Femal sexuality and female sexual dysfunction koc univ.

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Femal sexuality and female sexual dysfunction koc univ.

  1. 1. Female Sexuality and Female Psychosexual Dysfunction Dr Süleyman E. Akhan Istanbul University School of Medicine Department of Obstetrics and Gynecology
  2. 2. Sexuality is a multi- dimensional concept with ethical, psychological, biological and cultural dimensions. Sexuality reflects human character and the way in which people interact.
  3. 3. Sexuality is the lifelong process of acquiring information and developing values about one’s identity, relationships and intimacy. It includes learning sexual development, reproductive health, interpersonal relationships, affection, body image, and gender roles.
  4. 4. genotype  The main organ that affects male and female sexual response is the BRAIN. learning process pre-and postnatal hormonal environment experience
  5. 5. Estradiol aromatization Sex Steroids Testosterone ER-b Progesterone PR isoforms DHTAR Genomic & Non-Genomic Mechanism P metabolites Gaba Res. ER-a Neurotransmitter Neuropeptide Neuromodulator Growth Factors Cytokines Other factors.... Psychosocial Factors Experience Partner Sexual attitude of partner Sexual Behavior
  6. 6. The perception of sexuality is different for each individual. Is unique. The main factors affecting this individuality is how we spend our adolescence and form our relationship with the opposite sex.
  7. 7. Activated Areas During “Sexual Arousal” Medial insula Anterior cingulate cortex Hippocampus Striatum Nucleus accumbens Hypothalamus Concentration of dopamine is high in all these areas.
  8. 8. Inactivated Areas During “Sexual Arousal” Amygdala Frontal cortex Prefrontal cortex Temporal pole Prefrontal cortex is responsible for control mechanism. Amygdala acts like our emotional memory. Our fears, emotional moments, events that cause our worry are all evaluated and stored.
  9. 9. Sexually Sensitive Areas Clitoris Vagina Nipples (areola) Breasts Labium
  10. 10. Sexual Response Cycle of the Woman  Sexual response cycle of woman consists of 5 phases: 1. Sexual desire phase: Can last for days. Fantasies, dreams about the sexual object. 2. Arousal phase: Can last from 1-2 minutes to hours. 3. Plato phase: Between 30 seconds to 3 minutes. 4. Orgasm phase: 3-15 seconds 5. Relaxation phase: 10-15 minutes  In this cycle, there are two basic physiologic processes: Vasocongestion Neuromuscular tension– Myotonia  Vasocongestion takes place in lower and upper genital organs and breasts, while myotonia takes place in the whole body.
  11. 11. Sexual Desire Phase Motivation to be sexual Subjectivity (Experience) Adequate neuroendocrine function Sexual orientation Choice Psychological status Environmental factors
  12. 12. Arousal Phase  Can last from 1-2 minutes to hours. As a result of parasympathetic stimulation. Changes in organs that take place during arousal phase:  Nipples: Harden. Length can go up to 1cm. In addition, breast volume increases due to congestion.  Clitoris: Length of clitoris increase with venous congestion.  Labium majus: Labium majus moves upward and opens outward with erection.  Labium minus: Increase in size 2-3 times both in nullipara and multipara. Finally, vagina goes out of vault, passes labium majus by 1cm and becomes visible. In nullipara, its color is bright pink, while its color is dark red in multipara.
  13. 13. Vagina:  When there is an effective sexual stimulation, there is a light colored vaginal secretion 10-20 seconds after the initiation of the stimulation.  The stimulation can by physical or psychological. Secretion is in transuda form. When venous plexus that surrounds vagina fills up with venous congestion and dilated, capillary permeability increases. Then, droplets are formed in vagina and vaginal secretion is released.  Secretion has two purposes: 1. Providing vaginal lubrication 2. Neutralizing vaginal acidity.  Another important change is the increase of length up to 3 cm in vagina.
  14. 14. Plato Phase  Lasts around 30 seconds to 30 minutes. In 75% of women, there will be red spots, known as sexual flash, on the breasts and the skin. In reality, these spots start in the late section of the arousal phase and continue in the plate phase.  It is argued that the red areas are correlated to the intensity of the sexual arousal.  Breasts are tense and increase in size.  Clitoris becomes erect and only mechanical stimulus can be enough to reach orgasm.  Uterus re-locates in this phase. It is lengthened to the vagina.  Near the end of this phase, uterus starts to contract.
  15. 15. Orgasm Phase  Orgasm can be described as the conclusion of the vasocongestion, release of the collected blood and following stage of myotonia.  It is the shortest phase of all phases. It can only be reached when there is maximum sexual tension.  Uncontrolled muscle contractions happen every 0.8 seconds. 3-15 contractions can happen. During this phase, uterus also contracts.
  16. 16. Relaxation Phase Last phase of the sexual response. It is the phase with the most varying length. If orgasm is reached, it can last up to 15 minutes. If orgasm is not reached, it can last up to 1 day. Clitoris can turn into normal shape in 10-15 seconds. It will take 15 minutes to turn back to totally normal function. If orgasm is not reached, this period can go up to 6 hours.
  17. 17. Sexual Response Cycle of the Woman 1. Sexual desire phase: Can last for days. Fantasies, dreams about the sexual object. 2. Arousal phase: Can last from 1-2 minutes to hours. 3. Plato phase: Between 30 seconds to 3 minutes. 4. Orgaxm phase: 3-15 seconds. 5. Relaxationp phase: 10-15 minutes. ParasimpaticSimpatic
  18. 18. Biopsychosocial Approch to Female Sexual Function Cycle Basson R. Obstet Gynecol 2001;98:350–353 Emotional and physical satisfaction Arousal and sexual desire Sexual arousal Emotional intimacy Sexual stimuli + + motivates the sexually neutral woman to find/be responsive to psychological and biological factors govern “arousal” “Spontaneous” sexual drive “hunger”
  19. 19. Hormones that Influence Female Sexuailty 1. Estrogen  Sexual Identity: Secondary sexual characteristics  Functional Influence: a. Sexual desire: indirect influence (direct influence??) b. Arousal: Vasocongestion, vasodilation, lubrication c. Orgasm: Matures the orgasmic platform.  Influence on the Relation: Builds up woman’s unique scent (??)
  20. 20. 5. Androgens  Basic hormones that have central influence and triggers sexual desire and central arousal.  Modulate peripheral arousal.  Influence secretion of NO.  Increase clitoral arousal.  Increase “life energy”. Induce self-esteem.  Influence pheromone (??).
  21. 21. Sexual Desire Arousal, Desire for arousal Orgasm Experience- Satisfaction Systemic Androgens Systemic Estrogens Graziottin A. 2005 Basic Flow Diagram of Female Sexual Oritentation
  22. 22. Oxytocin Vasopressin Known as coupling and love hormones Oxytocin and V1a type vasopressin receptors are located at dopaminergic areas that are activated during romantic love. Oxyitocin; anxiolytic. Named as the trust hormone. Increases in the beginning of romantic love. Vasopressin increases response to fear and stress. Induces man’s claiming urge.
  23. 23. Oxytocin - Vasopressin Field Rat Monogamous One partner lifelong More oxytocin receptors at prelimbic cortex, nucleus accumbens and amigdaloid complex Mountain Rat Polygamous  Randomized partner selection Less vasopression receptors (V1a) at lateral amigdala, ventral pallidum Vazopressin reseptörleri Vasopressin V1a receptor Lim 2004
  24. 24. Oxytocin - Vasopressin Oxytocin Vasopressin Oxytocin Vasopressin
  25. 25. Dopamine  D1 receptors are important after coupling Increase in number Avoids new coupling Beninger & Miller, 1998; Edwards & Self, 2006 Dopamine antagonist
  26. 26. When we live so synthetically in the modern world, can sexuality and love be manipulated with hormones? Should we? Shouldn’t we?
  27. 27. Female Sexual Dysfunction Organic • Neurological problems • Cardiovascular diseases • Cancer, gynecological cancers • Urogynecologic pathologies • Drugs • Hormonal disorders Psychological • Depression/anxiety History of sexual and/or physical assault • Stress • Alcohol and/or drug addictions. Sociocultural Factors • Inadequate education • Conflict with religious, personal, family values Social taboos Relationship Level • Performance of the partner • Loss of the partner • Quality of the relation • Loss of specialness
  28. 28. Reasons for Female Sexual Dysfunction  Female sexual dysfunction can be temporary, episodic or continuous  Can resolve by itself or need treatment  Reasons are evaluated in 2 headings. I- Psychosocial Factors  Mental inhibition, education that refused sexuality during growing-up: pleasure regarded as a sin ethically.  Past psychosexual trauma.  Fears: unwanted pregnancy, somebody finding out about the cohabitation, pain during coitus  Problems with the partner: Not desiring intimacy with the partner, relations that are falling apart.
  29. 29. II – Organic Problems Gynecologic and Systemic Diseases:  Vulvitis, kolpitis, atrophy, vaginal stenosis  Endometriosis, intra-abdominal adhesions  Gynecologic surgeries, specially radical surgeries  Systemic disease: Malignant tumors, diabetes, stress related exhaustion, depression, multiple sclerosis  Drugs: Contraceptives, tricyclic antidepressant, MAO inhibitors, antihypertensive drugs
  30. 30. Sup. Hipogastrik pleksus (sempatik innervasyon) İnf. Hipogastrik pleksus (parasempatik innervasyon)
  31. 31. Radical Hysterectomy Oophorectomy Pelvic Radiotherapy Chemotherapy Vulvectomy  Damage to the innervation of the pelvic floor musculature  Shortness of the vagina  Decreased lubrication  Dyspareunia  Decrease in desire???  Decreased lubrication  Dyspareunia  Fibrosis and stenosis  Tiredness Nausea, vomiting Depression  Anatomic anomalies
  32. 32. Female Sexual Dysfunction 1999 Consensus Classification System (The Journal of Urology. Basson R. 2000)  Sexual Desire Disorders Decreased Sexual Desire (hypoactive) Sexual Aversion Disorder  Sexual Arousal Disorder  Orgasm Related Disorders  Sexual Pain Disorders Dyspareunia Vaginismus Other sexual pain disorders
  33. 33. What should we do to identify the problem? High sexual orientation High motivation Normal sexual desire and motivation High sexual orientation Low motivation Question the quality of the sexual intercourse and the relation with the partner Low sexual orientation High motivation Evalute the hormone profile Primarily the androgens and PRL Low sexual orientation Low motivation Which one comes first? Question depression, biochemical environment and the quality of the relationship Derogatis 2002
  34. 34. Female Sexual Dysfunction 1999 Consensus Classification System (The Journal of Urology. Basson R. 2000)  Sexual Desire Disorders Decreased Sexual Desire (hypoactive) Sexual Aversion Disorder  Sexual Arousal Disorder  Orgasm Related Disorders  Sexual Pain Disorders Dyspareunia Vaginismus Other sexual pain disorders
  35. 35. Female Sexual Dysfunction 1999 Consensus Classification System (The Journal of Urology. Basson R. 2000)  Sexual Desire Disorders  Decreased Sexual Desire (hypoactive)  Sexual Aversion Disorder  Sexual Arousal Disorder  Orgasm Related Disorders  Sexual Pain Disorder  Dyspareunia  Vaginismus  Other sexual pain disorders Subjective Genital
  36. 36. The Factors Affecting Female Sexual Function and the Relation with Different Contraception Methods Süleyman Engin Akhan, Ümran Oskay, Ebru Alıcı, Funda Güngör, Samet Topuz, Cem İyibozkurt, Önay Yalçın Department of Obstetrics and Gynecology, Istanbul University School of Medicine, Istanbul
  37. 37. Results  Totally 349 cases were taken into consideration.  They were 32,59±7.04 old on average and the number of weekly intercourse were 2,36±1,34 on average. 6.6% (23/349) were single.  While 39.8% of women used coitus interruptus as a contraception method,  21.5% used IUD,  16.3% preferred condom,  10% used oral contraceptive,  5.2% preferred tubal ligation  7.2% used none of the methods.
  38. 38. 24.6% of them were masturbating in different frequencies, 5% were performing anal sex and 26.1% were performing oral sex. 36.7% were complaining of dyspareunia. Sexual dysfunction was identified in 24.4% of the partners.
  39. 39. It is interesting that women performing oral sex was an independent factor which had a positive effect on arousal (p=0.02; RR=0.54; [95%CI: 0.32-0.909]), orgasm (p=0.0045; RR=0.48; [95%CI:0.29-0.8]) and total score (p=0.016; RR=0.505; [95%CI:0.28-0.88]). Woman performing oral sex, can be a sign of woman being capable of sexuality (motivated sexually or having a good sexual drive) and have a healthy relationship with her partner on a sexual level. So, the arousal and orgasm scores of women performing oral sex are affected positively.
  40. 40. Number of sexual intercourse showed negative correlation with age (-0.151; p=0.005) and the number of deliveries (-0.140; p=0.009). As the number of deliveries increases, the number of sexual intercourse decreases and the domains of desire, arousal and satisfaction were influenced negatively. Desire Arousa l Lubrication Orgasm Satisfaction Pain Total Score Age Pearson coeff. p - 0,91 0,0001 - 0,125 0,02 - 0,018 0,027 - 0,106 0,047 - 0,204 0,0001 - 0,94 0,078 - 0,138 0,01 Partus Pearson coeff. p - 0,147 0,006 - 0,109 0,042 - 0,077 0,154 - 0,061 0,253 - 0,145 0,007 0,94 0,81 - 0,092 0,085 Education Pearson coeff. p - 0,68 0,208 0,41 0,443 0,069 0,201 0,033 0,538 0,023 0,666 0,094 0,081 - 0,092 0,085 Number of coitus /week Pearson coeff. p 0,181 0,001 0,189 0,0001 0,171 0,001 0,17 0,001 0,186 0,0001 0,012 0,828 0,203 0,0001
  41. 41. Factors that directly affect female sexuality Age Physical and Emotional Health Education Quality of the relationship with the partner Sexual Performance of the Partner Hormonal Status

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