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Gynecology_Novak. 346. Stubblefield PG. First and second trimester abortion. In: Nichols DH, Clarke-Pearson DL, eds. Gynecologic, obstetric and related surgery. 2nd ed. St. Louis, MO: Mosby, 2000:1033–1045. 347. Hammond, C, Chason, S. Dilatation and evacuation. In: Paul M, Lichtenberg ES, Borgatta L, et al., eds. Management of unintended and abnormal pregnancy. Comprehensive abortion care. Oxford: Wiley-Blackwell, 2009:157–177. 348. Darney PD, Sweet RL. Routine intra-operative ultrasonography for second trimester abortion reduced incidence of uterine perforation. J Ultrasound Med 1989;8:71–75. 349. Hern WM. Abortion practice. Philadelphia, PA: Lippincott, 1984. 350. Hern WM, Xen C, Ferguson RA, et al. Outpatient abortion for fetal anomaly and fetal death from 15–34 menstrual weeks gestation: techniques and clinical management. Obstet Gynecol 1993;81: 301–306. 351.


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Gynecology_Novak. 351. Patel A, Talmont E, Morfesis J, et al. Adequacy and safety of buccal misoprostol for cervical preparation prior to termination of second-trimester pregnancy. Contraception 2006;73:420–430. 352. Chasen ST, Kalish RB, Gupta M, et al. Dilatation and evacuation at greater than or equal to 20 weeks: comparison of operative techniques. Am J Obstet Gynecol 2004;190:1180–1183. 353. Haddad L, Yanow S, Delli-Bovi L, et al. Changes in abortion provider practices in response to the Partial-Birth Abortion Ban Act of 2003. Contraception 2009;79:379–384. 354. Drey EA, Thomas LJ, Benowitz NL, et al. Safety of intra-amniotic digoxin administration before late second-trimester abortion by dilation and evacuation. Am J Obstet Gynecol 2000;182:1063–1066. 355. Pasquini L, Pontello V, Kumar S. Intracardiac injection of potassium chloride as method for feticide: experience from a single UK tertiary centre. BJOG 2008;115:528–531. 356.


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Gynecology_Novak. 355. Pasquini L, Pontello V, Kumar S. Intracardiac injection of potassium chloride as method for feticide: experience from a single UK tertiary centre. BJOG 2008;115:528–531. 356. Jackson RA, Teplin VL, Drey EA, et al. Digoxin to facilitate late second-trimester abortion: a randomized, masked, placebo-controlled trial. Obstet Gynecol 2001;97:471–476. 357. Borgatta L, Betstadt SJ, Reed A, et al. Relationship of intraamniotic digoxin to fetal demise. Contraception 2010;81:328–330. 358. Gemzell-Danielsson K, Lalitkumar S. Second trimester medical abortion with mifepristone-misoprostol and misoprostol alone: a review of methods and management. Reprod Health Matters 2008;16(31 Suppl):162–172. 359. Jain JK, Mishell DR. A comparison of intravaginal misoprostol with prostaglandin E for termination of second trimester pregnancy. N Engl J Med 1994;331:290–293. 360.


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Gynecology_Novak. 359. Jain JK, Mishell DR. A comparison of intravaginal misoprostol with prostaglandin E for termination of second trimester pregnancy. N Engl J Med 1994;331:290–293. 360. Ashok PW, Templeton A, Wagaarachchi PT, et al. Midtrimester medical termination of pregnancy: a review of 1002 consecutive cases. Contraception 2004;69:51–58. 361. Webster D, Penny GC, Templeton K. A comparison of 600 and 200 mg mifepristone prior to second trimester abortion with the prostaglandin misoprostol. BJOG 1996;103:706–709. 362. Royal College of Obstetricians. The care of women requesting induced abortion. Guidelines No. 7. London: Royal College of Obstetricians, 2004. 363. Chai J, Tang OS, Hong QQ, et al. A randomized trial to compare two dosing intervals of misoprostol following mifepristone administration in second trimester medical abortion. Hum Reprod 2009;24:320– 324. 364.


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Gynecology_Novak. 364. Royal College of Obstetricians and Gynaecologists. Termination of pregnancy for fetal abnormality in England, Scotland and Wales. London: RCOG, 1996. 365. Hern WM. Laminaria, induced fetal demise and misoprostol in late abortion. Int J Gynaecol Obstet 2001;75:279–286. 366. Winkler CL, Gray SE, Hauth JC, et al. Mid-second-trimester labor induction: concentrated oxytocin compared with prostaglandin E2 suppositories. Obstet Gynecol 1991;77:297–300. 367. Frick AC, Drey EA, Diedrich JT, et al. Effect of prior cesarean delivery on risk of second-trimester surgical abortion complications. Obstet Gynecol 2010;115:760–764. 368. Dickenson JE. Misoprostol for second-trimester pregnancy termination in women with a prior cesarean delivery. Am J Obstet Gynecol 2005;105:352–356. 369. Evans MI, Berkowitz RI, Wapner RJ, et al. Improvements in outcomes of multifetal pregnancy reduction with increased experience. Am J Obstet Gynecol 2001;184:97–103. 370.


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Gynecology_Novak. 369. Evans MI, Berkowitz RI, Wapner RJ, et al. Improvements in outcomes of multifetal pregnancy reduction with increased experience. Am J Obstet Gynecol 2001;184:97–103. 370. Evans MI, Goldberg JD, Horenstein J, et al. Selective termination for structural, chromosomal and mendelian anomalies: international experience. Am J Obstet Gynecol 1999;82:61–66. 371. He ZM, Fang Q, Yang YZ, et al. Fetal reduction by bipolar cord coagulation in managing complicated monochorionic multiple pregnancies: preliminary experience in China. Chin Med J (Engl) 2010;123:549–554. 372. Morris GC, Lacey CJ. Microbicides and HIV prevention: lessons from the past, looking to the future. Curr Opin Infect Dis 2010;23: 57–63. 373. van Damme L, Govinden R, Mirembe FM, et al. Lack of effectiveness of cellulose sulfate gel for the prevention of vaginal HIV transmission. N Engl J Med 2008;359:463–472. 374. McGowan I. Microbicides for HIV prevention: reality or hope? Curr Opin Infect Dis 2010;23:26–31.


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Gynecology_Novak. 374. McGowan I. Microbicides for HIV prevention: reality or hope? Curr Opin Infect Dis 2010;23:26–31. 375. Wu S, Hu J, Wildemeersch D. Performance of the frameless Gyne-Fix and theTCU380A IUDs in a three year multicenter randomized comparative trial in parous women. Contraception 2000;61:91–98. 376. Weisberg E, Brache V, Alvarez F, et al. Clinical performance and menstrual bleeding patterns with three dosage combinations of a Nestorone progestogen/ethinyl estradiol contraceptive vaginal ring used on a bleeding-signaled regimen. Contraception 2005;72:46–52. 377. Upadhyay UD. New contraceptive choices. Population Reports, Series M, No. 19. Baltimore: Johns Hopkins Bloomberg School of Public Health, INFO Project; April 2005. Available at: www.infoforhealth.org/pr/m19 378. Del Priore G, Malanowska-Stega J, Shalaby SW, et al. A pilot safety and tolerability study of a nonhormonal vaginal contraceptive ring. J Reprod Med 2009;54:685–690. 379.


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Gynecology_Novak. Del Priore G, Malanowska-Stega J, Shalaby SW, et al. A pilot safety and tolerability study of a nonhormonal vaginal contraceptive ring. J Reprod Med 2009;54:685–690. 379. Coffey PS, Kilbourne-Brook M. Wear and care of the SILCS diaphragm: experience from three countries. Sex Health 2010;7:159– 164. 380. Mbopi-Keou Trottier S, Omar RF, Nkelle NN, et al. A randomized, double-blind, placebo-controlled safety and acceptability study of two Invisible Condom® formulations in women from Cameroon. Contraception 2009;80:484–492. 381. Talwar GP, Singh O, Pal R, et al. A birth control vaccine is on the horizon for family planning. Ann Med 1993;25:207–212. 382. McLaughlin EA, Holland MK, Aitken RJ. Contraceptive vaccines. Expert Opin Biol Ther 2003;3:829–841. 383. Naz RK. Status of contraceptive vaccines. Am J Reprod Immunol 2009;61:11–18. 384. Lyttle CR, Kopf GS. Status and future direction of male hormonal contraceptive development. Curr Opin Pharmacol 2003;3:667–671. 385.


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Gynecology_Novak. 384. Lyttle CR, Kopf GS. Status and future direction of male hormonal contraceptive development. Curr Opin Pharmacol 2003;3:667–671. 385. Blithe D. Male contraception: what is on the horizon? Contraception 2008;78:S23–S27. 386. Zhao SC. Vas deferens occlusion by percutaneous injection of polyurethane elastomer plugs: clinical experience and reversibility. Contraception 1990;41:453–459. 387. Potts M, Benagiano G. Quinacrine sterilization: a middle road. Contraception 2001;64:275–276. 388. Sokal DC, Hieu do T, Loan ND, et al. Contraceptive effectiveness of two insertions of quinacrine: results from 10-year follow-up in Vietnam. Contraception 2008;78:61–65. 389. Hieu DT, Luong TT. The rate of ectopic pregnancy for 24,589 quinacrine sterilization (QS) users compared to users of other methods and no method in 4 provinces of Vietnam. 1994–1996.Int J Gynaecol Obstet 2003;83(Suppl 2):S35–S43. 390.


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Gynecology_Novak. 390. Sokal DC, Vach TH, Nanda K, et al. Quinacrine sterilization and gynecologic cancers: a case-control study in northern Vietnam. Epidemiology 2010;21:164–167. 391. Cancel AM, Dillberger JE, Kelly CM, et al. A lifetime cancer bioassay of quinacrine administered into the uterine horns of female rats. Regul Toxicol Pharmacol 2010;56:156–165. 392. SokalDC,TrujilloV,Guzm´anSC,etal. Cancer risk after sterilization with transcervical quinacrine: updated findings from a Chilean cohort. Contraception 2010;81:75–78. Sexuality, Sexual Dysfunction, Rosemary Basson David A. Baram Most young men and young women have multiple serial sexual partners but use condoms inconsistently, thereby exposing themselves to sexually transmitted diseases (STDs) and unintended pregnancies.


Gynecology_Novak

Gynecology_Novak. Most young men and young women have multiple serial sexual partners but use condoms inconsistently, thereby exposing themselves to sexually transmitted diseases (STDs) and unintended pregnancies. Sexual response reﬂects the fundamental interplay between the mind and body: psychological, interpersonal, cultural, environmental, and biological (hormonal, vascular, muscular, neurological) factors interact and modulate sexual experience. Factors that can affect sexual response include mood, relationship duration and quality, age and stage in life, past sexual experiences—wanted, coercive, or abusive—personal psychological factors stemming from relationships in childhood with parental figures, previous losses and traumas, and ways of coping with emotions, current and past illness, and use of medication, alcohol, and illicit drugs. Physical, emotional, and economic stressors of pregnancy may negatively affect emotional and sexual intimacy.


Gynecology_Novak

Gynecology_Novak. Physical, emotional, and economic stressors of pregnancy may negatively affect emotional and sexual intimacy. Sexual value systems, folklore, religious beliefs, physical changes, and medical restrictions inﬂuence sexual attitudes and behavior during pregnancy and postpartum. Despite the importance of issues relating to sexuality, many women find it difficult to talk to their physicians about sexual concerns, and many physicians are uncomfortable discussing sexual issues with their patients. Asking about sexual concerns gives physicians an opportunity to educate patients about the risk of STDs, encourage safer sex practices, evaluate the need for contraception, dispel sexual misconceptions, and identify sexual dysfunction. Many of the sexual problems couples encounter result from a deficit of knowledge or experience, sexual misconceptions, or inability of the couple to communicate about their sexual preferences.


Gynecology_Novak

Gynecology_Novak. Many of the sexual problems couples encounter result from a deficit of knowledge or experience, sexual misconceptions, or inability of the couple to communicate about their sexual preferences. Sexual problems are common. Vaginismus is an involuntary reﬂex precipitated by real or imagined attempts at vaginal entry. Dyspareunia may affect two-thirds of women during their lifetime. Vestibulodynia, the most common type of dyspareunia, has a prevalence of 15%. Sexual assault of children and adult women has reached epidemic proportions in the United States and is the fastest growing, most frequently committed, and most underreported crime. The terms sexual abuse survivor and assault survivor are preferable to victim. Childhood sexual abuse has a profound and potentially lifelong effect on the survivor. Although most cases of childhood sexual abuse are not reported by the survivor or her family, it is estimated that as many as one-third of adult women were sexually abused as children.


Gynecology_Novak

Gynecology_Novak. Women who were sexually abused as children or sexually assaulted as adults often experience sexual dysfunction and difficulty with intimate relationships and parenting. The National Women’s Study revealed that 13%, or one of eight adult women, are survivors of at least one completed rape during their lifetime. Most women feel that sexuality is an important part of their lives even when chronic illness is present. Providing patients with information about normal sexual changes that occur with puberty, pregnancy and postpartum, menopause, and older age is part of routine obstetric and gynecologic care.


Gynecology_Novak

Gynecology_Novak. Sexual dysfunction can arise from gynecologic diseases such as endometriosis, procedures such as those associated with infertility, and treatments such as pelvic radiation, bilateral salpingooophorectomy, and use of aromatase inhibitors or gonadotropin-releasing hormone (GnRH) antagonists. Sexual abuse can have long-lasting effects on sexuality and other psychophysiological aspects of a patient’s life. Women seen in gynecology clinics may have comorbid illnesses that interrupt their sexual function. Inquiry about sexual concerns and explanation of the implications of a disease and its treatment are integral components of gynecologic care.


Gynecology_Novak

Gynecology_Novak. The spectrum of normal sexual response varies from one woman to another and throughout a woman’s lifetime (1–3). Physicians should be aware of their patients’ sexual values, attitudes about specific practices, and concerns about their sexuality. Maintaining open communication with patients about their sexuality allows the physician to counsel them about sexual issues and problems and other aspects of their reproductive health.


Gynecology_Novak

Gynecology_Novak. Sexual Activity Sexual activity among adolescents in the United States increased during the past 20 years (3). The average age for first intercourse for both men and women is 16 years. By 19 years of age, as many as three-quarters of women have had intercourse. Most young men and young women have multiple serial sexual partners but use condoms inconsistently, thereby exposing themselves to sexually transmitted diseases (STDs) and unintended pregnancies. A recent study of North American women, using a large and diverse community-based sample, shows that of the 3,205 women aged 30 to 79 years almost one-half were not sexually active in the previous 4 weeks, with 52% of those citing lack of interest and 61% citing lack of partner as the major reasons. Of those who were sexually active recently, 13.7% noted sexual problems and dissatisfaction with their overall sexual lives (4).


Gynecology_Novak

Gynecology_Novak. Genital Anatomy For most women, their clitoral tissue is the most sexually sensitive part of their anatomy, and its stimulation produces the most intense sexual feelings and the most intense orgasms. Many women first need to experience both nonphysical and nongenital physical stimulation before clitoral stimulation can be enjoyed. In the absence of arousal, direct clitoral stimulation can be unpleasant and be perceived as too intense and even painful. Immunohistologic studies identified neurotransmitters thought to be associated with sensation concentrated right under the epithelium of the glans clitoris (5). Clitoral tissue extends far beyond the visible portion when the clitoral hood is retracted. It includes the clitoral head, shaft, rami running along the pubic arch, periurethral tissue in front of the anterior vaginal wall, and the bulbar tissue under the superficial perineal muscles surrounding the anterior distal vagina. Other sexually sensitive areas include the nipples,


Gynecology_Novak

Gynecology_Novak. tissue in front of the anterior vaginal wall, and the bulbar tissue under the superficial perineal muscles surrounding the anterior distal vagina. Other sexually sensitive areas include the nipples, breasts, labia, much of the skin generally, and to some extent, the vagina. Although the lower third of the vagina is responsive to touch, the upper two-thirds is sensitive primarily to pressure. The rich supply of nerves in the fascia anterior to the upper vagina (Halban’s fascia) and the proximity of the clitoral type of spongy tissue around the urethra anterior to the vagina contribute to the pleasurable sensations of intercourse. Many women experience orgasm more easily from direct clitoral touch, possibly provided at the same time as intercourse.


Gynecology_Novak

Gynecology_Novak. There is speculation about the existence of a “G-spot,” named after Ernest Gr¨afenberg, who first described it in 1944 (5). This area of the vagina, located anteriorly midway between the symphysis pubis and cervix, is thought to be exquisitely sensitive to deep pressure. Stimulation of this area associated with orgasm and loss of ﬂuid was not scientifically proven to be anything other than dilute urine. Women who are normally continent often leak urine at orgasm; this is not abnormal and does not require medical intervention.


Gynecology_Novak

Gynecology_Novak. Sexual Response Cycle Sexual response reﬂects the fundamental interplay between the mind and body: psychological, interpersonal, cultural, environmental, and biological (hormonal, vascular, muscular, neurological) factors interact and modulate sexual experience. The initial phase of the sexual response cycle may be one of desire, but more often women, particularly those in long-term relationships, are motivated by factors other than sexual desire (3). Women initiate or consent to sex for many reasons, including a wish to increase emotional intimacy with their partners. By directing her attention to sexual stimulation, a woman’s subjective sexual arousal/pleasure/excitement triggers sexual desire. Desire and arousal coexist and compound each other (Fig. 11.1). Sexual satisfaction (with one, many, or no orgasms) can be achieved if a woman can stay focused, her pleasure continues, the duration of the stimulation is sufficiently long, and there is no negative outcome (e.g., pain or


Gynecology_Novak

Gynecology_Novak. one, many, or no orgasms) can be achieved if a woman can stay focused, her pleasure continues, the duration of the stimulation is sufficiently long, and there is no negative outcome (e.g., pain or partner dysfunction). The response is circular, with phases overlapping and in variable order (e.g., desire may follow arousal, and higher arousal may follow the first orgasm). Desire, once triggered, increases the motivation to respond to sexual stimuli and to agree to or ask for more intensely erotic forms of stimulation. Any initial spontaneous desire will augment the response. This circular type of cycle can be experienced a number of times on any one occasion of sexual interaction. This motivation/incentives module reﬂecting the importance of the mind’s appraisal of sexual stimuli is supported by empirical research (6–7).


Gynecology_Novak

Gynecology_Novak. Do you have any sexual concerns now, such as pain with intercourse, lack of arousal, or lack of enjoyment? Yes No I will need to ask you more detailed questions (now or at a later visit) That is fine—sexual problems are common and most can be helped Figure 11.1 The blended sex response cycle showing the many reasons/incentives for initiating/accepting sexual activity.


Gynecology_Novak

Gynecology_Novak. Desire and Arousability Sexual desire provides one of many motivations to be sexual. Feelings of desire may be triggered by both internal (e.g., fantasies, memories, feelings of arousal) and external (e.g., an interested and interesting partner). Sexual cues are dependent on adequate neuroendocrine function. Multiple neurotransmitters, peptides, and hormones modulate desire and subjective arousal (9). Substances that promote sexual response include norepinephrine, dopamine, oxytocin, melatonin, and serotonin acting on some receptors. Prolactin, serotonin acting on other receptors, endocannabinoids, opioids, and γ -aminobutyric acid inhibit sexual response. These peptides and neurotransmitters are themselves modulated by sex hormones that direct the synthesis of enzymes involved in the production of neurotransmitters and the synthesis of their receptors. Biological factors do not act independently from environmental factors, a finding in human and animal models. Dopamine and


Gynecology_Novak

Gynecology_Novak. in the production of neurotransmitters and the synthesis of their receptors. Biological factors do not act independently from environmental factors, a finding in human and animal models. Dopamine and progesterone, acting on receptors in the hypothalamus, facilitate sexual behavior in female rats that underwent oophorectomy and received estrogen. The presence of a male animal in an adjacent cage can cause an identical change in sexual behavior (10). Likewise, the ability to be aroused and intensity of response can be increased in some women by giving them a modest dose of testosterone, by administering bupropion (dopaminergic), or by a change of partner (11–13). Even in rodents, complex networks exist whereby the female assesses the context of potential sexual activity and relates it to past experience and expectation of reward (14). In women, sexual interest is inﬂuenced by their psychological mindset, beliefs and values, expectations, sexual orientation, preferences, and the presence


Gynecology_Novak

Gynecology_Novak. experience and expectation of reward (14). In women, sexual interest is inﬂuenced by their psychological mindset, beliefs and values, expectations, sexual orientation, preferences, and the presence of a safe and erotic environmental setting. Empirical research confirms that an experimentally induced happy or sad mood can impact subjective sexual arousal (but not objective vaginal congestion as measured by a vaginal photoplethysmograph, a tamponlike photoelectric device placed in the vagina) while the woman views an erotic video, with subjects reporting significantly less subjective arousal and marginally significant fewer genital sensations when a negative mood was induced prior to viewing an erotic film clip (15). Moreover, other research concludes that cognitive factors (i.e., lack of erotic thoughts and being distracted or concerned about sexual behavior) were the best predictors of sexual desire: other dimensions including relationship factors, psychopathology, and medical


Gynecology_Novak

Gynecology_Novak. of erotic thoughts and being distracted or concerned about sexual behavior) were the best predictors of sexual desire: other dimensions including relationship factors, psychopathology, and medical problems appeared to have an indirect impact on sexual desire with the cognitive factors acting as the mediators (16). Sexual desire, interest, and arousability are most strongly inﬂuenced by mental health and feelings for the partner, both generally and specifically, at the time of sexual interaction (4,13,17,18). Sexual desire is strongly inﬂuenced by fatigue; as a result, sex late at night is not usually attractive to a busy woman. Similarly, chronic illness typically reduces desire and arousability (19).


Gynecology_Novak

Gynecology_Novak. Sexual Arousal Recent brain imaging reﬂects the complexity of sexual arousal, confirming that multiple areas of the brain are involved in sexual response. Brain imaging of healthy people during visual sexual stimulation identifies a model of sexual arousal involving complex brain circuitry, including cortical, limbic, and paralimbic areas known to be involved in cognition, motivation, and emotions linked to changes within the autonomic nervous system (20). Specific inhibitory regions deactivate these sexual responses (21). As demonstrated in this ongoing research, none of this is particularly simple. In a small study, sexually functional surgically menopausal women receiving no hormonal therapy viewed erotic videos during functional magnetic resonance imaging. The women failed to show the brain activation typical of premenopausal women and also typical of themselves when they were treated with both testosterone and estrogen, and yet, they reported sexual arousal from the erotic videos


Gynecology_Novak

Gynecology_Novak. brain activation typical of premenopausal women and also typical of themselves when they were treated with both testosterone and estrogen, and yet, they reported sexual arousal from the erotic videos without, and with, hormonal supplementation (22).


Gynecology_Novak

Gynecology_Novak. Accompanying the subjective excitement and erotic feelings of arousal are a number of physical changes. These changes include genital swelling; increased vaginal lubrication; engorgement of the breasts and nipple erection; increases in skin sensitivity to sexual stimulation; changes in heart rate, blood pressure, muscle tone, breathing, body temperature; mottling of the skin; and a “sex ﬂush” of vasodilatation over the chest, breasts, and face.


Gynecology_Novak

Gynecology_Novak. With sexual stimulation, brain activity in the hypothalamus and other areas inﬂuencing the genital response are activated, triggering the autonomic nervous system to allow increased blood ﬂow to the vagina. Vasodilatation of the arterioles in the submucosal vaginal plexus increases transudation of interstitial ﬂuid, which moves from capillaries between the epithelial intercellular spaces and into the vaginal lumen. Simultaneously, the autonomic nervous system allows relaxation of the smooth muscle cells surrounding blood spaces (sinusoids) in the extensive clitoral tissue and labia, causing clitoral swelling and vasodilatation in the labia. Recent immunohistologic studies indicate nerves containing nitric oxide are present in the genital skin covering the clitoris and labia (5). With arousal, the vagina lengthens, distends, and dilates, and the uterus elevates out of the pelvis. With increased sexual stimulation, vasocongestion reaches a maximum intensity.


Gynecology_Novak

Gynecology_Novak. With arousal, the vagina lengthens, distends, and dilates, and the uterus elevates out of the pelvis. With increased sexual stimulation, vasocongestion reaches a maximum intensity. Genitally, the labia become more swollen and darker red and the lower third of the vagina swells and thickens to form an “orgasmic platform.” The clitoris becomes more swollen and elevates to a position near the symphysis pubis, and the uterus elevates fully out of the pelvis. The breasts become more engorged, the skin more mottled, and the nipples more erect.


Gynecology_Novak

Gynecology_Novak. The neurobiology of arousal is incompletely understood but the genital vasocongestive responses appear to be highly automated, occurring within seconds of an erotic stimulus (23). Parasympathetic nerves release nitric oxide and vasoactive intestinal polypeptide (VIP), mediating vasodilatation (24,25). Acetylcholine (ACh) blocks noradrenergic vasoconstrictive mechanisms and promotes nitric oxide release from endothelium. The parasympathetic and sympathetic nervous systems and the somatic system function less independently than was previously believed. Communication was identified between the cavernous nerves to the clitoris, containing nitric oxide, and the distal portion of the (somatic) dorsal nerve of the clitoris from the pudendal nerve (5). The pelvic sympathetic nerves primarily release (vasoconstrictive) noradrenaline and adenosine triphosphate, but some release ACh, nitric oxide, and VIP. Nitric oxide is thought to be the major neurotransmitter involved in vulvar engorgement


Gynecology_Novak

Gynecology_Novak. (vasoconstrictive) noradrenaline and adenosine triphosphate, but some release ACh, nitric oxide, and VIP. Nitric oxide is thought to be the major neurotransmitter involved in vulvar engorgement (5,25). In the vagina, VIP, nitric oxide, and other unidentified neurotransmitters are involved (25).


Gynecology_Novak

Gynecology_Novak. Even in women without any sexual dysfunction, there is highly variable correlation between the degree of subjective sexual excitement and the increase in congestion around the vagina (23,26). This poor correlation was shown repeatedly over the past 30 years based on psychophysiologic studies using the vaginal photoplethysmograph. Congestion in response to a sexual video is reduced in women with disruption of the autonomic nerve supplying the vulva and vagina (e.g., from nonnerve-sparing radical hysterectomy). Otherwise healthy women experiencing chronic lack of arousal (including lack of subjective excitement and lack of any awareness of genital congestion) show increases in vaginal congestion from erotic stimuli that are similar those in control women (23,26). With the so-called cervico-motor reﬂex, cervical touch (in the laboratory with a balloon-tipped catheter to replicate penile pressure) leads to a reduction in pressure in the upper portion of the vagina and an increase in


Gynecology_Novak

Gynecology_Novak. reﬂex, cervical touch (in the laboratory with a balloon-tipped catheter to replicate penile pressure) leads to a reduction in pressure in the upper portion of the vagina and an increase in pressure in the middle and lower portions. Simultaneously, an increase in electromyographic activity in the levator ani and puborectalis muscles was recorded. It is thought that during intercourse penile thrusting on the cervix might cause contraction of the pelvic muscles to facilitate “ballooning” of the upper vagina, perhaps to facilitate pooling of semen. The same muscle contraction constricts the lower vagina, which may afford increased stimulation of the partner’s penis, thereby maintaining rigidity (27).


Gynecology_Novak

Gynecology_Novak. A further reﬂex demonstrated in laboratory studies shows reduced uterine tone in response to mechanical or electrical stimulation of the glans of the clitoris. Background activity of the uterine muscle was abolished by clitoral stimulation if either the glans clitoris or the uterus was anesthetized. Uterine pressure declined on clitoral stimulation. This reﬂex may underlie the known increase in size and the elevation of the uterus with sexual arousal (28).


Gynecology_Novak

Gynecology_Novak. Orgasm Orgasms is a brain event, typically triggered by genital stimulation that can occur during sleep or from stimulation of other body parts including the breast and nipple or by fantasy, occasionally by medication, and in spinal cord injured women by vibrostimulation of the cervix. In able-body women, it involves a myotonic response of smooth and striated muscle associated with feelings of sudden release of the sexual tension built up during arousal. It is described as the most intensely pleasurable of the sexual sensations. Reﬂex rhythmic contractions (3–20 0.8/sec) of the muscles surrounding the vagina and anus occur. Some women may subjectively perceive uterine contractions during orgasm and some may report a difference in their perception of orgasm after hysterectomy, but this is not objectively documented. An objective quantitative measure was established that shows strong correspondence with the subjective experience of orgasm. Analysis of rectal pressure data while


Gynecology_Novak

Gynecology_Novak. this is not objectively documented. An objective quantitative measure was established that shows strong correspondence with the subjective experience of orgasm. Analysis of rectal pressure data while volunteers imitated orgasm, tried to achieve orgasm and failed, or experienced orgasm showed a significant and important difference in this analysis between orgasm and both control tasks (29).


Gynecology_Novak

Gynecology_Novak. Brain imaging studies of women during orgasm showed brain activations and deactivations similar but not identical to those found in men (30). There is profound deactivation in the anterior part of the orbitofrontal cortex (OFC). This area is thought to be involved in urge suppression and behavioral release. This area is activated when experiences are particularly hedonic, with further activation increasing satiation and deactivated with feelings of satiety. The medial OFC is part of the neuronal network underlying self-monitoring and is connected to the amygdala. The latter is deactivated during the genital stimulation and arousal and remains deactivated during orgasm. Deactivation of this network is associated with a more carefree state of mind. The subjective description of orgasm is very much in keeping with this depiction (31). The majority of women most easily experience orgasm from direct clitoral stimulation.


Gynecology_Novak

Gynecology_Novak. The majority of women most easily experience orgasm from direct clitoral stimulation. More direct contact with the clitoris is possible from contact of pubis to pubis after the man has ejaculated and penile size is reduced, if the man maintains contact. The bodies are more closely approximated and the woman can move her pelvis on his at a rate that is most conducive to her orgasm. Breast stimulation, kissing, and clitoral stimulation during intercourse are other commons means of experiencing orgasm. Women are potentially multiorgasmic, capable of experiencing a number of orgasms close together during one sex response cycle and of resuming sexual activity without any refractory period.


Gynecology_Novak

Gynecology_Novak. Resolution Following the sudden release of sexual tension brought about by orgasm, women experience a feeling of relaxation and well-being. The gradual lessening of pelvic engorgement contrasts with the quicker loss of penile firmness in men. Nongenital changes that took place during arousal are reversed, and the body can return to a resting state after some 5 to 10 minutes. With further stimulation, the response can resume before or after this resting state is reached. As depicted in Figure 11.1, the cycle of response can be experienced a number of times during any given sexual encounter. Women who enjoy arousal without orgasm and without any sense that orgasm is very close but frustratingly absent report a similar sense of well-being and relaxation.


Gynecology_Novak

Gynecology_Novak. Numerous factors can affect sexual response (13,19,32–34). These factors include mood; age; relationship duration and quality; personal psychological factors stemming from relationships in childhood with parental figures; previous losses, traumas, and ways of coping with emotions; illness; and use of medication, alcohol, and illicit drugs.


Gynecology_Novak

Gynecology_Novak. Mental Health Studies find that mental health has the strongest links to women’s sexual function (4,17,35,36). Lack of mental well-being, even if it does not meet the criteria of a clinical diagnosis of mental disorder, is strongly linked to women’s symptoms of low desire (37). One study of women, where a diagnosis of clinical depression was excluded, showed a strong association between decreased sexual interest and self-reporting of negative emotional and psychological feelings, including low self-esteem, feelings of insecurity, and lost femininity (18). Impaired sexual desire is noted in most studies of women with depression, even before the administration of antidepressants with sexually negative side effects (35). Paradoxically, depressed women may masturbate more frequently than women who are not depressed, despite an increased prevalence of dyspareunia and difficulties with arousal and orgasm in partnered sex (38). Self-stimulation may cause calmness, relaxation, and improved


Gynecology_Novak

Gynecology_Novak. who are not depressed, despite an increased prevalence of dyspareunia and difficulties with arousal and orgasm in partnered sex (38). Self-stimulation may cause calmness, relaxation, and improved sleep and in women is often not a consequence of sexual urge or desire.


Gynecology_Novak

Gynecology_Novak. Aging The degree to which aging itself, the marked changes in ovarian function associated with menopause, and the marked reduction of adrenal production of prohormones (importantly dehydroepiandrosterone [DHEA]) that can become estrogen and testosterone may affect women’s sexual response was addressed in large population studies. Some studies showned little increase in sexual problems with age, whereas in others almost 40% of the sample reported reductions in responsiveness and an increased desire for nongenital sexual expression (13,39,40). In one study, the prevalence of reduced desire increased significantly as a function of both menopause status and age, from 22% in the premenopausal group to 32% in the postmenopausal group (41). Low levels of desire were strongly associated with other sexual problems, including difficulties with arousal and orgasm. One large cohort of women studied over 10 years from perito postmenopause showed a decline in desire and responsiveness as a function


Gynecology_Novak

Gynecology_Novak. sexual problems, including difficulties with arousal and orgasm. One large cohort of women studied over 10 years from perito postmenopause showed a decline in desire and responsiveness as a function of both age and menopause (42). The independent effect of menopause was indirect. The number of menopausal symptoms experienced inﬂuenced well-being, which in turn affected sexual responsiveness and sexual desire and interest.


Gynecology_Novak

Gynecology_Novak. Many studies of sexuality and aging show that older women report less distress about lack of desire when compared with younger women (17,18,43). In a nonclinical study of 102 women, the determinants of sexual satisfaction in those younger than 45 years of age were compared with those of women older than 45 years of age (18). There was no difference in sexual satisfaction achieved either by intercourse or noncoital sexual activities. Older women reported lower frequency of orgasm and different ratings on certain dimensions of sexual satisfaction. For the older women, the dominant qualities important to their satisfaction were those related to an emotional sense of calm and to factors such as feeling secure with their partner, whereas for younger women the subjective physical experience was more important.


Gynecology_Novak

Gynecology_Novak. Despite reports of reduced sexual interest and desire by some older women, most retain some interest and maintain the potential for sexual pleasure for their entire lives. In older women, a strong predictor of continued sexual interest is sexual behavior and enjoyment at an earlier age. A discrepancy between sexual interest and actual sexual activity occurs in many cases because an adequate partner is no longer available. In other instances, the cessation of sexual activity with age is more an expression of emotional problems resulting from lack of tenderness, communication, and attraction.


Gynecology_Novak

Gynecology_Novak. In addition to partner availability, an older woman’s sexuality is inﬂuenced by her partner’s general and sexual health and the relationship itself, which will determine how well the couple can adapt to changes in their sexual function as they age (17,44,45). Although some older women may retain negative societal attitudes toward sex that it is not “natural” (i.e., not focused intercourse), studies show a shift from intercourse to nonpenetrative sex and to a variety of activities that involve affection, romance, affectionate physical intimacy, and companionship (46). For some older women, it is clear that the setting, whether a nursing home or a grown-up child’s home, strongly inﬂuences the opportunity for sexual expression.


Gynecology_Novak

Gynecology_Novak. If intercourse is perceived as a necessary component of sexual activity with a partner, some older women will lose motivation and interest as a result of discomfort and dyspareunia associated with lack of estrogen. Although the increase in vaginal congestion in response to visual sexual stimulation is similar in women with and without estrogen, baseline vaginal blood ﬂow is lower in estrogen-deficient women (23). Thus, the increase in lubrication may be insufficient. There may be loss of elasticity and thinning of the vaginal epithelium, which becomes vulnerable to damage from intercourse. Estrogen depletion predisposes women to vulvar vaginitis and urinary tract infections, both of which contribute to dyspareunia and reduce sexual self-image. Women who remain sexually active, alone or with a partner, may have less vulvar and vaginal atrophy than sexually inactive women but may still be symptomatic (47).


Gynecology_Novak

Gynecology_Novak. Adrenal production of testosterone precursors gradually decreases with age, beginning in the late 30s. Large epidemiological studies have not shown serum levels of testosterone to correlate with women’s sexual function (48,49). Available assays were not sufficiently sensitive in the female range of serum testosterone to detect particularly low levels. When mass spectroscopy was used: serum testosterone levels were similar in 121 women carefully assessed and diagnosed with disorders of low desire and arousability to levels in 125 women similarly carefully assessed but to exclude any sexual dysfunction (50). A second difficulty, over and beyond the unreliable assays for serum testosterone, was the fact that intercellular production of testosterone in peripheral tissues (from adrenal and ovarian) precursor hormones—DHEA, DHEA sulfate (DHEAS), and androstenedione (A4)—previously could not be measured. Total testosterone activity (ovarian and peripherally produced “intracrine production”)


Gynecology_Novak

Gynecology_Novak. precursor hormones—DHEA, DHEA sulfate (DHEAS), and androstenedione (A4)—previously could not be measured. Total testosterone activity (ovarian and peripherally produced “intracrine production”) has been measured using mass spectrometry assays for androgen metabolites, most notably androsterone glucuronide (ADT-G). There appears to be a wide range of ADT-G among women of any given age, and levels decrease with age. Importantly there were no group differences in ADT-G between 121 women carefully diagnosed with desire and arousal disorders and 124 sexually healthy controls (50).


Gynecology_Novak

Gynecology_Novak. Illnesses that accompany aging may have an impact on sexual dysfunction. The association is weaker than that between male erectile dysfunction and hypertension, hyperlipidemia, diabetes, and coronary artery disease. Depression is the major factor inﬂuencing sexual function in women with chronic illness including end-stage renal disease (51), multiple sclerosis (52), or diabetes (53). Some sexual activities (e.g., intercourse) or responses (e.g., orgasmic intensity) may be limited by arthritic, cardiac, or respiratory disorders.


Gynecology_Novak

Gynecology_Novak. Personality Factors Studies show that, compared with functional women, those who have concerns about low levels of desire and arousability are characterized as having vulnerable self-esteem, high levels of anxiety and guilt, negative body image, introversion, and somatization (18). The clinical impression of women with orgasmic disorder is that many are extremely uncomfortable in conditions in which they are not in control of circumstances or their bodily reactions. For many women with vaginismus, there is a phobic quality to the fear of vaginal penetration. Many women with provoked vestibulodynia show a marked fear of negative evaluation by others, ultra conscientiousness, and self-criticism, as well as an increase in somatization and anxiety (54).


Gynecology_Novak

Gynecology_Novak. Relationships Most women who report loss of desire and arousability to physicians indicate that their partnerships are stable and satisfactory. An environment free of conﬂict, abuse, and the threat of separation or divorce is insufficient to nurture a woman’s sexual desire. Commonly, the woman reports that her partner is not emotionally intimate with her—not willing to reveal his (or her) feelings, fears, and hopes. Additionally, the woman’s need for eroticism and variety of sexual stimulation may not be met. These women frequently classify their relationship as being that of “very good friends.” Such a context is insufficiently sexual for nurturing or triggering a woman’s sexual desire. Change of partner is shown to be a major factor in increasing women’s desire and responsiveness, and there is a lessening of innate desire with the duration of a relationship (13,34). The woman’s feelings for her partner is one of the major determinants of lack of distress about sex; similarly, the


Gynecology_Novak

Gynecology_Novak. there is a lessening of innate desire with the duration of a relationship (13,34). The woman’s feelings for her partner is one of the major determinants of lack of distress about sex; similarly, the woman’s feelings for her partner, or a change of partner, were major determinants of a woman’s desire (13,17,55).


Gynecology_Novak

Gynecology_Novak. Sexual Dysfunction in Multiple aspects of a woman’s circumstances can inﬂuence her sexual function, and one the Partner of the most important aspects is sexual dysfunction in a male partner (56). Successful treatment of a male partner’s erectile dysfunction can result in reversal of the woman’s sexual problems, including difficulties with sexual arousal, lubrication, orgasm satisfaction, and pain (45).