the European Union.
Passage of seminal fluid through the urethra and its expulsion from the urethral meatus.
A condition where endometrium uterine lining tissue is found growing outside the uterus. The endometrial tissue, even when outside the uterus, responds to hormone alterations during the menstrual cycle. The most common symptoms of endometriosis are painful menstrual periods and/or pelvic pain. Endometriosis is a cause of sexual pain or dyspareunia. It is a non-cancerous condition, affecting 10% to 15% of pre-menopausal women.
The endothelium is the innermost lining of the blood vessels. The endothelium plays a critical role in the health of the blood vessel. The endothelium is instrumental in communicating to the adjacent blood vessel muscular layer to regulate blood vessel dilation or contraction. The endothelium also plays a central role in blood vessel inflammation. A healthy endothelium provides a protective coating. When endothelium is damaged, inflammation occurs, leading to atherosclerosis or fatty deposits narrowing the lumen of the blood vessel. Nitric oxide performs functions that protect the endothelium. Nitric oxide is synthesized in endothelial cells, diffusing freely across cell membranes into smooth muscle cells causing them to relax, and assisting blood flow through the vessels. Nitric oxide inhibits blood vessel inflammation.
Consistent or recurrent inability to attain and/or maintain a penile erection sufficient for sexual performance.
Eighteen carbon sex steroids or hormones produced primarily by the ovaries. The three estrogens include estrone, estradiol, and estriol. The most clinically important is estradiol, synthesized from androgens via the enzyme aromatase. Estrogens induce genital and non-genital cells to synthesize specific proteins, such as growth factors and enzymes. These proteins affect genital tissue growth, maintain genital tissue structure, and play a critical role in genital tissue physiology, including engorgement and blood flow changes with sexual stimulation. Estrogen-induced proteins also affect the development, growth, and maintenance of many organs and tissues in women, including the mammary gland, genital tissue, bone, and skin. In many cases, lack of estrogens can be associated with genital atrophy and sexual health problems, such as decreased pelvic blood flow, diminished vaginal lubrication, and thinning of the vaginal wall. See Estrogen Therapy
Systemic (affecting the whole body) or local (directed only to the vagina or vestibule) treatment indicated in women with sexual health concerns that may be related to low estradiol. At menopause, estradiol concentrations in the blood fall to low levels. This decrease is often accompanied by vascular instability (hot flashes and night sweats), a rise in incidence of heart disease, and an increasing rate of bone loss (osteoporosis). There is growing evidence that alterations in the estradiol blood levels may contribute to sexual health problems in menopausal women. Adequate estrogen levels are important to preserving vaginal sexual stimulation receptiveness and preventing dyspareunia.
There is no one estrogen intervention (systemic alone, local alone or a combination of systemic and local) that will be effective in all women with desire, arousal, and orgasm sexual health concerns secondary, in part, to estrogen deficiency states. Systemic or local estradiol treatment has been shown to re-establish vaginal integrity and lubrication in post-menopausal women. Systemic therapy, in particular, increases pelvic blood flow and improves sexual desire, arousal, orgasm, and frequency of sexual activity.
Among the most common estrogen side effects are break-through bleeding or spotting, excessively prolonged periods, breast pain, and breast enlargement. Migraine headaches and sodium and fluid retention have been associated with estrogen therapy. Cigarette smokers are at a higher risk for blood clots, therefore patients requiring estrogen therapy are strongly encouraged not to smoke. Estrogens can promote a buildup of the uterine lining and endometrial hyperplasia, and increase the risk of endometrial carcinoma. The addition of a progestin to estrogen therapy helps prevent endometrial carcinoma. There may be a small increase in risk of breast cancer.
Estrogen Therapy (Local)
Can successfully improve vaginal lubrication, dryness, and dyspareunia. Local estrogen improves perfusion, lubrication, tissue tone, and elasticity, and restores the normal acidic vaginal pH and vaginal health. Local vaginal estradiol also relieves dyspareunia, atrophic vaginitis, and vaginismus. Some systemic absorption occurs with all local estrogen. Studies have shown that local vaginal estradiol treatments can be used with caution in women with breast cancer.
Estrogen Therapy (Systemic)
Can successfully improve hot flushes, night sweats, and sleep disturbances that negatively affect body image, mood, and sexual desire. Women with low levels of estradiol report vaginal dryness, increased frequency, and intensity of dyspareunia, pain with penetration and deep insertion, and burning. The concept of maintaining estradiol values at low levels is to reduce side effect risk while achieving a minimum efficacious dose. Risks of systemic estrogen use include breast cancer, heart attack, and stroke. In women with an intact uterus, systemic estrogen should always be opposed by a progestin.
Food and Drug Administration, a regulatory body for pharmaceutical and device products in the United States.
Female Androgen Insufficiency Syndrome
A pattern of clinical symptoms in the presence of decreased “unbound” or calculated free testosterone and normal estrogen status. The syndrome includes a multitude of symptoms, including decreased sexual interest, decreased energy, tiredness, and depression.
Female Sexual Dysfunction (FSD)
Persistent or recurrent disorder, both psychological and physiological, of desire, arousal, orgasm, and/or pain causing personal distress.
Female Sexual Function Index (FSFI)
A widely used self-report questionnaire that has been extensively validated in numerous clinical trials of women with female sexual arousal disorder, hypoactive sexual desire disorder, sexual pain disorders, and multiple sexual dysfunctions. The FSFI consists of nineteen items that assess women’s sexual feelings and responses in the areas of sexual desire, subjective sexual arousal, lubrication, orgasm, satisfaction with sexual activity, and pain.
A benign growth in the wall of the uterus composed of fibrous and muscle tissue, often associated with painful cramps and excessive menstrual flow.
Free Testosterone Level
The fraction of testosterone that is “unbound.” Free testosterone values can be measured by a blood test called “analog free testosterone,” however this test is not reliable. “Unbound” testosterone can be calculated online using albumin, total testosterone, and sex hormone binding globulin (SHBG) blood values. “Calculated free testosterone” is one of the best ways to determine whether a woman is capable of producing sufficient “unbound” testosterone for her physiologic needs. See Androgen Therapy
The highly sensitive tissues that emanate to the left and right off the lower aspect of the glans clitoris. The right and left frenulae continue to form the right and left labia minora. The frenulae may be among the most sensitive locations of the woman’s genital area.
G-spot (Grafenberg Spot)
A sexually sensitive area in the upper vaginal wall, near the junction of the bladder and the urethra. The G-spot is not a spot but a gland, the female prostate, also called Skene’s gland. Female prostate tissue releases the same fluid containing the same protein, prostate specific antigen, during ejaculation in women as in men.
A sexually transmitted disease caused by the herpes simplex virus affecting the genital and anal regions, associated with painful lesions. Sexually transmitted diseases adversely affect sexual function by decreasing interest and arousal, and by causing pain.
Includes all the structures surrounding the vulva. The anatomy of the surface of the external genitalia differs noticeably among women. In some women, the surface anatomy includes only the mons and labia majora. Unless the labia are parted, the labia minora and clitoris may not be seen.
Includes all the structures of the vestibule, including the clitoris, the prepuce (hood) of the clitoris, the right and left frenulum, the urethral opening (meatus), the labia minora, the major (Bartholin) and minor vestibular glands, the hymen, the vaginal opening, and all the nerves, arteries, and veins to the skin.
Genital Sensation Test
A test in the physician’s office to assess the sensation of the genital skin, especially the clitoris, labia, and urethra. The test can measure skin vibration sensitivity with a device called a BioThesiometer™ or temperature sensitivity with a GenitoSensory Analyzer™. The woman is asked to inform the healthcare professional when she feels or does not feel the stimulus (vibration perception or temperature perception) on the tested area.
Genital Sexual Arousal
The response resulting in increased genital blood flow and relaxation of genital smooth muscle. Genital sexual arousal leads to vaginal lubrication, production of lubricating mucus from the cervix, Bartholin’s and minor vestibular gland lubrication, and engorgement and swelling of the genital tissues, including the labia and corpora spongiosa. During genital sexual arousal there is increased length and width of the clitoris, and increased angle of the shaft and glans clitoris to the vestibule. These physiological events are dependent upon the health of the genital tissues and the function of neural, endocrine, and vascular systems that regulate and coordinate the genital sexual arousal response.
Hood (of the Clitoris)
The fold of tissue (prepuce) that partially or fully covers and protects the unstimulated clitoris. During sexual arousal, the glans clitoris protrudes from the clitoral hood. The hood can undergo atrophy if the woman has hormone insufficiency. The hood can become scarred and not allow the glans to protrude during sexual arousal, called phimosis of the clitoral prepuce. If pain or infection occurs on the glans clitoris because of phimosis (closed compartment syndrome), a surgical procedure, dorsal slit of the clitoral prepuce, can be performed under either local or regional anesthesia. There is no evidence that dorsal slit prepucial surgery improves orgasm in women without pain or infection of the prepuce.
A chemical substance produced in the body’s endocrine glands that exerts a regulatory or stimulatory effect on another distant gland or tissue. Hormones act by stimulating the hormonally sensitive cell to synthesize proteins, such as growth factors and enzymes.
A sudden feeling of heat in the upper part or all of the body, associated with face and neck flushing, and red blotches on the chest, back, and arms. Heavy sweating and cold shivering can follow. Hot flashes can be a light blush or night sweats severe enough to awaken the woman from a sound sleep. They usually last from 30 seconds to 10 minutes. They may be experienced during menopause and for a few years after. Hot flashes are caused by an endocrine imbalance and commonly treated by systemic estradiol. Some women may be successfully treated by systemic androgens, since androgens convert to estrogens by the enzyme aromatase. Other treatments for hot flashes include SSRI’s, although they have many sexual side effects.
A thin and incomplete membrane of connective tissue at the junction of the vestibule and the vagina that varies widely in appearance. The hymen represents the junction of the inner vagina with the outer vagina. The hymen may or may not rupture with sexual activity or may rupture in certain physical activities unrelated to sexual activity. After hymenal rupture, the hymen becomes small round fleshy tissue outgrowths just on the inside of the vaginal opening. Regular use of tampons, regular sexual intercourse or injury from childbirth will reduce the hymen to a series of irregular tissue thickenings around the vaginal opening.
Hypoactive Sexual Desire Disorder (HSDD)
Persistent or recurrent deficiency and/or absence of sexual fantasies/thoughts, and/or desire for, or receptivity to, sexual activity that causes personal distress.
Having a physiologic “unbound” testosterone concentration below the normal range for healthy women. Values of “unbound” testosterone in the lowest quarter of the normal range are also considered suspicious for hypogonadism in a woman with sexual dysfunction. This is because the ”normal” range often includes women with sexual dysfunction who are otherwise considered healthy.
Surgical removal of a woman’s uterus. In many cases of hysterectomy, concomitant bilateral removal of the ovaries is performed. The combined removal of the uterus and ovaries is called a complete hysterectomy and results in surgical menopause. In surgical menopause there is an abrupt change in estradiol values, whereas in natural menopause the estradiol values gradually are diminished. After hysterectomy, women are often unable to achieve internal orgasm of the same quality as prior to surgery.
Removal of fibroid tumors through the cervix using an instrument called a resectoscope.This is a surgical device with a built in wire loop that uses high-frequency electrical energy to cut or coagulate the fibroid tissue.The resectoscope was developed to allow surgery inside an organ without having to make an incision. Removal of fibroid tumors on or near the lining of the uterus by hystoscopic myomectomy allows the fibroids to be removed and the uterus to be spared.
Interstitial Cystitis (IC)
Interstitial Cystitis (IC): A condition of recurring discomfort or pain in the bladder and the surrounding pelvic region. Symptoms such as mild discomfort, pressure, and tenderness vary widely in individuals. Some may experience intense pain in the bladder and pelvic area including an urgent need to urinate (urgency), a frequent need to urinate (frequency), or a combination of these symptoms. Pain may change in intensity as the bladder fills with urine or as it empties. Women's symptoms often get worse during menstruation. The most common sexual dysfunction associated with IC is pain with vaginal intercourse.
The commonly used name for pelvic floor exercise of muscles that are attached from the coccyx bone at the bottom of the spinal column to the pubic bone at the front of the pelvis. These muscles act like a hammock supporting the pelvic organs, including the vagina, uterus, and bladder. The pelvic floor muscles used in Kegel exercises can be identified by the stop and start of the flow of urine. Once the muscles have been located, the woman can strengthen them by contracting and relaxing them according to her ability. Performing Kegel exercises provides many benefits, including increase in sexual enjoyment of both partners, and help in preventing prolapse of pelvic organs and urine leakage during sneezing or coughing. There are many variations on Kegel exercises. A gynecologist or pelvic floor physical therapist can determine which exercises are appropriate and whether or not they are being performed properly. See Physical Therapy Section
The two prominent lateral boundaries of the vulva. Each labium has an external surface that is pigmented, hairy, and slightly wrinkled in the non-aroused state. The internal surface is smooth and has multiple large glands that release sebum. At the lower most portion, the labia majora meet together in front of the anus. The labia majora serve to protect the vestibule.
Two prominent lateral boundaries of the vestibule. The labia minora are composed of flexible, elastic skin, rich in glands that release sebum. The labia minora have many nerves, making them very sensitive to the touch. On the top, the labia minora help form the hood of the clitoral prepuce. At the bottom of the glans clitoris, the labia minora help form the clitoral frenulae. The labia minora continue to surround the sides of the vaginal opening. They commonly undergo atrophy if the estrogen and androgen hormones are low.
Laparoscopic Examination (Laparoscopy)
A direct visualization of the peritoneal cavity, ovaries, fallopian tubes, and uterus by laparoscope. The laparoscope is a miniature telescope with a fiber optic system that brings light into the abdomen. Carbon dioxide gas is administered into the abdomen through a special needle that is inserted just below the umbilicus. This gas helps to separate the organs inside the abdominal cavity, making it possible for the physician to manipulate the reproductive organs.
Sexual desire or interest for sexual activity. The opposite of hypoactive sexual desire disorder, sexual desire would therefore be the presence of, desire for, receptivity to and/or thoughts or fantasies about sexual activity. Desire is a “psychological” sexual interest in which individuals “want” or “crave” sexual activity.
The time of a woman’s last menstrual period, when levels of estrogen and progesterone stop being produced by the ovaries. Symptoms can begin during peri-menopause, several years before menopause. Such symptoms include: changes in menstrual periods; hot flashes; night sweats; difficulty sleeping; early waking; moodiness; irritability; depression; thinning of the skin; enlarging waist line; loss of muscle; memory problems; and stiff and achy joints. Menopause lasts for one year after the last menses. Post-menopause follows menopause and lasts the rest of a woman’s life. Menopause can happen any time after the age of thirty, but the average age is fifty-one. Smoking leads to earlier menopause. Surgical removal of both ovaries causes menopausal symptoms to begin immediately.
The genital sexual health concerns of menopause are related primarily to problems with the vagina and bladder. Changing estrogen levels can cause the genital area to get dry and thin, leading to uncomfortable sexual intercourse, vaginal or urinary infections, urgency to void, and stress incontinence during exercise, sneezing, coughing, laughing, or running.
Minor Vestibular Glands
The tubular glandular structures occurring around the vaginal opening. Typically there are 2–10 minor vestibular glands, but they vary in number from 1 to more than 30. Minor vestibular glands release mucous into the vestibule during sexual activity. Inflammation, irritation, and infection of the minor vestibular glands are associated with vulvar vestibulitis syndrome.
Forms the upper boundary of the vulva with the labia majora on both sides. The mons pubis is a prominent cushion of hair-bearing skin and subcutaneous fat overlying the pubic bone.
Use of a government-approved prescription drug to treat a condition for which the drug has not yet been approved by the government regulatory agency. An example is use of androgen gel for treatment of sexual dysfunction in women. In off-label drug use, it is important that the treating physician provide the patient with appropriate information concerning risks and benefits prior to starting drug therapy, so that the patient can make an informed decision whether or not to start the treatment.
Surgical removal of the ovaries. Common indications include ovarian involvement with endometriosis, cancers, and cysts.
A pleasurable feeling (a cerebral event) usually associated with emission and/or ejaculation
A variable, short-lived feeling of forceful and powerful pleasure that peaks with intensity. Orgasm follows repeated sexual stimulation and is initiated after accumulation of sufficient neurotransmitter in the thalamus. Orgasm is usually accompanied by rhythmic contractions of the pelvic floor musculature, especially the fibers surrounding the vagina. Orgasm is generated in association with a changed state of consciousness and is associated usually with the onset of wellbeing and contentment. Women may experience two kinds of orgasm, internal (deep stimulation-related) and external (clitoral-related). Orgasm may also be induced by stimulation of the peri-urethral glans, breast/nipple, mons, mental-imagery, fantasy or hypnosis.
Orgasm (External or Clitoral-related)
Induced by erotic stimulation of the clitoris.
Orgasm (Internal or Deep stimulation-related)
Deep penetration stimulating the vagina, cervix or G-sport resulting in an intense orgasm associated with uterine contraction. Internal orgasms are usually more intense than clitoral-based orgasms.
Persistent or recurrent difficulty, delay in or absence of attaining orgasm, following sufficient sexual stimulation and arousal, that causes personal distress.
An oral medication, such as Viagra, that inhibits the PDE5 enzyme in genital tissues. In a woman with normal hormone values, genital tissue changes include enhanced genital tissue smooth muscle relaxation, accumulation of blood, and engorgement. In the presence of sexual stimulation, a PDE5 inhibitor medication would facilitate the genital tissue arousal response.
Pelvic Floor Muscles
A group of muscles spanning the underlying surface of the bony pelvis. These muscles originate at the pubis just above the genitals and extend back to the coccyx or "tailbone," forming the floor of the pelvis. Weakness of the pelvic floor muscles can lead to both urinary and fecal incontinence and sexual health problems. Excessive pelvic floor muscle tone may adversely affect defecation, voiding, and sexual health, especially sexual pain.
The time leading up to menopause. Many different symptoms of variable intensity occur during peri-menopause, including altered menstrual periods, new onset hot flashes, and night sweats. Other symptoms include sleep disturbances, moodiness, irritability, depression, poor concentration and memory problems, dermatologic issues such as skin thinning, and muscular issues, including weakness and diminished strength. During peri-menopause, the blood levels of estradiol and progesterone fall. In many women, the fall in progesterone is faster, so that during peri-menopause there is often a relative estradiol-rich and progesterone-poor state.
Persistent Genital Arousal Disorder (PGAD)
A sub-classification of female sexual arousal disorder, defined as feelings of spontaneous, persistent, and intense arousal with or without orgasm, with or without genital engorgement, in the absence of sexual desire. PGAD is an uncommon sexual health problem that can significantly interfere with a woman's overall quality of life. The spontaneous, intrusive, and unwanted genital arousal and sexual tension (e.g. tingling, throbbing, pulsating) lead some PGAD victims to become humiliated, confused, isolated, frustrated, self-conscious, and shamed. There are no recognized safe and effective treatments that cure PGAD, leading some victims to consider suicide.
Persistent Sexual Arousal Syndrome (PSAS)
Current nomenclature is PGAD, emphasizing the genital arousal. Most women with this disorder are not sexually aroused. See Persistent Genital Arousal Disorder
Involves the scarring of a region of the tunica of the erection chambers and the formation of a hard, nodular plaque which is most commonly on the top part of the penis just under the skin. Peyronie's Disease may result in a bending of the erection toward the scarred, fibrous plaque. It may also result in painful intercourse (either from the erection itself or the pain felt by the partner), and erectile dysfunction.
A condition in which the clitoral hood or prepuce cannot be retracted to expose the underlying glans clitoris. Since the area under the hood cannot be exposed, an infection may occur in this closed compartment. When medical management cannot resolve infection, dorsal slit surgery can be performed under local or regional anesthesia to remove a portion of the prepuce, thus opening the closed compartment.
Premature Ejaculation (PE)
Persistent or recurrent occurrence of ejaculation with minimal sexual stimulation before, on or shortly after penetration and before the person wishes it (also called early ejaculation or rapid ejaculation).
An involuntary, non-physiologic, usually painful prolonged erection that does not result from sexual desire. The corpus spongiosum and glands are not effected, it is not relieve by ejaculation, and my ironically result in permanent erectile dysfunction.
Twenty-one carbon sex steroids or hormones, produced primarily by the ovaries and adrenal glands. Progesterone is critical during the reproductive years, as it has a direct effect on the uterus and is a prerequisite for normal menstrual cycling and achieving pregnancy. The action of progesterone in sexual activity is primarily central. In the hypothalamus, progesterone appears to regulate mood and sexual behavior. Progesterone does not appear to have any appreciable effect on genital tissue structure and function, nor does not it have any appreciable conversion to either androgen or estrogen. If systemic estradiol therapy is used in a menopausal woman who still has her uterus, progesterone is required as an anti-estrogen to prevent endometrial thickening, bleeding, and endometrial cancer. See Estrogen Therapy
Use of a cotton swab as part of the physical examination to assess the health of the vestibule in a woman with sexual health concerns. The examiner gently presses the swab at multiple locations around the labial-hymenal junction to assess for tenderness of the minor vestibular glands. Women who have significant discomfort during Q-tip testing may be considered to have vulvar vestibulitis syndrome. See Vulvodynia
Backward passage of semen into the bladder after emission, usually due to failure of closure of the bladder neck mechanism, demonstrated by presence of spematozoa in the urine.
Sexual Arousal Disorder
The persistent or recurrent inability to attain or maintain sufficient sexual excitement that causes personal distress. Women with sexual arousal disorder may have sexual complaints of diminished vaginal lubrication, increased time for arousal, diminished vaginal and clitoral sensation, and difficulty with orgasm. These clinical conditions may exist, in part, due to disruptions in the normal vascular, neural, and/or endocrine regulatory mechanisms, with associated changes in genital tissue structure or cellular organization. Chronic disease states, such as hypertension, atherosclerosis, diabetes, physical trauma, endocrine imbalances or medications, that adversely affect genital blood flow or sensation will contribute to genital arousal dysfunction.
Proteinaceous secretions (usually white-yellow in color) from the skin sebaceous glands. Sebum production is usually under the control of androgens. Sebum can accumulate in a closed compartment, such as under a clitoral hood that cannot be retracted to expose the underlying glans clitoris (phimosis).
Selective Serotonin Reuptake Inhibitor (SSRI)
Increases central levels of the neurotransmitter serotonin, a central sexual inhibitory neurotransmitter. SSRI’s (e.g. Prozac) are commonly prescribed for the safe and effective treatment of depression. Further, SSRI users have lowered testosterone levels and reduced dopamine, a central sexual excitatory neurotransmitter. The sexual side effects of SSRI’s are significant, including lowered sexual interest and arousal, and delayed, reduced or absent orgasm. The sexual side effects may occur in 15% to 70% of SSRI users.
Sexual Aversion Disorder
Persistent or recurrent phobic aversion to and avoidance of sexual contact with a sexual partner that causes personal distress. Aversion may be a more significant reaction in some women with low sexual interest
Sex Hormone Binding Globulin (SHBG)
Protein in the circulation that binds sex steroids, especially testosterone. The physiologic action of SHBG is to store sex steroids in the blood. Only the “unbound” fraction of testosterone is physiologically active and enters the cells to elicit the biological response. Increases in SHBG, often as a result of increases in estrogen or birth control pill use, contribute to androgen insufficiency syndrome and sexual health concerns in women. See Androgen Therapy
Sexual Pain Disorders
Include dyspareunia, non-coital sexual pain, vaginismus, and vulvodynia
Skene’s Glands or Female Prostate
Empties through ejaculatory duct openings that often exit on either side of the urethral meatus but can exit in varying locations, including the urethra and between the labia and hymenal tissue. Skene’s glands express fluid during orgasm, different from urine, which contains prostate specific antigen and prostate specific acid phosphatase
Statins are drugs that reduce the liver's production of cholesterol. Statins significantly reduce the level of LDL, or "bad" cholesterol, in the blood by increasing the ability of the liver to remove LDL from the blood. Statins also have a moderate ability to reduce triglyceride levels and increase levels of HDL, or "good" cholesterol. Statins have proven to be very effective in reducing the risk of heart attack and death, and can lower the blood measure of blood vessel inflammation, the C-reactive protein.
Administration of a mixture of steroids and anesthetic agents to help women with pain secondary to nerve damage, such as pudendal neuropathy. The mixture is injected near the tender nerve region. See Vulvodynia
Steroid Cream (Ultra-potent)
A topical treatment for itching, redness, dryness, inflammation, and discomfort of vulvar skin conditions, including lichen sclerosus, lichen planus, lichen simplex chronicus or contact dermatitis. Women who have dermatologic vulvar conditions that are treated effectively with an ultra-potent steroid cream (e.g. Clobetasol) require long-term clinical follow-up. See Vulvodynia
One of the nineteen carbon sex steroid androgens used in androgen therapy. The effects of testosterone (transdermal, topical gel or patch) on the sexual function of women have been evaluated in placebo-controlled, randomized, clinical trials. Transdermal testosterone has been reported to significantly improve sexual motivation, thoughts and fantasies of sexual activity, frequency of sexual activity, pleasure, orgasm, and satisfaction. In addition to the positive effects on sexual function, testosterone significantly improved patient wellbeing. Side effects at the dose used clinically include acne and hair growth. See Androgen Therapy
Records the combined portions of testosterone that are “unbound,” tightly bound to the protein SHBG, and loosely bound to the protein albumin. Total testosterone levels are not clinically useful in women who have elevated sex hormone binding globulin levels, such as birth control pill users, since the majority of the total testosterone will be “bound” and not physiologically available. See Androgen Therapy
Urethral Meatus (Peri-Urethral Glans):
The opening through which urine is expelled. It is located approximately 1 inch below the clitoral glans and above the vaginal opening in the midline of the vestibule. The appearance varies from a small vertical slit, to a crescent form, to a round opening. The tissue surrounding the urethral meatus is rich in sensory skin receptors, especially stretch receptors, and is an important sexual organ in women.
Fibromuscular tube that begins at the vaginal opening below the urethral meatus. The vagina terminates where the uterine cervix projects into the inner end of the tube, forming a circular recessed space. The vaginal upper wall covers the female prostate and urethra, and is thought to be particularly sensitive during sexual activity. The vaginal lower wall covers the rectum. The vaginal tube consists of a folded, smooth lining layer called the epithelium. Underneath is a blood vessel filled layer that is the source of vaginal lubrication. Underneath the blood vessel layer is the muscle layer that consists of an inner layer of circular-oriented muscle and outer thicker layer of longitudinal oriented muscle. During sexual intercourse, the vagina envelops the erect penis. The vaginal walls can constrict and dilate due to the presence of smooth muscles and fibroelastic tissue.
Vaginal Estrogen (Local Estradiol)
Essential for maintaining normal physiologic vaginal sexual functions. After menopause, with the ovarian synthesis of estradiol terminated, local estradiol administration can help relieve symptoms of vaginal irritation and dryness, and urinary tract irritation that occurs in some women. The symptoms of low levels of estrogen in the vagina are known as atrophic vaginitis. Some local estrogen delivery systems do not transfer any significant amount into the rest of the woman’s body. See Estrogen Therapy
A consequence of increased vaginal blood flow during sexual arousal. The vaginal fluid is plasma that “leaks” out of the capillaries in the vaginal lamina propria layer and passes to the epithelial inner lining layer. The lubrication fluid accumulating on the vaginal surface is clear, slippery and smooth, and acts to moisten the vagina.
A painful and often prolonged contraction of the vagina in response to the vulva or vagina being touched.
Inflammation of the vagina. Vaginitis is usually a consequence of the vaginal pH not being acidic. The acidic vaginal pH acts to control the overgrowth of vaginal organisms such as bacteria and yeast.
Diminished arterial inflow. It can be diminished vaginal and clitoral blood flow causing fibrosis and decreased smooth muscle of clitoral and vaginal tissues and can result in sexual arousal disorder.
See Vulvar Vestibulitis Syndrome
Tubular glands that line the vaginal opening that release mucous lubrication during sexual stimulation. There are approximately ten to twenty minor vestibular glands. There are two major vestibular glands, the right and left Bartholin’s glands. Pathology in the minor vestibular glands may lead to vestibular adenitis or vulvar vestibulitis syndrome. Pathology in the major vestibular glands may lead to Bartholin’s cysts.
The area between the labia minora. The vestibule is the outer one fifth of the vagina. The vestibule contains many sexual organs including the glans clitoris, the prepuce or clitoral hood, the right and left frenulae, the labia minora, the urethral meatus and peri-urethral glans, the minor vestibular glands, the duct openings from the major vestibular glands, the outside of the hymenal tissues, and nerves and arteries of the skin of the vestibule.
Surgical excision of a portion or the total vestibule, usually due to vulvar vestibulitis syndrome.
Comprised of the mons pubis, labia majora, and vestibule.
Denotes generalized and chronic pain (more than three to six months) of varying intensity and location in the vulvar region for which the cause is not understood. The pain from vulvodynia may be due to unknown genetic, psychologic, inflammatory, infectious, neurologic, pelvic floor disorder or hormonal factors. Elevated levels of psychologic distress, anxiety, depression, shyness, as well as low sexual self-esteem, have also been found in women with vulvodynia. Treatment of vulvodynia engages multiple specialists and various therapies including sex therapy, physical therapy, pain management, medical therapy, hormone therapy, and as a last resort, surgical therapy. One subset of vulvodynia, VVS, is where the pain appears localized to the vestibule but the exact cause of the vulvar pain is not known. Another subset of vulvodynia is where the cause of the vulvar pain is defined. In such cases, treatment involves management of the underlying cause. Cases where a specific cause is known may include dermatologic conditions, damage to sensory nerves during surgery, or damage to the pudendal nerve from sports trauma, childbirth or vaginal surgery. See Vulvodynia
Vulvar Vestibulitis Syndrome (VVS)
The most common pain syndrome in pre-menopausal women, also known as vestibular adenitis. Women with vulvar vestibulitis syndrome typically experience a severe burning pain of varying intensity in response to contact during both sexual and non-sexual activities. The distinguishing feature of VVS is that the pain occurs at a specific location, that is, at the entrance of the vagina just above the hymenal tissue and at the beginning of the labia minora. Often the pain is also on the sides of the urethral meatus. The classic description of VVS involves redness of the vulvar vestibule, especially with small red spots and pain with intercourse or tampon insertion. Positive Q-tip testing during physical examination is a hallmark. One of the most consistently reported findings associated with the onset of vulvar vestibulitis is a history of repeated yeast infections. Women with VVS exhibit an increase in pelvic floor muscle tension. Hormonal factors are also associated with VVS. See Vulvodynia
Typically caused by a fungus called Candida albicans. Symptoms include itching and burning in the vagina and around the vulva, a white vaginal discharge that may look like cottage cheese, pain during sexual intercourse, and swelling of the vulva. Yeast infections are so common that seventy-five percent of women will have one at some time in their lives. Half of all women have more than one infection in their lives. Yeast are tiny organisms that normally live in small numbers on the skin and inside the vagina. The acidic environment of the vagina helps keep yeast from growing. If the vagina becomes less acidic, too many yeast can grow and cause a vaginal infection. Your period, pregnancy, diabetes, some antibiotics, birth control pills, and steroids can change the acidic balance of the vagina. Moisture and irritation of the vagina also seem to encourage yeast to grow. Yeast infections are usually treated with intravaginal creams, ointments or suppositories or by systemic pills that contain medications directed against the yeast fungus.