Destigmatizing Female Sexual Dysfunction

Urologist Karen Boyle tackles female sexual dysfunction.


July 3, 2008— -- As many as four in 10 women suffer from sexual dysfunction that can be both physically and emotionally damaging, according to the Mayo Clinic.

Many women remain untreated because of the taboos associated with female sexual dysfunction, a term that relates to problems that affect a woman's sex life, including inability to achieve orgasm, decreased sex drive, arousal disorder, vaginal dryness and sexual pain disorders.

But one urologist hopes to debunk the myths and remove the stigmas to help women suffering from sexual dysfunction.

Dr. Karen Boyle, a urologist at Johns Hopkins Hospital who specializes in both male and female sexual dysfunction, said that many women have misconceptions about their sexual problems that stem from being told "it's all in your head."

"There's still this perception that these problems are psychogenic, that if a woman gets more rest, takes a bubble bath, focuses on romance, her problems will go away," Boyle said. "I think romance is important, but if you have underlying sexual dysfunction, it's not going to matter how romantic you are."

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The women who see Boyle fill out a female sexual function index, a screening tool. For a woman to be diagnosed with FSD, she must be distressed by her symptoms.

"There are a fair amount of women who have issues but really don't care. If a woman has never had an orgasm, but she isn't troubled by that, she doesn't have FSD," Boyle said.

Even if the symptoms do not bother a woman, Boyle said that they still may be an important indicator of her overall health.

"Erectile dysfunction in men is one of the biggest indicators of small vessel disease, diabetes and high cholesterol," Boyle said.

Although this link has not been studied in women, Boyle said that certain symptoms can suggest bigger problems for women.

"A woman's response to stimulation and her ability to orgasm depend on blood flow to the clitoris. A problem with either could be an indicator of cardiovascular disease," she explained. "Arousal disorder, on the other hand, can be caused by hormonal imbalances, and these same imbalances can also cause bone disease, like osteoporosis, in women."

Boyle expanded her urology practice to include FSD patients when she realized the importance of treating both partners in a couple.

"I would treat men who had erectile dysfunction, and we'd get them working again, and they still wouldn't be having sex," Boyle said.

Patients began asking Boyle whether there was anything she could do to help their partners with sex drive, dryness and arousal problems. Today she prides herself in her practice that focuses on optimizing sex for both partners.

"As a urologist," as opposed to being a gynecologist, "I am in a unique position to work with both men and women."

Although she dismisses the long-held belief that women's sexual problems are merely psychogenic, Boyle acknowledges that sexual dysfunction can cause emotional problems for a couple, and ultimately break down a relationship. She encourages both partners to be involved in treatment, calling her work "couples therapy."

"Inviting the significant other allows them to see it's not them, that they're not too fat or not sexy enough or simply not doing the right thing to arouse their partner. It's a medical problem," Boyle said.

The little blue pill changed the way our culture views erectile dysfunction. Celebrities have hyped the drug on television, and a problem that was once kept under the covers is now discussed openly.

Practitioners debate the merits of using Viagra to treat women with FSD.

Boyle said that she sometimes prescribes it for male patients with normal hormonal balance and problems achieving orgasms. She notes that Viagra helps with blood flow but does not affect libido.

Centrally acting drugs that target certain chemical receptors in the brain — and are designed to increase sex drive — have yet to be approved by the FDA for treatment of FSD.

"The development and approval of a drug for FSD would break the barrier down," she said.

Boyle argues that women, like men, will feel more comfortable discussing sexual dysfunction with their doctors if they feel doctors have something to offer them.

For now, there is no magic pill for women with FSD, and even if there were, Boyle's approach to treatment would still start with the basics.

"Often, treatment of FSD begins with medical management of an underlying problem, like a yeast infection that has been undiagnosed or just never really went away," Boyle said.

While an infection can obviously hamper enjoyment, sometimes the problem stems from hormonal changes.

"Hormonally, women are set up for issues their whole lives," Boyle said, noting that contraceptives, pregnancy and menopause can alter a woman's hormone levels, change her sex drive and decrease her ability to experience sexual pleasure. "It's really a roller coaster for women during and following their reproductive years."

Hormone treatment is controversial because of possible side effects. But according to Boyle, even women who are concerned about the systemic effects of hormone therapy can benefit from localized treatment. For instance, Boyle prescribes estrogen crème, which is applied directly to the vagina to increase natural lubrication in postmenopausal women.

Boyle encourages some patients who have issues with vaginal penetration to experiment with vibrators and vaginal dilators. "It's a way to allow stimulation and to practice achieving an orgasm," she said.

Vibrators have gotten a bad rap, Boyle said. Some women dismiss a vibrator as a sex toy and do not consider it a viable treatment option. Women who have never masturbated sometimes find these tools beneficial, she said, adding, the treatment allows them to figure out what works.

"They can't communicate to a partner what they themselves don't know," Boyle said.

She suggests that women select vibrators and dilators without bells and whistles. "Nothing fancy. Just functional and safe," she said.

There is even an FDA-approved device for the treatment of sexual arousal disorder. Not to be confused with a vibrator, Eros Therapy is a system comparable to the vacuum pump designed to help men achieve an erection. A small cap fits over the clitoris, and suction draws blood into the area. By encouraging blood flow, it "helps with genital engorgement and vaginal lubrication," Boyle said.

Pain disorders such as vaginisimus and vestibulitis can be difficult to treat. Boyle turns to biofeedback and physical therapy as part of her standard treatment plan. When these options fail, sometimes she suggests more invasive procedures.

In women with vaginisimus, vaginal muscle contractions cause painful spasms. These muscles clamp down so tightly they can prevent penetration.

Sometimes Boyle injects Botox into these problematic muscles. Botulinum toxin, the same chemical used to decrease the appearance of wrinkles, paralyzes muscles. Boyle considers Botox treatment a last resort because it is not always effective and almost never permanent.

An even more extreme treatment exists for women with vestibulitis — a difficult to cure pain disorder with no known cause. Boyle first tries medical management, biofeedback and physical therapy. On rare occasions, and as a last resort, Boyle performs a vestibulectomy — surgical removal of the painful tissue and glands.

"I'm very cautious about operating for pain, because the surgery itself can result in more pain," Boyle said. "But for some it's an effective treatment."

Boyle focuses on treating FSD as a biological rather than psychological condition, but she acknowledged that for some couples, sexual dysfunction is only part of their problem.

Sometimes she encounters couples who need more psychological therapy than she is qualified to perform. For these patients, she refers them to a practicing sex therapist. For the vast majority of her patients, Boyle combines practical advice about intimacy with solid medical treatment.

Boyle said that there is stigma attached to female sexuality that prevents many women from addressing these intimate issues with their doctors. Despite her strides in the field, Boyle said that there is still a discrepancy between how male and female sexual issues are dealt with in the medical community. Doctors do not know about the full spectrum of treatment options for women with FSD, she said.

"The gender bias still exists. We have so many really good medical treatments for men. When the FDA approves a drug for the treatment of FSD it will give real credibility to the biological basis of this type of disease," Boyle said.

Before that can happen, she said more people need to commit to doing research and practice this subspecialty of medicine.

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