Combination of hormonal and psychological treatment for female sexual unresponsiveness: a comparative study

Psychological and Behavioral Treatment of Female Orgasmic Disorder

INTRODUCTION

Female orgasmic disorder (FOD) is defined as the absence, delay, infrequency, or marked diminishment in intensity of orgasm in at least 75% of sexual experiences, persisting for at least 6 months and causing distress, has specified subtypes, and affects up to 28% of women in the United States and up to 46% in countries across Asia. Orgasmic difficulties are relatively common and create distress for a substantial number of women, though efficacious treatments exist.

OBJECTIVE

This article provides a review of psychological treatment of FOD.

METHODS

A literature search was conducted using PsycINFO to identify research reporting methods and outcomes of psychological treatment of FOD in peer-reviewed journals and textbooks. Search terms were female orgasmic disorder, anorgasmia, female sexual dysfunction, and orgasm. This search was supplemented with hand-searching references of review articles and journal articles.

RESULTS

Psychological treatment has been shown to be effective in helping women with FOD to gain or regain the ability to have orgasms, with higher success rates overall of treating lifelong or generalized vs acquired or situational FOD. Of the variety of treatment approaches that have been tested, the most consistent support emerges for directed masturbation, sensate focus, and psychotherapy. Approaches with little evidence for efficacy as a primary mode of treatment include systematic desensitization, bibliotherapy, and coital alignment technique training.

CONCLUSION

While existing research provides a solid foundation of knowledge, treatment of FOD has seen little innovation since the 1980s. Future research should aim for broader understanding of etiologies of all types of FOD, understanding reasons for lack of treatment success for women who have not improved with treatment, and identifying ways of tailoring FOD treatment and success rates for multicultural and community populations. Erica Marchand. Psychological and Behavioral Treatment of Female Orgasmic Disorder. Sex Med Rev 2021;9:194-211.

Effect of androgens combined with hormone therapy on quality of life in post-menopausal women with sexual dysfunction

AIM

To evaluate with validated instruments changes in quality of life and sexuality in women receiving hormonal replacement therapy (AHT).

DESIGN

Randomised, double-blind, double-dummy study with two parallel treatment arms.

PATIENTS AND METHODS

Forty-seven healthy post-menopausal women, aged 45-64 years, were evaluated using the Female Sexual Function Index (FSFI) and the menopause-specific quality of life questionnaire (MENQOL). Of them, 40 diagnosed with sexual dysfunction were randomised (1:1) to receive daily 0.625 mg of conjugated estrogens plus 1.25 mg of methyl-testosterone and 100 mg of micronised progesterone or placebo. After 3 months follow-up, FSFI and MENQOL questionnaires were administered for a second time.

RESULTS

Quality of life was unchanged in the placebo group whereas AHT significantly improved scores of vasomotor, psychological, physical and sexual symptoms. As expected, FSFI was not modified in the placebo group while in AHT group the FSFI score improved significantly. In addition, at the end of the study, 68.7% of subjects of the AHT group did not fit did not fit the criteria for sexual dysfunction as per the FSFI (p < 0.0001).

CONCLUSIONS

Adding methyl-testosterone to hormone therapy improves quality of life and sexuality in post-menopausal women with sexual dysfunction.

Basic science and neurobiological research: potential relevance to sexual compulsivity

A unique challenge posed by advancing scientific knowledge about the biology of human behavior is how to integrate that understanding with the desire to hold ourselves--and one another--morally accountable. As human beings, we are something more than just passive agents whose behavior is the sum product of biologic determinism. Because of the existence of the mind, we are also active agents with the capacity to influence, at least to some extent, our own destinies. Behavior may be determined, but it is not predetermined. We are one of its determinants. Misconduct by a person of sound mind should not be attributed improperly to brain pathology. On the other hand, suffering, legitimate mental disorder, and associated impairments should not be trivialized. Historically, persons who once were labeled "lazy" are often more appropriately understood by modern standards as clinically depressed. Frequently they are more in need of pharmacologic treatments that alter brain chemistry than "a kick in the behind." Gluttony, one of the original cardinal sins, is often more properly understood as morbid obesity, a condition that deserves appropriate medical care. Persons who have alcoholism, once judged morally as "bums in the gutter," are more frequently referred to treatment facilities, such as The Betty Ford Clinic. One should not approach the issue of human sexual behavior without at least some appreciation of moral values and scientific research. Although clearly some persons choose to act in a sexually selfish and self-indulgent fashion with wanton disregard, others seem to be more genuinely burdened and struggle to integrate their sexual desires into an otherwise healthy and fully responsible lifestyle. When a person, whether male or female, seems to be so driven that it becomes difficult to master erotic desires and he or she experiences difficulty serving his or her own best longterm interests, the concept of sexual compulsivity seems to be relevant. Ultimately, a better understanding of any associated neuropathologies may help to facilitate future treatments and public acceptance. The possibility exists, at least in some instances, that a sexually compulsive individual is less an example of a bad person deserving of punishment than a "broken mind" in need of repair. In time, increased knowledge about the precise workings of the brain in reciprocally initiating and sustaining the sexual interests of the mind may facilitate a much clearer appreciation of the issues at hand.

Sexual effects of androgens in women: some theoretical considerations

OBJECTIVE

To consider explanations for the inconsistent evidence concerning behavioral effects of androgens in women. The following possible explanatory mechanisms are explored: [1] Women vary in their behavioral responsiveness to T. [2] Some reported effects of exogenous T may be induced by increasing bioavailable estrogen. [3] Sexual effects of T may be secondary to direct effects on mood. [4] The relationship between T and sexuality is readily obscured by psychological mechanisms. [5] Stress-induced increases in adrenal androgens may further confuse the picture. [6] Women who respond to T respond to levels that are ineffective in men. There is no evidence of a threshold in women above which further increases in T have no additional effect.

CONCLUSION(S)

A theoretical model, involving desensitization of the central nervous system to T during early development in the male, is presented as a possible explanation for some of these relevant differences between men and women and for much of the conflicting evidence in the literature on women.

Hormonal and non-hormonal interventions for menopausal symptoms

Recent cohort studies confirm that only flushes, night sweats and vaginal dryness are provenly associated with ovarian failure. Experiments nave demonstrated that these symptoms and insomnia associated with nocturnal vasomotor symptoms are more effectively controlled by oestrogen than placebo. Hormonal interventions include a variety of oestrogen or oestrogen/progestogen regimes. Non-hormonal treatments of flushes include exercise, paced respiration and psychotherapy. After the menopause vaginal atrophy and some urinary symptoms respond to local oestrogen and vaginal dryness in also prevented by lubricants. Libido is not increased by oestrogen therapy but may be improved by testosterone. Depression is common in middle-aged women but is not specifically associated with the hormonal changes occurring at the menopause. Oestrogen therapy may improve and stabilise mood during the peri-menopause but there is no firm evidence that it is effective for depression after the menopause. Arthralgia is not a symptom specific to menopause and experimental evidence concerning the role of oestrogen in the treatment of rheumatoid arthritis is inconclusive. Cognitive function is not related to menopause and measures such as stopping smoking, exercise and maintaining body weight may be partly effective in preventing menopausal symptoms.

Treatment of sexual dysfunctions by sex therapy and other approaches

BACKGROUND

The treatment of sexual dysfunctions underwent a great change when sex therapy was developed more than 25 years ago. Since then the treatment programme has been modified in various ways, the response to treatment evaluated and other treatment approaches introduced.

METHOD

A review of the literature concerning the application and outcome of sex therapy and other treatments for sexual dysfunction was conducted.

RESULTS

The format of effective conjoint sex therapy is now fairly clear and there is good understanding of the sexual dysfunctions that respond best to this treatment and the couples most likely to benefit. Less is known about the effects of treatment of individuals without partners, bibliotherapy and combining sex therapy with marital therapy and with physical methods of treatment.

CONCLUSIONS

Sex therapy is now a well-established form of treatment. It should be more widely available for patients seen in psychiatry departments.

Androgens and sexuality

A review of the literature reveals that the endocrine determinants of female sexuality are complex and difficult to characterize. In adolescent males, free testosterone directly affects sexual motivation, with social factors exerting little or no effect. In adolescent girls, by contrast, societal and peer pressure play a pivotal role in the appearance of certain sexual behaviors. Throughout a woman's life, hormonal and psychosocial factors are critical influences. It is possible that cyclic patterns of testosterone are less important for female sexual behavior than the "tonic" effect of overall testosterone levels. Although the estrogen dependence of the vaginal epithelium--important for postmenopausal women--has been clearly established, the role of other hormonal factors and treatments, particularly those involving androgens, in human female sexual behavior remains enigmatic. The search for an understanding of these relationships is not merely an interesting academic exercise but is necessary to determine what role, if any, androgens may play in the treatment of sexual dysfunction during the female reproductive years.

Gender differences in behaviour: activating effects of cross-sex hormones

The relative contribution of organizing and activating effects of sex hormones to the establishment of gender differences in behaviour is still unclear. In a group of 35 female-to-male transsexuals and a group of 15 male-to-female transsexuals a large battery of tests on aggression, sexual motivation and cognitive functioning was administered twice: shortly before and three months after the start of cross-sex hormone treatment. The administration of androgens to females was clearly associated with an increase in aggression proneness, sexual arousability and spatial ability performance. In contrast, it had a deteriorating effect on verbal fluency tasks. The effects of cross-sex hormones were just as pronounced in the male-to-female group upon androgen deprivation: anger and aggression proneness, sexual arousability and spatial ability decreased, whereas verbal fluency improved. This study offers evidence that cross-sex hormones directly and quickly affect gender specific behaviours. If sex-specific organising effects of sex hormones do exist in the human, they do not prevent these effects of androgen administration to females and androgen deprivation of males to become manifest.

The female androgen deficiency syndrome

We evaluated the sexual functioning of 11 women who developed demonstrable androgen deficiencies after undergoing chemotherapy with cytotoxic agents and/or bilateral salpingo-oophorectomies for a variety of medical conditions. For comparison, we evaluated the sexual status of 11 subjects with comparable medical, menopausal, marital, and sexual histories, whose levels of circulating testosterone were within normal limits. The results of this clinical study confirm and extend the observations originally made by Waxenberg and his colleagues in 1959, that testosterone deficiency in women produces a marked decrease in libido and sexual responsiveness. Our findings further indicate that the female androgen deficiency syndrome is often indistinguishable from psychogenic desire disorders on clinical grounds alone.

Hypothalamic involvement in sexuality and hostility: comparative psychological aspects

Evidence presented in this article shows the representation of sexual and aggressive behaviors at the level of the hypothalamus to be more prominent than in all other brain areas involved. Indeed, there are good arguments to attribute a central position to the hypothalamus within larger structural systems encompassing the limbic system, where aspects of the behaviors involved can be influenced. So far, however, the arguments are purely descriptive and factual and do not contribute much to answering questions about hypothalamic function: the grounds for and consequences of this massive representation of apparently almost all emotionally relevant social behavioral complexes, so universally established in a diversity of species, still has to be detected. A second and equally important aspect of hypothalamic function obviously has to be related to its central position within various hormonal systems. The present article concentrated on the acute dynamics and behavioral significance of activation of the pituitary-adrenocortical and pituitary-gonadal axes. Evidence indicates that the unconditioned behavioral stimuli or the consequences of behavior, but also stimuli conditioned to emotionally relevant events, may drastically alter hypothalamic hormonal regulation. Most importantly, these hormonal consequences in themselves again seem to determine further behavior and responses in relevant situations. The evidence presented with respect to reward and aversion, associated with alterations of specific hormones of the gonadal axis, may add a new dimension to our understanding of psychoendocrine functions of the hypothalamus (see also Gary, 1975; Leshner et al., 1981; Carey, 1987). Psychologically, such data can be taken as an argument for a more thorough study of the relation between memory processes and emotion (Bower et al., 1981). However fragmentary and incomplete this review may be, it will be clear that hypothalamic substrates and directly related areas, as well as affiliated hormonal mechanisms, play a central role in many of the most complex motivational and emotional syndromes and disorders. The prime idea in this is that the psychological concomitants of hypothalamic (dys)function are as much output as input, and as much the consequences as the cause within related syndromes. Such a view places the hypothalamus at the core of psychological theories of emotion and motivation, which from their most early origin have been heavily set towards hormonal and humoral changes and their relationships with psychological experience.(ABSTRACT TRUNCATED AT 400 WORDS)

Low sexual desire: sex therapy results and prognostic factors

In a prospective study of 60 couples who entered sex therapy because of the female partners' low sexual desire, 38 (63.3%) completed treatment and 34 (56.7%) had a positive outcome. The principal predictor of completion of treatment was the male partners' apparent motivation at the outset. Poorer outcome was associated with younger age of the couple (especially the male partner) and a shorter duration of the sexual problem. Surprisingly, few aspects of the couples' general relationships prior to treatment were related to outcome, except for poorer outcome being associated with a history of previous separations. The apparent lack of significant contribution of general relationship factors and psychopathology to outcome probably reflects the stringency of the initial selection process. Eventual outcome was also related to couples' progress by the third treatment session. The modest outcome of treatment for low sexual desire in this and other studies emphasises the need for further understanding of factors which contribute to this problem and for the development of novel treatment strategies.

Emotional well-being, sexual behaviour and hormone replacement therapy

Improvements in the design of epidemiological studies of the climacteric and postmenopause have been made in the past 25 years. But more complex theoretical models are necessary if we are to give due emphasis to the influence of psychological, social, cultural and hormonal factors and their interactions. The majority of studies show that emotional problems are not more prevalent during the climacteric and postmenopause and that psychosocial factors, such as stressful life-events, are more likely causes of emotional distress during mid-life. Vaginal dryness increases in postmenopausal women but there are varied reasons for changes in other aspects of sexual behaviour which require further research. While estrogen may have a "mental tonic" effect when prescribed in high doses, HRT does not appear to have a significant effect upon mood or sexual behaviour over and above placebo effects and the relief from vasomotor and vaginal symptoms.

Effects of adrenalectomy upon proceptivity, receptivity and sexual attractiveness in ovariectomized marmosets (Callithrix jacchus)

The sexual behaviour of seven pairs of marmosets was observed during blocks of 30 minute tests before and after the ovariectomized partners were bilaterally adrenalectomized. Adrenalectomized females were maintained by intramuscular injections of deoxycorticosterone pivalate (DC) and hydrocortisone hemisuccinate (HC). Twice daily injections of HC were required to maintain the high levels of plasma cortisol typical of marmosets and some other New World primates. Adrenalectomy had no significant effects upon proceptivity, receptivity or female sexual attractiveness. Increasing the replacement dose of DC had no effects upon sexual behaviour. Oestradiol treatment caused a marked increase in proceptivity (tongue-flicking, staring and immobile displays) and in receptive tongue-flicking behaviour. Males ejaculated more frequently during tests with oestradiol-treated partners. These results indicate that during "pair tests" adrenocortical sex steroids are not essential for maintenance of sexual behaviour in female marmosets and that activation of proceptivity by oestradiol 17 beta can occur in the absence of the adrenal glands.

Sex therapy outcome research: a reappraisal of methodology. 1. A treatment study of male sexual dysfunction

In the first section a controlled treatment study of male sexual dysfunction is described. 'Unlucky' randomization of subjects yielded treatment groups which differed with respect to variables of possible prognostic significance. Hence the results are largely uninterpretable. In the second section the predominantly negative or inconsistent findings in sex therapy outcome research are reviewed and methodological problems, such as those described in the first part, are considered as possible reasons for these negative findings. The interrelationships are explored between small treatment groups, prognostic variability, bias, power, and small expected treatment effects. A strategy for future research is proposed, with particular emphasis on the recognition and use of relevant prognostic indices.

Factors related to successful outcome in the treatment of sexually unresponsive women

Couples in whom the main complaint was of a lack of female sexual response were treated using a practical counselling approach. A number of pre-treatment measures were studied to determine which factors were predictive of treatment outcome. While age and chronicity were not predictive, the quality of the general relationship and measures of sexual attitude did give useful indications of likely outcome.

Hormones and human sexual behavior

The role of sex hormones in the sexuality of men is now becoming clearer. Androgens are necessary for normal sexual appetite and for ejaculation. Erectile mechanisms, providing that appropriate erotic stimuli are available, are probably not androgen dependent. How much testosterone is required to obtain maximum sexual effect is not yet clear but it probably varies from individual to individual and may be well within the normal range in some men. Androgens may therefore be beneficial in treating loss of sexual appetite in men but are unlikely to improve erectile dysfunction unless it is secondary to loss of sexual appetite. In women the picture is much less clear. Apart from the estrogen dependence of the vaginal epithelium, important for the postmenopausal woman, female sexuality shows a very unpredictable relationship with reproductive hormones. Possible reasons for this variable picture are discussed, in particular a greater genetic variability and behavioral sensitivity to hormones in women than in men.

Psychological and hormonal factors in the treatment of female sexual dysfunction

Forty-eight couples with a presenting problem of female sexual unresponsiveness were treated in a controlled study using a balanced factorial design. The factors varied in this design were medication (testosterone or placebo), treatment frequency (weekly or monthly sessions), and the number of therapists involved (one female or a male/female pair). All counselling was adapted from that described by Masters & Johnson (1970) and Heiman et al. (1976). Results were assessed before and after a 3-month treatment period, and again 6 months later. Contrary to expectations from earlier work, there was no benefit attributable to testosterone or to the use of two therapists; self-ratings favoured weekly sessions with one therapist. It was concluded that testosterone (at least in the dosage used) is unlikely to have a useful place in the treatment of sexually unresponsive women, but that weekly counselling sessions with a single therapist is a reasonably effective and economic form of sex therapy. Findings from this research suggest the need for a clearer understanding of aetiological and treatment mechanisms.

Methodological issues in the study of sex therapy: effective components in the treatment of secondary orgasmic dysfunction

Three components commonly utilized in sex therapy for secondary orgasmic dysfunction (Sensate Focus I, Sensate Focus II, and ban on intercourse) were studied, with the aim of not only exploring their effects on therapy outcome but also, in part, of sensitizing investigators to the benefits of incorporating component analyses within larger investigations of therapy outcome. The subjects were 23 married couples with the problem of secondary orgasmic dysfunction in the wife. Subjects were administered a multicomponent therapy program over a 14-week period. Daily self-monitoring data were analyzed to assess the impact of Sensate Focus exercises and banning intercourse on both broad (e.g., enjoyment) and narrow (e.g., orgasmic response) criteria of therapeutic effectiveness. Results indicated that for females, sensate focus exercises, in combination with a ban on intercourse, led to a significant increase in level of enjoyment for subsequent noncoital sexual caressing as well as intercourse. Orgasmic responsiveness, however, was not affected. The methodological issues of broad versus narrow therapeutic effects, compliance with treatment, and cost-effective techniques for the study of sex therapy components are discussed.

Progress in the treatment of female sexual dysfunction

Over a decade of research since the publication of Human Sexual Inadequacy by Masters and Johnson has confirmed the effectiveness of psychological treatment for sexual problems, but has not advanced our understanding of aetiology very much. It is generally assumed that anxiety blocks normal function in sexual disorders such as impotence or frigidity, although hormonal changes have also been suggested. Evidence for either proposition is lacking. Our own attempts to understand mechanisms have included the use of a dismantling strategy to investigate the effective components of psychological treatment, and latterly the role of exogenous androgens. In our first study, brief treatment modelled on that of Masters and Johnson proved superior to another version of graded practice in sexual contact which lacked the counselling component. Similarly, the fuller version had more effect than did imaginal desensitization, suggesting that sexual dysfunctions cannot be treated like phobic anxiety. A second study focused on women complaining of little sexual interest or enjoyment. The use of a minor tranquillizer was compared with that of androgen (testoral) in the hope that different treatments would be shown to be best for different types of disorder. Unexpectedly, the androgen proved best overall while another variable, monthly vs weekly sessions, did not produce any differences in effect. In the most recent study, a further 48 women were given androgens or placebo, and were seen weekly or monthly for four months by either one or two therapists. There were few significant differences, the most consistent being greater subjective improvement by the women being seen at weekly intervals. The failure to find a positive hormone effect in comparison with placebo raises the possibility that the anxiolytic used earlier may have been counter-productive. If so, it seems unlikely that either excessive anxiety or simple androgen deficiency is an adequate aetiological explanation for female sexual dysfunction.

Personality and sexuality in relation to an index of gonadal steroid hormone balance in a 70-year old population

Relationships between an index of gonadal steroid hormone function and personality as well as sexual activity were studied in a sample representative for 70-year-olds in Gotenburg, Sweden. Personality was described by means of inventories, sexual activity through a systematic interview and the balance between androgen and oestrogen activity by the quotient between lecithin and lysolecithin in plasma. Men with a relative dominance of oestrogen activity reported a lower frequency of sexual intercourse than other men. Women with a relative dominance of oestrogen activity described themselves as more resourceful, active, confident, unconcerned with the opinion of others, and able to take care of themselves than other women. There were no associations in women between the hormonal balance and the frequency of sexual intercourse.

Pharmacosexology: the effects of drugs on sexual function a review

The literature on the sexual side effects of drugs and chemicals has been reviewed. There are many substances which alter the human sociosexual response cycle either negatively, positively or both. Many of the drugs used therapeutically have been reported to have adverse effects on sexuality, and this must be taken into account when these drugs are used clinically. Many substances which are used for recreational purposes (or sometimes abused) also have profound effects on sexual response. Many of these substances are used in such a way that they can correct underlying sexual problems. Treatment of a drug abuser may well prove unsuccessful without consideration of preexistent sociosexual problems and concerns. From the dawn of recorded history, many substances have been used for the purpose of sexual enhancement. Some of these have known success and their reputations have been passed down through the millenia. The chapter has not yet been closed on aphrodisiacs, even though none have survived the rigors of scientific scrutiny. As long as humans place value on optimal sexual functioning, there will be a demand for sex-enhancing drugs. In order for the scientific and medical community to successfully meet these challenges, more effective and relevant study designs will have to be utilized in order to separate fact from fancy. The study of pharmacosexology is in its infancy, and in order for it to grow and contribute to the world body of knowledge, more researchers and clinicians must be trained in both pharmacology and sexology.

Psychophysiological aspects of sexual dysfunction

The argument is made that human sexual dysfunction is particularly well suited for investigation within the conceptual framework embraced by psychophysiology, due to the unique participation of both physiological and psychological components in the sexual response cycle. The literature relating psychophysiological research to the investigation of sexual dysfunction is reviewed, indicating promising applications in the diagnosis and treatment of some sexual dysfunctions as well as in the evaluation of sex therapy programs and the testing of medical theories about the etiology and maintenance of sexual dysfunctions.

Training in the mangement of psychosexual problems

Personnel from a variety of professional backgrounds meeting in a weekly group have been trained to carry out effective treatment of patients with psychosexual problems. The skills necessary in this type of work and the training method are described. Assessment of outcome for forty consecutive couples treated by trainees revealed significant improvement in 70%. The advantages and disadvantages of this type of training are discussed.

Androgens and sexual behaviour in women using oral contraceptives

Twenty women using oral contraceptives and complaining of impaired sexual function were compared with twenty women without sexual problems, matched for age and oral contraceptive. Whilst the sexual behaviour differed in the two groups, the plasma testosterone, androstenedione, oestradiol and SHBG concentrations were very similar. The total androgen levels were low in both groups. Plasma testosterone and oestradiol concentrations were correlated with measures of sexual interest in the no-problem group, but not in the problem group. Administration of exogenous androstenedione to women in the problem group, using a double blind cross-over comparison with a placebo, failed to improve their sexual function except in one case. The majority of women showed a rise in androgen and oestradiol between day 24 of one pill cycle and day 4 of the next. The possible behavioural indications of this pattern are discussed.

Androgens and human sexual behaviour

Androgens are generally believed to be necessary for normal sexual responsiveness in the human male and female. The evidence for this is limited and sometimes conflicting. This paper considers evidence from experiments in which exogenous androgens are given to people with impaired sexual response. Results from a study in which testosterone was given to unresponsive women are reported, together with the preliminary results of giving androstenedione to sexually unresponsive women taking oral contraceptives and giving testosterone undecanoate to hypogonadal males. In the first study, when testosterone was combined with counselling, significant effects were produced by the addition of testosterone. In the androstenedione study, where no counselling was given, beneficial effects of the androgen have been unusual. Examples of the evaluation of androgen replacement in hypogonodal males are also presented. Finally, some methodological problems of evaluating the effects of exogenous hormone in human sexual behaviour are briefly discussed.