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Sexual Dysfunction

Sexual dysfunction is a broad term which simply describe the overall or specific, sexually related problems which include, feelings of no sexual interest or desire, problems of arousal including reaching orgasm and genital pain associated with sexual activity. Also, the term covers genitalia defects such as vagina muscle tightness (involuntary) and persistence of non stimulated sexual arousal.


Presentation

Although, the manifestation of SD may vary, however, sexual problems are better defined when there are specific elicited signs or symptoms because many affected women may broadly describe the dysfunction to reduced libido or general dissatisfaction. Some women however are more specific, complaining of symptoms such as pain during sexual arousal or intercourse, anorgasmia (coughlan's syndrome), retarded orgasm, and reduced sexual arousal. Reduced vaginal lubrication may be common among postmenopausal women due to estrogen shortage and vaginal atrophy.Therefore, careful assessment including physical examination is important to identify the specific problem. 

Body examination may be done including the reproductive organ in order to evaluate or localize pain associated with vaginal penetration and overall sexual activity  [27]. Clinical examination of external genitalia to asses the skin color, texture, including the thickness is necessary. Also, features such as skin turgor, distribution and strands number of the pubic hair assist diagnosis. Internal mucosa and anatomy should then be examined and cultures taken if indicated. Specific vaginal structure such as muscle tone, incision site of episiotomy, tissue atrophy, as well as vaginal discharge. Bi-manual examination with the use of speculum for female patient with vaginismus (vaginism) and severe form of dyspareunia may be painful however, mono-manual evaluation using fingers could be better [26]. These techniques are also good in assessing the position or size of  uterus, cervical motion tenderness (CMT), vaginism and diagnosing rectal disease. Also, other conditions such as, vaginal internal muscle tone, depth, and size or position of the both ovarian and adnexal mass.

Medication Noncompliance
  • Sexual dysfunction is a key adverse effect leading to medication noncompliance. Psychotropic drugs associated with sexual dysfunction include antiepileptic drugs, antidepressants, and antipsychotics.[ncbi.nlm.nih.gov]
Inguinal Hernia
  • METHODS: This study was part of the randomized ONLI trial ( NCT01753219 , Onstep versus Lichtenstein for inguinal hernia repair).[ncbi.nlm.nih.gov]
Galactorrhea
  • One patient developed galactorrhea. These adverse effects were reversed by bromocriptine. The pathophysiology of cocaine abuse and the central dopaminergic influence on sexual function are discussed.[ncbi.nlm.nih.gov]
Hypotension
  • All PDE5 inhibitors should be administered cautiously and at lower initial dosages to patients receiving alpha-blockers (eg, prazosin, terazosin, doxazosin, tamsulosin ) because of the risk of hypotension.[merckmanuals.com]
  • He feels that the major contributor to impotence in hypotensive men is angiotensin. Most cases of sexual dysfunction are related to a physical cause.[verywell.com]
Decreased Libido
  • Two of these 7 patients who underwent rehabilitation for cocaine abuse and developed hyperprolactinemia and decreased libido are described. One patient developed galactorrhea. These adverse effects were reversed by bromocriptine.[ncbi.nlm.nih.gov]
  • Sexual dysfunction is one of these comorbidities, with an extremely high prevalence, which will only increase as the population ages.In light of this ubiquity, recent research has explored the mechanisms of decreased libido, hypogonadism and erectile[ncbi.nlm.nih.gov]
  • Sexual dysfunction, including problems with vaginal dryness, dyspareunia, decreased libido, and difficulty with orgasm, is a common complaint among female breast cancer survivors.[ncbi.nlm.nih.gov]
  • Opioid-Induced Deficiencies Hypogonadism Decreased GNRH Decreased LH Decreased Testosterone Adrenal Androgen Deficiency Decreased DHEA Decreased DHEAS Decreased androstenedione Symptoms Anemia Decreased Libido Decreased Muscle Mass Depression Erectile[practicalpainmanagement.com]
  • But insufficient sleep, such as that caused by sleep apnea, can reduce testosterone levels, resulting in poor erections and decreased libido. In addition, sleep-deprived men often feel fatigued and stressed, which may worsen sexual problems.[issm.info]
Sciatica
  • A shorter time to decompression was associated with more sciatica at FU 1 (p 0.042) which effect had disappeared at FU 2.[ncbi.nlm.nih.gov]
Mental Distress
  • Age, cultural factors, relationship status, education, religion, employment, mental distress, depression, medications, menopausal status, multiple psychiatric disorders and a variety of medical conditions impact on sexual function.[ncbi.nlm.nih.gov]
Sexual Dysfunction
  • Sexual dysfunction in PwMS is underdiagnosed and undertreated; however, many healthcare providers may already have the skills required to care for PwMS with sexual dysfunction.[ncbi.nlm.nih.gov]
  • Sexual dysfunction is a key adverse effect leading to medication noncompliance. Psychotropic drugs associated with sexual dysfunction include antiepileptic drugs, antidepressants, and antipsychotics.[ncbi.nlm.nih.gov]
  • Results Approximately two-thirds of the women (66.7%) showed signs of risk of sexual dysfunction (FSFI 26.5).[ncbi.nlm.nih.gov]
  • Dysfunction Due to a General Medical Condition : Female Dyspareunia Female Hypoactive Sexual Desire Disorder Male Erectile Disorder Male Hypoactive Sexual Desire Disorder Male Dyspareunia Other Female Sexual Dysfunction Other Male Sexual Dysfunction[web.archive.org]
  • Even less is known about the epidemiology of female sexual dysfunction. Professional and public interest in sexual dysfunction has recently been sparked by developments in several areas.[doi.org]
Kidney Failure
  • NFB DAN volunteers share their experiences and encouragement with those facing similar complications, such as kidney failure, amputation, and neuropathy. For more information please contact: Bernadette M.[nfb.org]
  • Any number of medical conditions, including cancer, kidney failure, multiple sclerosis, heart disease and bladder problems, can lead to sexual dysfunction.[mayoclinic.org]
  • Diseases such as cardiovascular disease, multiple sclerosis, kidney failure, vascular disease and spinal cord injury are the source of erectile dysfunction.Due to its embarrassing nature and the shame felt by sufferers, the subject was taboo for a long[en.wikipedia.org]
  • In addition to these health conditions, certain systemic digestive (gastrointestinal) and respiratory diseases are known to result in erectile dysfunction: Scleroderma (stiffening or hardening of the skin) Kidney failure Liver cirrhosis Hemachromatosis[emedicinehealth.com]
Secondary Amenorrhea
  • However, women with extreme weight loss may experience secondary amenorrhea. In men, zinc deficiency may lead to impaired testosterone synthesis resulting in hypogonadism and impotency.[ncbi.nlm.nih.gov]

Workup

Diagnosis of sexual dysfunction usually involves comprehensive history taking from both sex partners, either individually or collectively. General information about the observed symptoms, medications and other clinical conditions. Also, mental hand social status of the patient are important. These include, patient  relationship status, self-evaluation, mood, self-esteem, previous sexual experiences, including personality traits.

Female patient with complaint of sexually related pain may require pelvic examination, which are carefully done by the clinician. The use of special instrument such as vaginal speculum may not be necessary during the diagnosis depending on the discretion of the clinician. However, in case of sexually transmitted diseases,  speculum may be required to open the vagina canal for specimen collection (either high vaginal swab (HVS) or endocervical swab (ECS)). The samples are collected for microbiological test for cultural technique to identify the disease-causative agents. Generally, there are no specific laboratory investigations which are known to be recommended in diagnosing FSD, however, laboratory techniques such as normal Pap and stool guaiac (faecal occult blood) tests may assist in diagnosis. Chemistry test such as hormonal analysis may be requested. These include, prolactin (PRL), estradiol, sex steroid-binding globulin (SSBG) or sex hormone-binding globulin (SHBG), thyroid-stimulating hormone (TSH), follicle-stimulating hormone (FSH), and luteinizing hormone (LH) and total and free testosterone (TTFT) hormone levels, .

Both primary and secondary forms hypogonadism can be evaluated using FSH and LH. An increase in FSH and LH may indicate primary gonadal failure, while reduced levels shows an impairment of the pituitary region of the hypothalamus. Reduced estrogen levels in the body can result into reduced libido, vaginal dryness, and painful intercourse (dyspareunia). Lack of testosterone may also cause FSD, including reduced libido, arousal, and satisfaction. The level of SHBG usually increases with age but often decreases by using an exogenous estrogens [28]. Also, hyperprolactinemia may lead to reduction in libido.

Treatment

Different forms of therapy are used in managing sexual dysfunction. These ranges from mental therapy to medications. Patient are counseled to improve the sexual relationship through a clear, open and effective communication and apply best method to achieve sexual satisfaction. These may assist in treating sexual dysfunction.Another psycho-social treatment involving the use of cognitive-behavioral approach and/or mindfulness, may aid treatment of sexual dysfunction which is related to mental issues.
Therapeutic approach may involve hormone replacement treatment which may change the sexual urge. Menopausal and premenopausal women may be treated with estrogen which can improve the sensitivity of clitoral stimulation, enhance atrophied vaginal muscle, and reduce dyspareunia. Estrogen may also improve symptoms associated with vasomotor diseases, mood disorders, including symptoms observed with urinary frequency or urgency [29]. In addition, estrogen replacement used in managing postmenopausal women, may help in ameliorating urogenital atrophy which constitute one of the causes of arousal. Treatment with progesterone may be used for women having intact uteri using estrogen, it has contraindication of affecting mood negatively as well as contributing to a reduced sexual desire. There are controversial report as regards the therapeutic use of testosterone in treating premenopausal women with androgen deficiency, however, it is known to  directly increase or stimulate sexual desire. Testosterone replacement are usually recommended for clinical conditions such as premature ovarian failure, symptomatic form of testosterone deficiency in pre and postmenopausal women that develops naturally, surgically, or induced by chemotherapy [29]. Presently, there are no any national guideline for treating sexual dysfunction using testosterone replacement for women and also there are no known, designated therapeutic regimen of testosterone therapy is acceptable as standard in managing women with sexual dysfunction [27].
SD resulting from arousal disorder may be due to insufficient stimulation, fear, and urogenital atrophy.  A study involving the use of sildenafil (Viagra) in treating arousal disorder among 48 women revealed a significantly increase in physiological markers associated with a satisfactory sexual response in female [30]. Sexual arousal disorder may also be improved by increasing foreplay, distraction approach, relaxation and use of lubricants, vitamin E including mineral oils. After therapy, most women having sexual dysfunction due to orgasmic disorders usually show significant improvement. Sex therapists usually counsel women to improve on the stimulation technique and reduces difficulties in vaginal penetration. Vaginal muscle tone and sexual tension are enhanced by pelvic muscle exercises while masturbation method including vibrator usage can improve stimulation. Distraction approach such as fantasy, music has proven to be effective as well [26].

Sexual pain are usually classified into; superficial, vaginal, and deep pain. Superficial pain is due to vaginism, anatomic defects, or conditions causing irritations of the vaginal mucosa. Vaginal pain is caused by irritation or friction due to reduced lubrication while the deep pain may be due to muscular problems or due to pelvic disease [27]. Sexual pains may be treated with lubricants, estrogens, lidocaine (topically administered), vaginal moistening, Non-steroidal anti-inflammatory drugs (NSAIDs), pelvic physical therapy, and postural changes. Women with vaginism or vaginismus are better managed by sex therapy which often result from traumatic experience or sexual abuse history.

Prognosis

Different factors such as the demographic information (e.g age) are very significant in predicting the sexual problems, especially erectile dysfunction.  SD are commonly observed among young adult women and aged men. These differences in prevalence is due to many factors which influences the outcome of the condition. Because young adult women may be probably single, there are possibilities of periodic times of sexual inactivities and sometimes, increase risk of partner turnover which may cause negative sexual experience. This may result into sexual difficulties and anxiety which may also be influenced by inexperience. This may be contrasting to the experience of young adult men sexual activity. However, older men may have reduced interest in sex and difficulties in producing or maintaining erection. Symptoms such as low sexual desire and erectile dysfunction are commonly age-dependent conditions, possibly due to physiological changes that are related to aging.

Factors which include, poor medical condition and unhealthy lifestyle are also demographic conditions which may determine the outcome of sexual response. Sexual dysfunction in unmarried women may vary depending on the individuals sexual  sexual lifestyles. Similarly, increased risk of SD commonly observed among less educated and low income earner showed that education and income play some roles in determining the level of sexual satisfaction.

Etiology

Common cause of sexual dysfunction include, smoking, obesity, high blood pressure, diabetes as well as dyslipidemia. These are the major cause of erectile dysfunction particularly among the elderly men [2] [3] [4]. Although, erectile dysfunction are known to be related to vascular commodities, previous study involving neural computational networks revealed the relationship between the age, total testosterone level including depression scale with moderate erectile dysfunction open link (ED) [5]. Lower urinary tract infection has been implicated to be a major risk factor of sexual dysfunction among all age groups [6] [7]. with relative risk value of about 1.8–7.5% of ED occurrence among individuals with LUTS [8].

Sometimes, women may have an occasional or periodic difficulties associated with sexual activity or decreased urge and ability to reach orgasm or painful sexual intercourse. Increase in the manifestation of these symptoms is indicative of SD, which may be due to an underlying disease [9] [10]. Sexual dysfunction in female (FSD) have been reported in about 30–50% among women population and known to be associated with age, educational status, physical and emotional health [11] [12] [13]. The dysfunction in women can also be associated with the male partner's sexual ability as it is reported that corrections of erectile problems increases women's sexual urge, orgasm and overall sexual satisfaction [14].

Another factor which could cause FSD is depression, accounting for 70% of cases and may be severe during treatment. Therefore, the choice of drugs must not impair sexual activity [15]. Most often, sexual dysfunction may develop as a consequence of main depressive disorder although, it is not referred as the symptoms of the disorder. A condition called anhedonia, which is depression related may also cause a reduction in sexual urge and arousal.Also, treatment with some drugs such as the the selective serotonin reuptake inhibitors (SSRIs) usually cause SD in both men and women by reducing libido, while drugs which include bupropion hydrochloride, mirtazepine (remeron) and nefazodone do not cause ED or FSD often [16] [17]. Sildenafil are often recommended in cases where antidepressants result into SD [18]. Tricyclic antidepressants (TCAs) have less contraindicating properties on sexual desire, however, the anticholinergic side effects may cause LUTS and any related SD. Dopamine antagonists such as neuroleptic drugs that increase prolactin cause decrease in libido by acting as testosterone antagonist.

Epidemiology

The prevalent rate of sexual dysfunction among women (43%) is higher than men (31%) and is usually related with different demographic features such as age and educational status. There are different patterns of SD among women population depending on the racial background. Psychological and physical factors can also influence the development of sexual dysfunction, as the problem is more common among individuals with poor health conditions including emotional instability. Also, social issues such as unpleasant sexual experience as well as general well-being may result in sexual dysfunction is highly associated with  in sexual relationships.The statistical analysis of the prevalence of SD among male and female involving 27,000 subjects between 40–80 year age groups, within year 2001 and 2002 in 29 countries showed that about 28% and 39% population of men and women respectively reported one or more forms of sexual dysfunction.

In men, ED usually increases with age while in women, loss of sexual urge and failure to attain orgasm (anorgasmia) are common with no age dependence. A comparative study carried out involving clinical and non-clinical subjects showed higher prevalence of FSD among clinical subject with the effect of age factor [19] [20].

Sex distribution
Age distribution

Pathophysiology

The sexual dysfunction in female (FSD) may either be physiologic or psychological in nature. Physiologically, sexual stimulation is initiated from the medial preoptic area, hypothalamus (anterior side), and limb-hippocampal part of the central nervous system (CNS). Electrical impulse are then sent through both parasympathetic (PNS) and sympathetic nervous systems (SNS) [21].

Chemical mediators which include neurotransmitters (such as neuropeptide Y (NPY) and vasoactive intestinal polypeptide (VIP)), nitric oxide synthase (NOSs), cyclic guanosine monophosphate (cGMP), and substance P are detected in the nerve fibers of the vaginal muscle . Nitric oxide (NO) is known to be involved mediating clitoral stimulation and labial engorgement, while vasoactive intestinal polypeptide (VIP) is a non-adrenergic neurotransmitter,which enhances blood flow and proper lubrication of the vaginal through secretions [22].

Different physiological changes are observed in the female reproductive system during sexual stimulation. There is an increase in the blood flow initiated by vasocongestion in the genitalia. Also, cells from both uterus and Bartholin glands secrete fluid which help in lubricating the vaginal canal wall. The smooth muscle in the vaginal wall usually relaxes and assists in dilation or extension of the vagina. Moreover, following clitoral stimulation, the size of the clitoris increases and becomes engorged due to an increased blood flow in the the labia minora.

Response cycle in female during sexual activity was first described in the year 1966 by Masters and Johnson. The cycle was classified into four phases, which include, the excitement stage, plateau stage, orgasm, and resolution stage [23]. This theory was adjusted by Kaplan in the year 1974, and classified into three-cycle model which include, desire, arousal stage, and orgasm period [24]. Basson on the other hand proposed a new theory of sexual response cycle among female [25], stating that the urge to improve intimacy or closeness induces female sexual response. The cycle starts on a neutral, sexual activity level and changes to an arousal stage after the signal from sexual stimulus. Arousal stimulates the sexual urge, and hence, inducing the female's readiness to respond and absorb more additional stimuli. Increased sexual desire ultimately result into satisfaction both emotional and physically including intimacy. Different factors either biological or psychological may negatively alter the sexual cycle, thereby resulting into FSD.

It is important to identify and understand the type or form of the sexual dysfunction affecting the patient as there may be more than one types and may be inter-related in development. As an example, a patient with complaint of reduced sexual desire may have an underlying primary orgasmic problems due to inadequate stimulation. Therefore, the reduced sexual desire is not the major symptoms but a secondary response resulting from unfulfilled sexual activity [26]. In this case, treatment administered for the orgasmic disorder may indirectly improves the sexual desire while, the treatment for the former condition may a not yield the expected result. Hence, this may cause more pschological problems relating to dysfunction.

Prevention

Sexual dysfunction is prevented by identifying and avoiding the possible causes which result into the condition. As an example, diseases which include, diabetes and hypothyroidism which could lead to SD must be appropriately treated. A change of medication or drug dosage should be monitored for any possible contraindication. In cases where etiological factor can not be established, an effective treatment regimen should be done. This management may involve an encouragement or counseling on the need for proper sexual attention including increase in genitalia stimulation. Increase in sexual satisfaction may be achieved by using sex videos, books, as well as masturbation.

Also, the condition can be prevented by engaging in pelvic muscle therapy during sexual intercourse and employing distraction methods such as background music, exciting fantasy is helpful in eliminating anxiety and increases body relaxation. Sexual dysfunction forms like erectile dysfunction may be prevented using noncoital behavioral approach, such as body massage and oral sex. In addition, the use vaginal lubricants and moisturizers including positional or postural changes, with nonsteroidal anti-inflammatory (NSAIDs) drugs may prevent or reduce dyspareunia [30].

Summary

Sexual dysfunction is usually characterized by impairment in sexual urge or desire and affect the psycho-physiological  behavioral changes in relation to the sexual response stages both in male and female [1]. These dysfunctions include, pain during intercourse or sexual discomfort, vaginal pain caused by muscle spasm or contraction, and problems associated with sexual urge, arousal, or reaching orgasm which may be a challenge. Generally, about 30-50% of women population are reported to have experienced sexually related problems at a particular time of their life. Depending on the severity of the condition, affected individual may be distressed or psychologically disturbed.

Patient Information

Sexual dysfunctions (SD) is a condition associated with the disturbances or problem of sexual desire including psycho-physiological changes that is related with sexual responses in both men and women. SD may include, painful sexual intercourse, vaginal pain caused by muscle spasm or contraction, and other sex related problems such as reduced sexual urge, stimulation, or orgasm which are usually disturbing.

Among the elderly men, factors such as smoking, hypertension (HTN), obesity, diabetes and dyslipidemias  usually contribute to erectile dysfunction. Among women, depression has been implicated as one of the causes of sexual dysfunction in females accounting for more than 70% of cases and may be worsened during treatment. Drugs used in treating depression, which are referred to as selective serotonin reuptake inhibitors (SSRIs) are known to cause SD in both men and women, by reducing sexual urge. Other drugs such as bupropion hydrochloride, mirtazepine (remeron) and nefazodone seldomly cause ED or FSD.

The diagnosis of sexual dysfunction are easily managed if there is an observable signs or symptoms because some women may broadly classify sexually related problems as a reduction in sexual urge or general dissatisfaction. Some women may specifically complain about pain during sexual stimulation or during intercourse, anorgasmia, retarded orgasm, and reduced sexual arousal. Diagnosis are made by series of detailed, sex history of both sex partners individually and collectively. Although, there are no specific laboratory investigations, that is universally recommended in the diagnosis of FSD, common tests such as normal Pap smears and (fecal occult blood) tests may assist in diagnosis. Other test such as high vaginal swab (HVS), endocervical swab (ECS), hormonal assay may be requested by the Clinician. Different approach are used in treating sexual dysfunction, depending on the discretion of the Clinician. Apart from medication, general counseling about open communication in relationship and arrangement of convenient sex environment are also helpful in treating sexual dysfunction. Also, cognitive-behavioral therapy including mindfulness and psychotherapy are helpful in managing sexual dysfunction.

References

Article

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; 1994; 493-522.
  2. Morley JE, Tariq SH. Sexuality and disease. Clin Geriatr Med 2003; 19:563–573.
  3. Billups KL et al. Relation of C-reactive protein and other cardiovascular risk factors to penile vascular disease in men with erectile dysfunction. Int J Impot Res 2003; 4:231–236.
  4. Barret-Connor E. Cardiovascular risk stratification and cardiovascular risk factors associated with erectile dysfunction: assessing cardiovascular risk in men with erectile dysfunction. Clin Cardiol 2004; 4 (Suppl 1):I8–I13.
  5. Wald M et al. Computational models for detection of erectile dysfunction. J Urol 2005; 173:167–170.
  6. Rosen R et al. Lower urinary tract symptoms and male sexual dysfunction: the multinational survey of the ageing male (MSAM-7). Eur Urol 2003; 44:637–639.
  7. MacFarlane GJ et al. The relationship between sexual life and urinary condition in the French community. J Clin Epidemiol 1996; 49:1171–1176.
  8. Blanker MH et al. Correlates of erectile and ejaculatory function in older Dutch men: a community-based study. J Am Geriatr Soc 2001; 49:436–442.
  9. Moynihan R. The making of a disease: female sexual dysfunction. BMJ 2003; 326:45–47.
  10. Basson R et al. Report of the International Consensus Development Conference on Female Sexual Dysfunction: definitions and classifications. J Urol 2000; 163:888–893.
  11. Salonia A et al. Women's sexual dysfunction: a pathophysiological review.BJU Int 2004; 93:1156–1164.
  12. Doruk H et al. Effect of diabetes mellitus on female sexual function and risk factors. Arch Androl 2005; 51:1–6.
  13. Seagraves RT. Female sexual disorders: psychiatric aspects. Can J Psychiatry 2002; 5:419–425.
  14. Cayan S, Bozlu M, Canpolat B, Akbay E. The assessment of sexual functions in women with male partners complaining of erectile dysfunction: does treatment of male sexual dysfunction improve female partner's sexual function? J Sex Marital Ther 2004; 30:333–341.
  15. Clayton AH. Female sexual dysfunction related to depression and antidepressant medications. Curr Womens Health Rep 2002; 3:182–187.
  16. Gregorian RS et al. Antidepressant-induced sexual dysfunction. Ann Pharmacother 2002; 10:1577–1589.
  17. Montejo AL, Llorca G, Izquierdo JA, Villademoros F. Incidence of sexual dysfunction associated with antidepressants agents: a prospective multicenter study of 1022 outpatients. J Clin Psychiatry 2001; 62:10–21.
  18. Damis M, Patel Y, Simpson GM. Sildenafil in the treatment of SSRI-induced sexual dysfunction: a pilot study. Primary care companion. J Clin Psychiatry 1999; 6:184–187.
  19. Salonia A et al. Women's sexual dysfunction: a pathophysiological review.BJU Int 2004; 93:1156–1164.
  20. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States. Prevalence and predictors. JAMA 1999; 281: 537–544.
  21. Berman JR, Berman L, Goldstein I: Female sexual dysfunction: Incidence, pathophysiology, evaluation, and treatment options. Urology 1999; 54:385-391.
  22. Park K, Moreland RB, Goldstein I, et al: Sildenafil inhibits phosphodiesterase type 5 in human clitoral corpus cavernosum smooth muscle. Biochem Biophys Res Commun 1998; 249:612-617.
  23. Masters EH, Johnson VE: Human Sexual Response. Boston, Little, Brown, 1966.
  24. Kaplan HS: The New Sex Therapy: Active Treatment of Sexual Disorders. London: Bailliere Tindall, 1974.
  25. Basson R: Human sex-response cycles. J Sex Marital Ther 2001; 27:33-43.
  26. Phillips NA. The clinical evaluation of dyspareunia. Int J Impot Res. 1998; 10(suppl 2):S117–20.
  27. Phillips NA. Female sexual dysfunction: Evaluation and treatment. Am Fam Physician 2000; 62:127-136, 141-142.
  28. Messinger-Rapport BJ, Thacker HL: Prevention for the older woman. A practical guide to hormone replacement therapy and urogynecologic health. Geriatrics 2001; 56:32-34, 37-38, 40-42.
  29. Berman JR, Goldstein I: Female sexual dysfunction. Urol Clin North Am 2001; 28:405-416.
  30. Striar S, Bartlik B: Stimulation of the libido: The use of erotica in sex therapy. Psychiatr Ann 1999; 29:60-62.

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Last updated: 2019-07-11 21:29