Sexual arousal disorders can be categorized as subjective, genital, or combined. All definitions are clinically based, distinguished in part by the woman’s response to genital and nongenital stimulation, as follows:
Subjective: Women do not feel aroused by any type of sexual genital or nongenital stimulation (eg, kissing, dancing, watching an erotic video, physical stimulation), despite the occurrence of physical genital response (eg, genital congestion).
Genital: Subjective arousal occurs in response to nongenital stimulation (eg, an erotic video) but not in response to genital stimulation. This disorder typically affects postmenopausal women and is often described as genital deadness. Vaginal lubrication and/or genital sexual sensitivity is reduced.
Combined: Subjective arousal in response to any type of sexual stimulation is absent or low, and women report absence of physical genital arousal (ie, they report the need of external lubricants and may state they know that swelling of the clitoris no longer occurs).
Causes may involve psychologic (eg, depression, low self-esteem, anxiety, stress, distractibility) or physical factors or both (see Overview of Female Sexual Function and Dysfunction : Etiology). Inadequate sexual stimulation or the wrong setting for sexual activity can also contribute.
Genital arousal disorder may result from a low level of estrogen after menopause or postpartum. Age-related reduction of testosterone or vulval dystrophy (eg, lichen sclerosus) may contribute. Certain chronic disorders (eg, diabetes, multiple sclerosis) can damage autonomic or somatic nerves, leading to decreased congestion or sensation in the genital area.
Diagnosis is clinical (see Overview of Female Sexual Function and Dysfunction : Diagnosis).
Treatment is similar to that of sexual desire/interest disorder (see Sexual Desire/Interest Disorder).
When estrogen is deficient, initial treatment is vaginal estrogen (or systemic estrogen if indicated for other postmenopausal symptoms). Other investigational therapy includes vaginal dehydroepiandrosterone (DHEA) 13 mg at night. This drug may increase lubrication and lessen vulvovaginal atrophy in 2 wk and improve genital sensitivity and orgasm in 12 wk. This drug does not appear to increase serum testosterone or estrogen. It modestly increases serum DHEA, but levels are still considerably lower than those in younger women.