comport. sexual nou- 2016

8/18/2019 Comport. Sexual NOU- 2016

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ComportamentulComportamentul

sexualsexual

Conf.Conf. Dr.Dr. Daniel GrigorieDaniel Grigorie CatedraCatedra de Endocrinologie,de Endocrinologie,UMF “Carol Davila”,UMF “Carol Davila”,

Institutul “C.I.Parhon”Institutul “C.I.Parhon”, Bucureşti, Bucureşti


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ISTORICISTORIC

Kaasutra ! "riul tratat e#"licit de se#ologie uanaKaasutra ! "riul tratat e#"licit de se#ologie uana

Kinse$ ! varia%ilitatea "racticilor se#uale la aericaniKinse$ ! varia%ilitatea "racticilor se#uale la aericani

Masters si &ohnson ' la a%ele se#e e#ista ras"unsuriMasters si &ohnson ' la a%ele se#e e#ista ras"unsuri

()iologice "revi)i%ile du"a stiularea se#uala si au()iologice "revi)i%ile du"a stiularea se#uala si audescris ciclul ras"unsului se#ual noral "e %a)a caruiadescris ciclul ras"unsului se#ual noral "e %a)a caruia

se clasi(ca dis*unctiile se#ualese clasi(ca dis*unctiile se#uale

Freud ! atri%uie "ro%leele se#uale ale adultuluiFreud ! atri%uie "ro%leele se#uale ale adultului

di(cultatilor aturarii se#uale in co"ilarie si de)voltariidi(cultatilor aturarii se#uale in co"ilarie si de)voltarii

relatiilor "arinte+co"ilrelatiilor "arinte+co"il -/ ! elucidarea ec. ()ico+chiice ale erectiei, care-/ ! elucidarea ec. ()ico+chiice ale erectiei, care

este consecinta rela#arii uschilor cavernosi si aeste consecinta rela#arii uschilor cavernosi si a

cresterii 0u#ului sg. "enian, ediate de 12cresterii 0u#ului sg. "enian, ediate de 12


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INTRODUCEREINTRODUCERE

Endocrine disease and its treatent can *re3uentl$Endocrine disease and its treatent can *re3uentl$

distur% se#ual *unction in en and 4oen.distur% se#ual *unction in en and 4oen.

In addition, "atients a$ %elieve, o*ten incorrectl$,In addition, "atients a$ %elieve, o*ten incorrectl$,

that their se#ual d$s*unction ust necessaril$ %e duethat their se#ual d$s*unction ust necessaril$ %e dueto horonal i%alance and see5 anageent *roto horonal i%alance and see5 anageent *ro

endocrinologists.endocrinologists.

Patients consider their se#ual lives to %e i"ortant6Patients consider their se#ual lives to %e i"ortant6

recogni)ing the i"ortance o* se#ual *unction as arecogni)ing the i"ortance o* se#ual *unction as a

deterinant o* 3ualit$ o* li*e, the 7orld 8ealthdeterinant o* 3ualit$ o* li*e, the 7orld 8ealth2rgani)ation declared2rgani)ation declared sexual health a fundamentalsexual health a fundamental

right of men and womenright of men and women


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!"E#E CIC#U#UI SE$U!#!"E#E CIC#U#UI SE$U!#

9he traditional odel o* huan se#ual res"onse 9he traditional odel o* huan se#ual res"onse

steing *ro the research o* Masters, &ohnson, andsteing *ro the research o* Masters, &ohnson, and

Ka"lan envisioned a linear "rogression *ro desire toKa"lan envisioned a linear "rogression *ro desire to

arousal to a "lateau o* high arousal *ollo4ed %$arousal to a "lateau o* high arousal *ollo4ed %$orgas:e;aculation, *ollo4ed %$ a "hase o* resolutionorgas:e;aculation, *ollo4ed %$ a "hase o* resolution..

In ar5ed contrast to this earlier odel de"icting aIn ar5ed contrast to this earlier odel de"icting a

linear invaria%le "rogression o* discrete "hases, recentlinear invaria%le "rogression o* discrete "hases, recent

research conce"tuali)es se#ual res"onse as aresearch conce"tuali)es se#ual res"onse as a

otivation:incentive+%ased c$cle co"rising "hases o*otivation:incentive+%ased c$cle co"rising "hases o*"h$siologic res"onse and su%;ective e#"erience."h$siologic res"onse and su%;ective e#"erience.

9he "hases o* the c$cle overla" and their order is 9he "hases o* the c$cle overla" and their order is

varia%levaria%le


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R!S%UNSU# SE$U!# ESTE CIRCU#!RR!S%UNSU# SE$U!# ESTE CIRCU#!R

Poate ince"e cu stiuli nu nea"arat se#ualiPoate ince"e cu stiuli nu nea"arat se#uali

Dorinta si e#citatia co+e#ista si se "otentea)aDorinta si e#citatia co+e#ista si se "otentea)a

reci"roc.reci"roc.

In %oth en and 4oen, the relationshi"In %oth en and 4oen, the relationshi"

%et4een desire and arousal is varia%le and%et4een desire and arousal is varia%le and

co"le#, and %oth are o*ten una%le toco"le#, and %oth are o*ten una%le to

se"arate the t4o.se"arate the t4o.

E#citatia su%iectiva este ai i"ortantaE#citatia su%iectiva este ai i"ortanta

decat congestia genitaladecat congestia genitala


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%r&esarea &ere'rala e esentiala%r&esarea &ere'rala e esentiala

Even 4ith su=cient se#ual otivation and theEven 4ith su=cient se#ual otivation and the

"resence o* ade3uate stiuli, the arousal and"resence o* ade3uate stiuli, the arousal and

"leasure a$ not occur i*"leasure a$ not occur i* attention is not fo&usedattention is not fo&used..

>e#ual in*oration is "rocessed in the ind %oth>e#ual in*oration is "rocessed in the ind %othautoaticall$ and consciousl.9he se#ual nature o* theautoaticall$ and consciousl.9he se#ual nature o* the

stiuli is "rocessed %$ the li%ic s$ste, allo4ingstiuli is "rocessed %$ the li%ic s$ste, allo4ing

genital congestion ?o%served to %e 3uic5 andgenital congestion ?o%served to %e 3uic5 and

autoatic in 4oen and slo4er %ut still involuntar$ inautoatic in 4oen and slo4er %ut still involuntar$ in

[email protected]@.

Conscious a""raisal o* the se#ual stiuli and theConscious a""raisal o* the se#ual stiuli and the

conte#tual cues can lead to su%;ective arousal.conte#tual cues can lead to su%;ective arousal.


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(OTI)!TII*STI(U#I(OTI)!TII*STI(U#I

9he otivations and incentives *or se# are ulti"le and 9he otivations and incentives *or se# are ulti"le and

variedvaried and enhance eotional intiac$ %et4een theand enhance eotional intiac$ %et4een the

"artners is i"ortant *or %oth en and 4oen."artners is i"ortant *or %oth en and 4oen.

De"ression is a a;or cause o* reduced se#ual otivationDe"ression is a a;or cause o* reduced se#ual otivation

in other4ise health$ "ersons and in those 4ith endocrinein other4ise health$ "ersons and in those 4ith endocrinedisease' re"eatedl$, coor%id de"ression has %eendisease' re"eatedl$, coor%id de"ression has %een

identi(ed as a *actor underl$ing increased se#ualidenti(ed as a *actor underl$ing increased se#ual

d$s*unction in 4oen 4ith dia%etes.d$s*unction in 4oen 4ith dia%etes.

Even in the a%sence o* clinical de"ression, lo4 se#ualEven in the a%sence o* clinical de"ression, lo4 se#ual

interest is associated 4ith having ore de"ressed andinterest is associated 4ith having ore de"ressed and

ore an#ious thoughts and lo4er se#ual sel*+iage thanore an#ious thoughts and lo4er se#ual sel*+iage than

that in control su%;ects.that in control su%;ects.

Endocrine disorders can ar5edl$ lessen se#ual sel*+iageEndocrine disorders can ar5edl$ lessen se#ual sel*+iage

es"eciall$ 4hen associated 4ith altered a""earances,es"eciall$ 4hen associated 4ith altered a""earances,

in*ertilit$, or a%ilit$ to %e gain*ull$ e"lo$ed.in*ertilit$, or a%ilit$ to %e gain*ull$ e"lo$ed.


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%h+siolog+ of Desire and !rousal%h+siolog+ of Desire and !rousal

un&tional ,rain Imaging of Sexualun&tional ,rain Imaging of Sexual!rousal in (en and -omen!rousal in (en and -omen >+au>+au iidenti(cat arii activatoare ?corte#ul or%ito*rontal@denti(cat arii activatoare ?corte#ul or%ito*rontal@

si arii inhi%itoaresi arii inhi%itoare

Brain iaging in h$"ogonadal en %e*ore and a*terBrain iaging in h$"ogonadal en %e*ore and a*tertreatent suggests that the le*t 2FC ight e#ert atreatent suggests that the le*t 2FC ight e#ert a

testosterone+de"endent inhi%itor$ tonic control ontestosterone+de"endent inhi%itor$ tonic control on

se#ual arousal and that this control decreases u"onse#ual arousal and that this control decreases u"on

visual se#ual stiulation.visual se#ual stiulation.

Also the res"onse o* the right anterior insula to visualAlso the res"onse o* the right anterior insula to visual

se#ual stiulation 4as *ound to de"end on the level o*se#ual stiulation 4as *ound to de"end on the level o*

"lasa testosterone."lasa testosterone.


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Neurotransmitters and ormonesNeurotransmitters and ormones

In/ol/ed in Sexual Desire andIn/ol/ed in Sexual Desire and

Su'0e&ti/e !rousalSu'0e&ti/e !rousal The role of testosterone in desire and arousal isThe role of testosterone in desire and arousal is

'etter do&umented in men than in women'etter do&umented in men than in women ..

>eru levels o* testosterone do not correlate 4ith>eru levels o* testosterone do not correlate 4ith

4oens se#ual *unction according to large4oens se#ual *unction according to largee"ideiologic studiese"ideiologic studies

AA lin5 %et4een lo4 desire and lo4 androgen activit$ aslin5 %et4een lo4 desire and lo4 androgen activit$ as

re0ected %$ seru testosterone levels or androgenre0ected %$ seru testosterone levels or androgen

eta%olites has not %een identi(ed to dateeta%olites has not %een identi(ed to date

In anial odels, steroid horones odulate se#ualIn anial odels, steroid horones odulate se#ualarousal %$ directing s$nthesis o* the en)$es and thearousal %$ directing s$nthesis o* the en)$es and the

rece"tors *or a nu%er o* neurotransitters, includingrece"tors *or a nu%er o* neurotransitters, including

dopamine1 noradrenalin1 melano&ortin1 anddopamine1 noradrenalin1 melano&ortin1 and

ox+to&inox+to&in..


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(odele animale(odele animale2 &ai stimulatorii si2 &ai stimulatorii si

inhi'itoriiinhi'itorii

It is thought thatIt is thought that dopamine transmission in thedopamine transmission in the

medial preopti& areamedial preopti& area ?MP2A@ and the nucleus?MP2A@ and the nucleus

accu%ens *ocuses the "ersons attention on se#ualaccu%ens *ocuses the "ersons attention on se#ual

stiuli ?the incentives or otivations *or se#ual activit$@stiuli ?the incentives or otivations *or se#ual activit$@..

It is "ostulated that the %ehavioral "attern stiulated %$It is "ostulated that the %ehavioral "attern stiulated %$those s$stes and the su%;ective *eelings thatthose s$stes and the su%;ective *eelings that

acco"an$ the constitute the "henoenon coonl$acco"an$ the constitute the "henoenon coonl$

re*erred to asre*erred to as sexual desiresexual desire oror arousal arousal 4hen genital4hen genital

sensations triggered %$ these s$stes are su%;ectivel$sensations triggered %$ these s$stes are su%;ectivel$

*elt*elt Brain "ath4a$s *orBrain "ath4a$s *or sexualsexual inhibitioninhibition include o"ioid,include o"ioid,

endocanna%inoid, and serotonin neural transissionsendocanna%inoid, and serotonin neural transissions

*eeding %ac5 to various levels o* the e#citator$ "ath4a$s.*eeding %ac5 to various levels o* the e#citator$ "ath4a$s.

It is thought that the %ehavioral "attern stiulated %$It is thought that the %ehavioral "attern stiulated %$

the inhi%itor$ "ath4a$s includes %oththe inhi%itor$ "ath4a$s includes %oth sexual rewardsexual rewardand satiet+ refra&toriness.and satiet+ refra&toriness.


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Endogenous o"ioids odulate the *eed%ac5 eects o* se#Endogenous o"ioids odulate the *eed%ac5 eects o* se#

steroids on the h$"othalaus and "ituitar$.+Endor"hin issteroids on the h$"othalaus and "ituitar$.+Endor"hin is

s$nthesi)ed in the anterior "ituitar$, the h$"othalaus,s$nthesi)ed in the anterior "ituitar$, the h$"othalaus,

and the nucleus o* the tractus solitarius in the %rainste.and the nucleus o* the tractus solitarius in the %rainste.

9he 9he sexual inhi'iting e4e&ts of opioids o&&ur mainl+sexual inhi'iting e4e&ts of opioids o&&ur mainl+

through their a&tion in the (%O!through their a&tion in the (%O! and the a$gdalaand the a$gdala..

Adinistration o* elanocortin rece"tor agonists hasAdinistration o* elanocortin rece"tor agonists has

%een associated 4ith an increase in s"ontaneous%een associated 4ith an increase in s"ontaneous

erections in health$ en and in en 4ith ED, and 4itherections in health$ en and in en 4ith ED, and 4ith

increased desire, %ut not genital res"onses, in 4oen.increased desire, %ut not genital res"onses, in 4oen. Ox+to&inOx+to&in levels increase close to orgas. 9his horonelevels increase close to orgas. 9his horone

is 5no4n to %e involved inis 5no4n to %e involved in pair 'ondingpair 'onding in soe anialin soe anial

s"ecies, %ut its relevance in huans is unclear.s"ecies, %ut its relevance in huans is unclear.

(odele animale(odele animale


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Rolul prola&tineiRolul prola&tinei

9he "h$siologic role o* "rolactin in the huan se#ual 9he "h$siologic role o* "rolactin in the huan se#ual

res"onse reains uncertain.res"onse reains uncertain.

Because a generali)ed reduction o* do"aine activit$Because a generali)ed reduction o* do"aine activit$

in the h$"othalaus results in increased "rolactinin the h$"othalaus results in increased "rolactinsecretion, it has %een di=cult to distinguish %et4eensecretion, it has %een di=cult to distinguish %et4een

the eects o* raised "rolactin itsel* and the "ossi%lethe eects o* raised "rolactin itsel* and the "ossi%le

eects o* the reduced do"aine transission.eects o* the reduced do"aine transission.

igh le/els of prola&tin are asso&iated withigh le/els of prola&tin are asso&iated with

impaired sexual fun&tion in men and womenimpaired sexual fun&tion in men and women


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Genital Sexual Congestion andGenital Sexual Congestion and

!rousal!rousal

Men and 4oen dier su%stantiall$ 4ith res"ect to theMen and 4oen dier su%stantiall$ 4ith res"ect to the

correlation %et4een genital congestion and su%;ectivecorrelation %et4een genital congestion and su%;ective

se#ual arousal ?e#citeent@. 7hereasse#ual arousal ?e#citeent@. 7hereas su'0e&ti/esu'0e&ti/e

arousal is t+pi&all+ &on&ordant with genitalarousal is t+pi&all+ &on&ordant with genital

&ongestion in men1 there is a poor &orrelation&ongestion in men1 there is a poor &orrelation

'etween su'0e&ti/e arousal and measures of'etween su'0e&ti/e arousal and measures of

genital &ongestion in women.genital &ongestion in women.

9here are soe e#ce"tions in en' slee"+related 9here are soe e#ce"tions in en' slee"+related

erections are ostl$ dissociated *ro erotic dreas orerections are ostl$ dissociated *ro erotic dreas or

*ro su%;ective se#ual arousal.*ro su%;ective se#ual arousal. Also "s$cho"h$siologic studies have *ound that enAlso "s$cho"h$siologic studies have *ound that en

can get erections in res"onse to (ls o* assault or ra"ecan get erections in res"onse to (ls o* assault or ra"e

4hile e#"eriencing no su%;ective arousal.4hile e#"eriencing no su%;ective arousal.


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%h+siologi& (e&hanisms of %enile%h+siologi& (e&hanisms of %enile

Ere&tionEre&tion

The (%O! of the h+pothalamus ser/es as theThe (%O! of the h+pothalamus ser/es as the

integration site for the &entral ner/ous s+stemintegration site for the &entral ner/ous s+stem

&ontrol of ere&tions&ontrol of ere&tions6 it receives sensor$ in"ut *ro the6 it receives sensor$ in"ut *ro the

a$gdala and sends i"ulses to the "araventricular nucleia$gdala and sends i"ulses to the "araventricular nuclei

o* the h$"othalaus and the "eria3ueductal gra$ atter.o* the h$"othalaus and the "eria3ueductal gra$ atter.

1eurons in "araventricular nuclei "ro;ect onto the1eurons in "araventricular nuclei "ro;ect onto the

thoracolu%ar and sacral nuclei associated 4iththoracolu%ar and sacral nuclei associated 4ith

ere&tions.The paras+mpatheti& input to the penis isere&tions.The paras+mpatheti& input to the penis is

proere&tile1 and s+mpatheti& input is mainl+ inhi'itorproere&tile1 and s+mpatheti& input is mainl+ inhi'itor Penile erection results *ro a series o* %iocheical andPenile erection results *ro a series o* %iocheical and

heod$naic events that are associated 4ith activation o*heod$naic events that are associated 4ith activation o*central nervous s$ste sites involved in regulation o*central nervous s$ste sites involved in regulation o*

erections, rela#ation o* cavernosal sooth uscle,erections, rela#ation o* cavernosal sooth uscle,

increased %lood 0o4 into cavernosal sinuses, and venousincreased %lood 0o4 into cavernosal sinuses, and venous

occlusion resulting in "enile engorgeent and rigidit$.occlusion resulting in "enile engorgeent and rigidit$.


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9he ole o* 9estosterone in egulating 9he ole o* 9estosterone in egulating

>e#ual Function in Men>e#ual Function in Men

Although androgen+de(cient en can achieve "enile erections inAlthough androgen+de(cient en can achieve "enile erections in

res"onse to visual erotic stiuli, their overall se#ual activit$ isres"onse to visual erotic stiuli, their overall se#ual activit$ is

decreased.decreased. Spontaneous 'ut not stimulus2'ound ere&tions areSpontaneous 'ut not stimulus2'ound ere&tions are

testosterone2responsi/etestosterone2responsi/e ..Testosterone promotes sexualTestosterone promotes sexual

thoughts and desirethoughts and desire and in&reases sexual arousal andand in&reases sexual arousal and

attenti/eness to eroti& auditor+ and other stimuliattenti/eness to eroti& auditor+ and other stimuli . 1octurnal. 1octurnalerections, te"orall$ related to "ea5s o* nighttie testosteroneerections, te"orall$ related to "ea5s o* nighttie testosterone

secretion, are o* lo4er a"litude and duration in androgen+de(cientsecretion, are o* lo4er a"litude and duration in androgen+de(cient

en, and testosterone thera"$ increases the *re3uenc$, *ullness,en, and testosterone thera"$ increases the *re3uenc$, *ullness,

and duration o* nocturnal "enile tuescence.and duration o* nocturnal "enile tuescence. (aximum rigidit+(aximum rigidit+

ma+ re5uire a threshold le/el of androgenma+ re5uire a threshold le/el of androgen

a&ti/it+a&ti/it+.9estosterone regulates nitric o#ide s$nthase ?12>@ in the.9estosterone regulates nitric o#ide s$nthase ?12>@ in thecavernosal sooth uscle,e#erts tro"hic eects on cavernosalcavernosal sooth uscle,e#erts tro"hic eects on cavernosal

sooth usclesooth uscle and ischiocavernosus and %ul%os"ongiosus uscles,and ischiocavernosus and %ul%os"ongiosus uscles,

and is necessar$ *or the veno+occlusive res"onse.and is necessar$ *or the veno+occlusive res"onse. !ndrogen2!ndrogen2

de6&ient men show dela+ed orgasm and low e0a&ulator+de6&ient men show dela+ed orgasm and low e0a&ulator+

/olume/olume..


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Ph$siolog$ o* Ph$sical >e#ual Arousal inPh$siolog$ o* Ph$sical >e#ual Arousal in

7oen' enital Congestion7oen' enital Congestion

A nu%er o* "h$sical changes acco"an$ 4oensA nu%er o* "h$sical changes acco"an$ 4oens

se#ual e#citeent ?i.e., their su%;ective se#ual arousal@,se#ual e#citeent ?i.e., their su%;ective se#ual arousal@,

including genital s4elling, increased vaginal lu%rication,including genital s4elling, increased vaginal lu%rication,

%reast engorgeent, and ni""le erection6 increased s5in%reast engorgeent, and ni""le erection6 increased s5in

sensitivit$ to se#ual stiulation6 changes in heart rate,sensitivit$ to se#ual stiulation6 changes in heart rate,%lood "ressure, uscle tone, %reathing, and te"erature6%lood "ressure, uscle tone, %reathing, and te"erature6

and ottling o* the s5in 4ith a se#ual 0ush o*and ottling o* the s5in 4ith a se#ual 0ush o*

vasodilatation over the chest and *ace.vasodilatation over the chest and *ace.

9hese changes are re0e#ive, ediated %$ the autonoic 9hese changes are re0e#ive, ediated %$ the autonoic

nervous s$ste.nervous s$ste.

As the clitoris %ecoes ore s4ollen, it elevates to lieAs the clitoris %ecoes ore s4ollen, it elevates to lie

nearer the s$"h$sis "u%is. 9he vagina lengthens andnearer the s$"h$sis "u%is. 9he vagina lengthens and

dilates during arousal, elevating the uterus. 9he la%iadilates during arousal, elevating the uterus. 9he la%ia

%ecoe s4ollen and dar5er red, and the lo4er third o* the%ecoe s4ollen and dar5er red, and the lo4er third o* the

vagina s4ells.vagina s4ells.


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9 9he correlation %et4een genital congestion andhe correlation %et4een genital congestion and

su%;ective arousal are *ound to %e highl$ varia%le.9hissu%;ective arousal are *ound to %e highl$ varia%le.9his

is true in se#uall$ health$ 4oen and in 4oenis true in se#uall$ health$ 4oen and in 4oen

re"orting a lac5 o* desire or arousal or se#ual "ain.re"orting a lac5 o* desire or arousal or se#ual "ain. 9he "h$siolog$ o* nongenital "h$sical changes and 9he "h$siolog$ o* nongenital "h$sical changes and

their correlation 4ith su%;ective e#citeent reaintheir correlation 4ith su%;ective e#citeent reain

"oorl$ understood."oorl$ understood.

Ph$siolog$ o* Ph$sical >e#ual Arousal inPh$siolog$ o* Ph$sical >e#ual Arousal in

7oen' enital Congestion7oen' enital Congestion


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%h+siolog+ of Orgasm%h+siolog+ of Orgasm

2rgas is a %rain event, triggered t$"icall$ %$ genital2rgas is a %rain event, triggered t$"icall$ %$ genital

stiulation %ut also %$ slee", stiulation o* other "arts o* thestiulation %ut also %$ slee", stiulation o* other "arts o* the

%od$ ?including %reast and ni""le@, *antas$, certain%od$ ?including %reast and ni""le@, *antas$, certain

edications, and in 4oen 4ith s"inal cord in;ur$,edications, and in 4oen 4ith s"inal cord in;ur$,

vi%rostiulation o* the cervi#.vi%rostiulation o* the cervi#.

2rgas is a su%;ective e#"erience in %oth en and 4oen,2rgas is a su%;ective e#"erience in %oth en and 4oen,and it has %een di=cult to deterine an o%;ective ar5er. Inand it has %een di=cult to deterine an o%;ective ar5er. In

health$ en, there is the associated e;aculation and, in %othhealth$ en, there is the associated e;aculation and, in %oth

genders, involuntar$ ?re0e#ive@ uscular contractions o* thegenders, involuntar$ ?re0e#ive@ uscular contractions o* the

striated "erineal uscles.striated "erineal uscles.

9he role o* o#$tocin and "rolactin in orgas is unclear. Both 9he role o* o#$tocin and "rolactin in orgas is unclear. Both

horone levels increase at the tie o* orgas' PE9 scanninghorone levels increase at the tie o* orgas' PE9 scanninghas con(red increased "ituitar$ %lood 0o4 in 4oen, %uthas con(red increased "ituitar$ %lood 0o4 in 4oen, %ut

not in en, at the oent o* orgas.not in en, at the oent o* orgas. Both horones canBoth horones can

cause uterine and vaginal sooth uscle contraction, 4hichcause uterine and vaginal sooth uscle contraction, 4hich

a$ contri%ute to the sensations o* orgas.a$ contri%ute to the sensations o* orgas.


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The Re/ised De6nitions of SexualThe Re/ised De6nitions of Sexual

D+sfun&tion in (enD+sfun&tion in (en

a.a. Male h$"oactive se#ual desire disorderMale h$"oactive se#ual desire disorder

'.'. EDED

&.&. Preature e;aculationPreature e;aculation

d.d. Dela$ed e;aculationDela$ed e;aculation


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(ale +poa&ti/e Sexual Desire(ale +poa&ti/e Sexual Desire

DisorderDisorder

Androgen de(cienc$ is an i"ortant, treata%le causeAndrogen de(cienc$ is an i"ortant, treata%le cause

o* 8>DD and should %e e#cluded %$ easuring seruo* 8>DD and should %e e#cluded %$ easuring seru

total testosterone levels.total testosterone levels.


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Ere&tile DisorderEre&tile Disorder

ED, "reviousl$ re*erred to asED, "reviousl$ re*erred to as impotenceimpotence oror male EDmale ED, is, is

the ina%ilit$ to attain or aintain an erection or tothe ina%ilit$ to attain or aintain an erection or to

achieve "enile rigidit$ su=cient *or satis*actor$ se#ualachieve "enile rigidit$ su=cient *or satis*actor$ se#ual

intercourse.intercourse. CGD and ED share coon ris5 *actors, such asCGD and ED share coon ris5 *actors, such as

dia%etes ellitus, o%esit$, h$"ertension, so5ing, anddia%etes ellitus, o%esit$, h$"ertension, so5ing, and

d$sli"ideiad$sli"ideia

ecent surve$s have revealed an association o* lo4erecent surve$s have revealed an association o* lo4er

urinar$ tract s$"tos ?HU9>@ 4ith EDurinar$ tract s$"tos ?HU9>@ 4ith ED


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E0a&ulator+ disordersE0a&ulator+ disorders

E;aculator$ disorders include "reature e;aculation,E;aculator$ disorders include "reature e;aculation,

dela$ed e;aculation, retrograde e;aculation,dela$ed e;aculation, retrograde e;aculation,

ane;aculation:anorgasia, and "ain*ul e;aculation.ane;aculation:anorgasia, and "ain*ul e;aculation.

E;aculator$ disorders are at least as "revalent andE;aculator$ disorders are at least as "revalent anda$ %e even ore "revalent than ED.a$ %e even ore "revalent than ED.

Premature ejaculationPremature ejaculation,, de(ned as e;aculationde(ned as e;aculation

associated 4ith lac5 o* or "oor e;aculator$ control thatassociated 4ith lac5 o* or "oor e;aculator$ control that

causes distress in one or %oth "artners, is the ostcauses distress in one or %oth "artners, is the ost

"revalent se#ual disorder in en to - $ears o* age."revalent se#ual disorder in en to - $ears o* age. Delayed ejaculationDelayed ejaculation re*ers to ina%ilit$ to e;aculate in are*ers to ina%ilit$ to e;aculate in a

reasona%le "eriod that inter*eres 4ith se#ual orreasona%le "eriod that inter*eres 4ith se#ual or

eotional satis*action and is associated 4ith distress.eotional satis*action and is associated 4ith distress.


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Current De6nitions of SexualCurrent De6nitions of Sexual

Disorders in -omenDisorders in -omen

Sexual Interest*!rousal DisorderSexual Interest*!rousal Disorder

emale Orgasmi& Disorderemale Orgasmi& Disorder

Genitopel/i& %ain*%enetration DisorderGenitopel/i& %ain*%enetration Disorder

%ersistent Genital !rousal Disorder%ersistent Genital !rousal Disorder


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Sexual D+sfun&tion in the Context ofSexual D+sfun&tion in the Context of

Endo&rine DiseaseEndo&rine Disease

In health$ 4oen, *actors such as attitudes to4ardIn health$ 4oen, *actors such as attitudes to4ard

se#, *eelings *or the "artner, "ast se#ual e#"eriences,se#, *eelings *or the "artner, "ast se#ual e#"eriences,

duration o* relationshi", and ental and eotionalduration o* relationshi", and ental and eotional

health have %een sho4n to ore strongl$ odulatehealth have %een sho4n to ore strongl$ odulate

desire and arousa%ilit$ than do %iologic *actors.desire and arousa%ilit$ than do %iologic *actors.

Contrar$ to gender stereot$"es'Contrar$ to gender stereot$"es'

++ens "h$sical se#ual "leasure 4as ore closel$ens "h$sical se#ual "leasure 4as ore closel$

lin5ed to relational *actors than 4as the case *orlin5ed to relational *actors than 4as the case *or

4oen.4oen. ++en rated the i"ortance o* se# *or closeness anden rated the i"ortance o* se# *or closeness and

intiac$ to their "artner ore highl$ than did theirintiac$ to their "artner ore highl$ than did their

*eale "artners*eale "artners


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!ndrogen De6&ien&+ S+ndromes!ndrogen De6&ien&+ S+ndromes

9he testosterone levels re3uired to aintain se#ual *unction 9he testosterone levels re3uired to aintain se#ual *unction

are close to the lo4er liit o* the noral ale range.are close to the lo4er liit o* the noral ale range.

Androgen de(cienc$ is an i"ortant treata%le cause o* aleAndrogen de(cienc$ is an i"ortant treata%le cause o* ale

8>DD. 9here*ore, the en diagnosed 4ith 8>DD should %e8>DD. 9here*ore, the en diagnosed 4ith 8>DD should %e

evaluated *or androgen de(cienc$ %$ easureent o*evaluated *or androgen de(cienc$ %$ easureent o*testosterone levels, "re*era%l$ in an earl$ orning *astingtestosterone levels, "re*era%l$ in an earl$ orning *asting

%lood sa"le.%lood sa"le.

Although ED and androgen de(cienc$ in en are distinctAlthough ED and androgen de(cienc$ in en are distinct

disorders 4ith se"arate "atho"h$siologic echaniss, thedisorders 4ith se"arate "atho"h$siologic echaniss, the

t4o can coe#ist in the sae "atient. 9estosterone levelst4o can coe#ist in the sae "atient. 9estosterone levels

should %e easured in en "resenting 4ith an$ *or o*should %e easured in en "resenting 4ith an$ *or o*se#ual d$s*unction %ecause androgen de(cienc$ is treata%le,se#ual d$s*unction %ecause androgen de(cienc$ is treata%le,

and *urtherore, androgen de(cienc$ a$ %e aand *urtherore, androgen de(cienc$ a$ %e a

ani*estation o* another underl$ing disease, such as aani*estation o* another underl$ing disease, such as a

"ituitar$ tuor."ituitar$ tuor.


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Dia'etes and Sexual D+sfun&tion inDia'etes and Sexual D+sfun&tion in

(en(en

9he en 4ith dia%etes have signi(cantl$ lo4er scores 9he en 4ith dia%etes have signi(cantl$ lo4er scores

*or se#ual desire, activit$, arousal, and satis*action,in*or se#ual desire, activit$, arousal, and satis*action,in

"art due to the edical and "s$chological *actors"art due to the edical and "s$chological *actors

associated 4ith dia%etes, such as the variations inassociated 4ith dia%etes, such as the variations in

gl$ceic control, reduced energ$, altered sel*+iage,gl$ceic control, reduced energ$, altered sel*+iage,

and inter"ersonal di=culties regarding dietar$and inter"ersonal di=culties regarding dietar$

co"liance, glucose onitoring, and edications.co"liance, glucose onitoring, and edications.

Dia%etes also is associated 4ith increased ris5 o* lo4Dia%etes also is associated 4ith increased ris5 o* lo4

testosterone levels.testosterone levels.

Endothelial and sooth uscle d$s*unction, autonoicEndothelial and sooth uscle d$s*unction, autonoic

neuro"ath$, and "s$chological and inter"ersonal issuesneuro"ath$, and "s$chological and inter"ersonal issues

contri%ute to se#ual d$s*unction in en 4ith dia%etescontri%ute to se#ual d$s*unction in en 4ith dia%etes


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Sexual D+sfun&tion !sso&iated withSexual D+sfun&tion !sso&iated with

Therapies for ,enign %rostati&Therapies for ,enign %rostati&

+pertroph++pertroph+

Benign "rostatic h$"ertro"h$ is *re3uentl$ associatedBenign "rostatic h$"ertro"h$ is *re3uentl$ associated

4ith HU9> and se#ual d$s*unction4ith HU9> and se#ual d$s*unction


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+perprola&tinemia and Sexual+perprola&tinemia and Sexual

D+sfun&tionD+sfun&tion

Prolactin lo4ers testosterone levels through itsProlactin lo4ers testosterone levels through its

inhi%itor$ eects on n8 secretion and on theinhi%itor$ eects on n8 secretion and on the

"ituitar$ res"onse to n8. Most, %ut not all, en"ituitar$ res"onse to n8. Most, %ut not all, en

4ith se#ual d$s*unction and h$"er"rolactineia have4ith se#ual d$s*unction and h$"er"rolactineia have

lo4 testosterone levels.lo4 testosterone levels.

7hether and ho4 h$"er"rolactineia directl$ aects7hether and ho4 h$"er"rolactineia directl$ aects

erectile *unction through target organ eects is noterectile *unction through target organ eects is not

4ell understood. Erectile *unction generall$ i"roves4ell understood. Erectile *unction generall$ i"roves

in h$"er"rolactineic en *ollo4ing treatent 4ithin h$"er"rolactineic en *ollo4ing treatent 4ith

do"aine agonists.do"aine agonists.


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Sexual D+sfun&tion in %atients withSexual D+sfun&tion in %atients with

Th+roid DiseaseTh+roid Disease

8$"oth$roidis has %een associated 4ith increased8$"oth$roidis has %een associated 4ith increased

ris5 o* h$"oactive se#ual desire and EDris5 o* h$"oactive se#ual desire and ED

8$"erth$roidis has %een o%served in a sall *raction8$"erth$roidis has %een o%served in a sall *raction

o* en 4ith EDo* en 4ith ED..


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Natural (enopauseNatural (enopause

A a;orit$ o* 4oen 4ho discontinue "osteno"ausalA a;orit$ o* 4oen 4ho discontinue "osteno"ausal

estrogen su""leentation develo" signs o* vulvovaginalestrogen su""leentation develo" signs o* vulvovaginal

atro"h$, 4hich is a ris5 *actor *or se#ual d$s*unctionatro"h$, 4hich is a ris5 *actor *or se#ual d$s*unction

9he traditional notion that aintaining se#ual activit$ 9he traditional notion that aintaining se#ual activit$

4ill "revent s$"toatic vulvovaginal atro"h$ has %een4ill "revent s$"toatic vulvovaginal atro"h$ has %een

re*uted.re*uted. >u%;ective s$"tos and o%;ective signs o*>u%;ective s$"tos and o%;ective signs o*

vulvovaginal atro"h$ correlate "oorl$.vulvovaginal atro"h$ correlate "oorl$.

E"ideiologic studies have not sho4n an increase in theE"ideiologic studies have not sho4n an increase in the

"revalence o* d$s"areunia 4ith age. Clearl$ not all"revalence o* d$s"areunia 4ith age. Clearl$ not all

"osteno"ausal 4oen develo" se#ual s$"tos o*"osteno"ausal 4oen develo" se#ual s$"tos o*estrogen de(cienc$' o* J 4oen *ollo4ed *ro ageestrogen de(cienc$' o* J 4oen *ollo4ed *ro age

L to $ears, the vast a;orit$ 4ere not aected %$L to $ears, the vast a;orit$ 4ere not aected %$

the a;or horonal shi*ts.the a;or horonal shi*ts.


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It is li5el$ that ulti"le *actors contri%ute to se#ual s$"tos,It is li5el$ that ulti"le *actors contri%ute to se#ual s$"tos,

including variations in the "roduction o* estrogen *ro adrenalincluding variations in the "roduction o* estrogen *ro adrenal

"recursors, the nu%er and sensitivit$ o* estrogen rece"tors,"recursors, the nu%er and sensitivit$ o* estrogen rece"tors,

and the degree o* se#ual arousal or e#citeent at the tie o*and the degree o* se#ual arousal or e#citeent at the tie o*

vulval stiulation and vaginal entr$.vulval stiulation and vaginal entr$. Ps$chological *actors rather than estrogen levels 4ere sho4nPs$chological *actors rather than estrogen levels 4ere sho4n

to oderate s$"tos 4hen vulvovaginal atro"h$ is "resent.to oderate s$"tos 4hen vulvovaginal atro"h$ is "resent.

Most studies re"ort a decrease in se#ual desire 4ith advancingMost studies re"ort a decrease in se#ual desire 4ith advancing

ageage that is not easil$ e#"lained %$ horonal de(cienc$that is not easil$ e#"lained %$ horonal de(cienc$

9 9he negative association %et4een age and se#ual desire 4ashe negative association %et4een age and se#ual desire 4as

"articularl$ "ronounced in 4oen e#"eriencing little intiac$."articularl$ "ronounced in 4oen e#"eriencing little intiac$.

Natural (enopauseNatural (enopause


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Surgi&al (enopauseSurgi&al (enopause

>urgical eno"ause is a state o* %oth androgen and>urgical eno"ause is a state o* %oth androgen and

estrogen de"letion o* sudden onset and has o*ten %eenestrogen de"letion o* sudden onset and has o*ten %een

vie4ed as a ris5 *actor *or se#ual d$s*unction. 8o4ever,vie4ed as a ris5 *actor *or se#ual d$s*unction. 8o4ever,

ost 4oen undergoing %ilateral B>2 *or %enign clinicalost 4oen undergoing %ilateral B>2 *or %enign clinical

indications do not develo" se#ual d$s*unction. 9hree "roindications do not develo" se#ual d$s*unction. 9hree "ro

s"ective studies *ound that 4oen choosing B>2 "luss"ective studies *ound that 4oen choosing B>2 "lush$sterecto$ *or %enign indications did not develo" se#ualh$sterecto$ *or %enign indications did not develo" se#ual

d$s*unction over the ne#t to $ears.d$s*unction over the ne#t to $ears.

IIn 4oen undergoing nonelective surger$, the theaticn 4oen undergoing nonelective surger$, the theatic

conte#t o* %ilateral oo"horecto$ a$ i"air se#ual desireconte#t o* %ilateral oo"horecto$ a$ i"air se#ual desire

and *unction. For e#a"le, 4oen 4ho are treated *orand *unction. For e#a"le, 4oen 4ho are treated *oralignant disease or those 4ho desire to "reserve theiralignant disease or those 4ho desire to "reserve their

*ertilit$ a$ e#"erience greater distress a%out lo4 se#ual*ertilit$ a$ e#"erience greater distress a%out lo4 se#ual

desire a*ter B>2 than those 4ho undergo B>2 *or %enigndesire a*ter B>2 than those 4ho undergo B>2 *or %enign

conditions.conditions.


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ormonal Contra&epti/esormonal Contra&epti/es

9he estrogen in co%ined s$steic contrace"tives 9he estrogen in co%ined s$steic contrace"tives

increases >8B and thus decreases availa%le *reeincreases >8B and thus decreases availa%le *ree

testosterone. 9he decrease in se#ual desire andtestosterone. 9he decrease in se#ual desire and

su%;ective arousa%ilit$ in soe 4oen receiving oralsu%;ective arousa%ilit$ in soe 4oen receiving oral

contrace"tives has %een attri%uted to the decrease incontrace"tives has %een attri%uted to the decrease in

*ree testosterone levels.*ree testosterone levels.


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%ol+&+sti& O/ar+ S+ndrome%ol+&+sti& O/ar+ S+ndrome

Hiited research has sho4n that 4oen 4ithHiited research has sho4n that 4oen 4ith

"ol$c$stic ovar$ s$ndroe a$ %e less se#uall$"ol$c$stic ovar$ s$ndroe a$ %e less se#uall$

satis(ed and a$ regard theselves as less attractivesatis(ed and a$ regard theselves as less attractive

than control su%;ects.than control su%;ects.

9he "resu"tion is that o%esit$ and androgen+related 9he "resu"tion is that o%esit$ and androgen+related

s$"tos a$ contri%ute to "oor %od$ iage, 4hichs$"tos a$ contri%ute to "oor %od$ iage, 4hich

a$ increase the ris5 o* se#ual d$s*unction.a$ increase the ris5 o* se#ual d$s*unction.

ecent studies sho4 little evidence that "ol$c$sticecent studies sho4 little evidence that "ol$c$stic

ovar$ s$ndroe ?as o""osed to o%esit$@ is a ris5ovar$ s$ndroe ?as o""osed to o%esit$@ is a ris5*actor *or se#ual d$s*unction.*actor *or se#ual d$s*unction.

comport. sexual nou- 2016

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