Treatment for adjustment disorder exists, which means that as disruptive as adjustment disorder may be, it’s temporary. Adjustment disorders can negatively impact all areas of a person’s life and functioning, but with treatment, they can disappear.

Adjustment disorder treatment addresses both the stressor(s) that led to the disorder as well as the resulting adjustment disorder symptoms. With treatment, people have control to take charge of their lives and their mental health.

Adjustment Disorder Treatment: Therapy

Therapeutic treatment for adjustment disorder addresses the stressor(s) people experience and helps people define goals and enhance coping skills. Adjustment disorder therapy is usually brief and time-limited. It’s not unusual for therapy to last only four- to six sessions, but there are individual differences in both therapists and clients that determine the exact number of therapy visits.

Adjustment disorder therapy takes many forms. Among them:

• Cognitive-behavioral therapy; an approach that helps people reframe problems and outlook by learning to identify automatic negative thoughts and replace them with more realistic ones
• Acceptance and commitment therapy (ACT); a mindfulness and coping therapy that helps people accept difficulties and reactions, choose a meaningful direction, and then take action to achieve goals
• Solution-focused brief therapy; an approach that helps people identify where they want to be and how they are going to get there

Regardless of the approach, therapeutic adjustment disorder treatment focuses on crisis relief, stress reduction, goal setting, strengths building, and coping skills creation. Therapists help clients gather relevant information and identify and use resources.

Adjustment Disorder Treatment: Coping Skills

Coping skills are thoughts people have and the actions they take in order to achieve mental health and wellness. They play a key role in adjustment disorder treatment.

The more coping skills people develop and use, the better equipped they are to deal with the stressors and symptoms of adjustment disorder. While this list is by no means exhaustive, it contains proven techniques that many people have found helpful in adjustment disorder treatment. 

• Self-exploration; through journaling and recording gratitude, look for patterns to discover what makes meaning for you and enhances your wellbeing
• Make room for the positive by changing the part of the stressors you can and creating wellness around what you can’t
• Mindfulness; be in the present moment rather than ruminating about the stressor
• Reframe your thoughts about the problem
• Increase physical activity
• Create calming strategies
• Change things in your environment (rearrange to-do lists, ask for help with things like housework, shopping, little tasks around a new baby, etc.)
• Develop a routine to re-establish a sense of normalcy
• Draw on or build a social support system
• Enhance sleep habits; treating your sleep helps increase the ability to cope and function
• For more ideas, read You Can Practice Self-Care on a Budget

Adjustment Disorder Treatment: Medication

Mental health medication isn’t always a part of adjustment disorder treatment because the disorder is stress-induced. However, adjustment disorder can occur with depression and/or anxiety. When it does, temporarily taking medication can be helpful. Sometimes, too, sleep medication can help people get the restorative sleep that is needed to handle difficulties.

It’s important to keep track of symptoms and discuss them with your regular doctor or nurse practitioner. He or she can help decide whether medication would be useful in treating symptoms of adjustment disorder.

Treating Adjustment Disorder is Possible

It might not always feel like it, but people are strong and capable. Everyone has strengths to draw on as they transcend difficulties, including adjustment disorder. Receiving support from a therapist, doctor, friend, or family member can enhance adjustment disorder treatment. With therapy, coping skills, and occasionally medication, people can fully overcome the stressors and symptoms of adjustment disorder and live a life in which they thrive.

article references

Solving problems in a relationship is fundamental to its success. Here are the basic steps to problem-solving and keeping your relationship on track.

Problem-solving has a time and a place. Problem-solving has an agenda. Problem-solving is task-oriented; it is not a power struggle. Problem-solving has two distinct phases: a problem definition phase and a problem solution phase.

When defining a problem:

• Be specific (refer to what both partners can observe)
• Be brief
• Express your feelings about the behavior which is the subject of the conflict

When solving problems:

• Brainstorm solutions
• Evaluate their costs and benefits to each partner and to the relationship
• Decide on the best solution
• Be willing to compromise; problem-solving involves give-and-take

Also, when defining and solving problems:

• Discuss only one problem at a time
• Paraphrase what you hear your partner saying and check the accuracy of your paraphrase

Remember, the attitude with which you approach problem-solving is very important. Problem-solving requires collaboration and problem-solving requires that each problem being discussed is seen as a mutual problem.

Does your anger get out of control? Is your anger impacting your relationships? Here are some strategies for controlling your anger.

We all know what anger is, and we've all felt it, whether as fleeting annoyance or as full-fledged rage.

Anger is a completely normal, and usually healthy, human emotion. But when it gets out of control and turns destructive, it can lead to problems: problems at work, in your personal relationships, and in the overall quality of your life. And it can make you feel as though you're at the mercy of an unpredictable and powerful emotion.

What is Anger?

Anger is an emotional state that varies in intensity from mild irritation to intense fury and rage. Like other emotions, it is accompanied by physiological and biological changes; when you get angry, your heart rate and blood pressure go up, and so does the level of your energy hormones, adrenalin and noradrenalin.

Anger can be caused by external or internal events. You could be angry at a specific person (such as a coworker or supervisor) or event (a traffic jam, a canceled flight), or your anger could be caused by worrying or brooding about your personal problems. Memories of traumatic or enraging events can also trigger angry feelings.

Expressing Anger

The instinctive, natural way to express anger is to respond aggressively. Anger is a natural, adaptive response to threats; it inspires powerful, often aggressive, feelings and behaviors that allow us to fight and defend ourselves when we are attacked. A certain amount of anger, therefore, is necessary to our survival.

On the other hand, we can't physically lash out at every person or object that irritates or annoys us. Laws, social norms, and common sense place limits on how far we should let our anger take us.

People use a variety of both conscious and unconscious processes to deal with their angry feelings. The three main approaches are expressing, suppressing, and calming.

Expressing Anger

Expressing your angry feelings in an assertive -- not aggressive -- manner is the healthiest way to express anger. To do this, you have to learn how to make clear what your needs are, and how to get them met, without hurting others. Being assertive doesn't mean being pushy or demanding; it means being respectful of yourself and others.

Suppressing Anger

Another approach is to suppress anger and then convert or redirect it. This happens when you hold in your anger, stop thinking about it, and focus on something positive to do instead. The aim is to inhibit or suppress your anger and convert it into more constructive behavior. The danger in this type of response is that if your anger isn't allowed outward expression, it can turn inward--on yourself. Anger turned inward may cause hypertension, high blood pressure, or depression.

Unexpressed anger can create other problems. It can lead to pathological expressions of anger such as passive-aggressive behavior (getting back at people indirectly, without telling them why, rather than confronting them head-on), or a perpetually cynical and hostile attitude. People who are constantly putting others down, criticizing everything, and making cynical comments haven't learned how to express their anger constructively. Not surprisingly, they aren't likely to have many successful relationships.

Calm Yourself

Finally, you can calm yourself down inside. This means not just controlling your outward behavior, but also controlling your internal responses, taking steps to lower your heart rate, calm yourself down, and let the feelings subside.

Anger Management

The goal of anger management is to reduce both your emotional feelings and the physiological arousal that anger causes. You can't get rid of or avoid the things or people that enrage you, nor can you change them; but you can learn to control your reactions.

Are You Too Angry?

There are psychological tests that measure the intensity of angry feelings, how prone to anger you are, and how well you handle it. But chances are good that if you do have a problem with anger, you already know it. If you find yourself acting in ways that seem out of control and frightening, you might need help finding better ways to deal with this emotion.

Why Are Some People More Angry Than Others?

Some people are really more 'hotheaded' than others; they get angry more easily and more intensely than the average person. There are also those who don't show their anger in loud spectacular ways but are chronically irritable and grumpy. Easily angered people don't always curse and throw things; sometimes they withdraw socially, sulk, or get physically ill.

People who are easily angered generally have what some psychologists call a low tolerance for frustration, meaning simply that they feel that they should not have to be subjected to frustration, inconvenience, or annoyance. They can't take things in stride, and they're particularly infuriated if the situation seems somehow unjust: for example, when they are corrected for a minor mistake.

What makes these people this way? A number of things. One cause may be genetic or physiological; there is evidence that some children are born irritable, touchy, and easily angered, and that these signs are present from a very early age. Another may be how we're taught to deal with anger. Anger is often regarded as negative; many of us are taught that it's all right to express anxiety, depression, or other emotions, but not to express anger. As a result, we don't learn how to handle it or channel it constructively.

Research has also found that family background plays a role. Typically, people who are easily angered come from families that are disruptive, chaotic, and not skilled at emotional communication.

Is It Good to 'Let It All Hang Out'?

Psychologists now say that this is a dangerous myth. Some people use this theory as a license to hurt others. Research has found that 'letting it rip' with anger actually escalates anger and aggression and does nothing to help you (or the person you're angry with) resolve the situation.

It's best to find out what it is that triggers your anger, and then develop strategies to keep those triggers from toppling you over the edge.

Do You Need Anger Counseling?

If you feel that your anger is really out of control, if it is having an impact on your relationships and on important parts of your life, you might consider counseling to learn how to handle it better. A psychologist or other licensed mental health professional can work with you in developing a range of techniques for changing your thinking and your behaviors.

When you talk to a prospective therapist, tell her or him that you have problems with anger that you want to work on, and ask about his or her approach to anger management. Make sure this isn't only a course of action designed to help you 'get in touch with your feelings and express them' That may be precisely your problem.

With counseling, psychologists say, a highly angry person can move closer to a middle range of anger in about 8 to 10 weeks, depending on the circumstances and the counseling techniques used.

Sources: Charles Spielberger, Ph.D., of the University of South Florida in Tampa; Jerry Deffenbacher, Ph.D., of Colorado State University in Ft. Collins, Colorado, a psychologist who specializes in anger management.

Some of us aren't very good in dealing with confrontation. These confrontation skills may help you.

Confrontation Skills

Employ "I messages"

"I messages" are irrefutable statements about the communicator's feelings, thoughts, observations, perceptions, and reactions.   When confronting someone, talk in terms of yourself, for example, "I think," "I feel," "In my experience," "for myself," "I need," "I've observed."

State your request clearly

Be honest and direct.   Do not overexplain or apologize.

Focus on the offending behavior involved, not the person

Be specific in your description of the behavior and the effect it had on you.

Use appropriate non-verbal behaviors

Show the intensity of your feelings. Look the other person in the eye.  Speak clearly, without hesitation, leaning toward the listener.

Alcohol can impair female sexual arousal even before intoxication takes place. Source: Masters and Johnson on Sex and Human Loving page 521.

Addictive narcotics such as heroin and morphine caused 27% of the 85 female addicts surveyed to experience orgasmic dysfunction, and 57% to experience decreased sexual interest. The root cause of these problems is unknown due to numerous factors that could cause addicts to experience sexual dysfunction. The sexual dysfunction could even be the root cause for the addition. Source: Masters and Johnson on Sex and Human Loving page 521.

Amphetamines and cocaine can cause sexual dysfunction in men when used in large doses or over long periods of time. One would have to assume women would also experience sexual dysfunction under these conditions, do to similar anatomy and sexual physiology. Source: Masters and Johnson on Sex and Human Loving page 522.

Marijuana caused some women to report temporary vaginal dryness resulting in painful intercourse. Source: Masters and Johnson on Sex and Human Loving page 523.

How you and your partner fight is the key to whether or not you will have a successful, long-term marriage or relationship. Fighting fairly is an important skill to learn.

Conflict: What is it and who needs it?

Even the healthiest relationships at times experience conflict. That is to say, persons who care about one another often find it necessary to make important decisions. In that process, the couple may find that differences in perspective and opinion exist. These variances may occur around the definition of a problem, how it is to be solved, or even what is assumed to be an appropriate outcome. The important thing to remember is that people who care about each other do not always think or behave alike. But because they care about each other, the couple who cares can usually find a way to resolve the conflict in a way constructive to the relationship. Conflict, therefore, can be a means to an end, namely constructive decision-making and enhanced respect for one another's perspectives and contributions.

The following suggestions are made to assist you in planning and implementing conflict resolution. While the steps may sometimes seem mechanical or overly simplistic, take a chance and try them. The approach has been employed successfully by many couples seeking to use their differences creatively in problem-solving.

How do I do this when I feel so upset?

When we become angry or fearful, our bodies react accordingly. We may feel some unusual and discomforting feelings. Often, the more important the issue and the closer our relation to the other person, the more intense our reactions. The body's way of managing this stress is to initiate a fight or flight response. While of benefit in dangerous situations, these automatic reactions may not lead to effective and thoughtful decision-making. To varying degrees, we may feel ourselves become worked up (e.g., increases in heart and breathing rate, queasiness, dryness of the mouth, muscle tension, and tightness in the stomach). If voices are raised, some persons feel an upwelling of sadness or fear while others experience rising anger. These are normal responses to what our body thinks is a threat. To adjust this reaction try the following:

• Remind yourself that you are experiencing the body's normal way of dealing with what is initially perceived as threatening and stressful;
• Take several nice slow breaths, breathing in through the nose and out slowly from the mouth;
• Try to stand or sit in a relaxed posture;
• If you feel you are becoming very sad or angry, tell your partner. Perhaps a time-out is in order until you collect yourself;
• Respect each other by keeping a reasonable distance and avoiding physical touch that may be interpreted as condescending or prematurely intimate;
• Try to avoid raising your voice as this may be interpreted as intimidating or elicit similar defensive behavior on the part of the other person;
• Remember the person with whom you are talking is someone who cares about you and vice versa.

How do we get to the point?

Several things are important to remember as the two of you attempt to reconcile differences. Remember this does not have to be a win-lose experience. Setting the problem up so someone has to be the victor usually restricts the range of solutions available and will result in someone being cast as the loser. Stay open to the possibilities that exist when both perspectives are applied to the problem solving. Here are some suggestions:

• Make sure you understand the other person. Seek information by asking open-ended questions. These are questions that invite information to be shared. They begin with the inquiries of who, when, what, how, or where. Avoid the interrogative "why" as this invites a more defensive reply. If necessary it is okay to stop and begin your question over to assure you are inviting information;
• Before you reply, repeat what the other person said as a way of clarifying potential areas of misunderstanding and demonstrating respect;
• As you respond, try to avoid what are called "Blaming" attacks. This occurs when we use the second person pronoun 'you' and attach blame to an action. For example, "We would not have been late had 'you' not taken so long getting back here."
• Similarly, avoid using language that may be perceived as provocative or insulting to your partner;
• Keep focused on the here and now. Slipping into conflict over past issues can derail even the most caring of couples. Sometimes we do not recall the details of past conflicts, nor do we have any control over changing the past. Stay in the present;
• Only one problem at a time can be solved. Avoid gunnysacking, that is the practice of unloading several problems at once. This only serves to confuse the parties and often results in limited, if any, closure on the central concerns;
• Look for several solutions. Look outside the lines and see if the two of you can think of multiple ways of solving the problem. Be creative;
• Keep a sense of humor. Nurture your creativity by using your humor.

What if we can't get anywhere?

Sometimes problems can not be solved on the first attempt. Perhaps emotions are too intense or the circumstances appear too complex for an easy resolution. It is important to remember that it may take time to think through the issues. Try the following ideas when you feel stuck:

• Either or both parties can call for a "time-out". This is a rest period that allows for each person to have some physical and emotional space. It is important to establish a time to come back together. Failure to schedule this re-joining time may otherwise appear to be a slight or disrespectful to one's partner. Remember, it only takes one person to call a time out;
• Take into consideration the time and place of the conflict. Perhaps where you are physically and emotionally merits a change in time and location before the discussion continues. It is also okay to contract for time limits on the discussion for any given session;
• If during the process of clarification you discovered a lack of the information necessary to respond, seek out the necessary resources. Try to be informative but not judgmental with your findings;
• Experiment with some exercises to gain insight into your partner's perspective. For instance, trade places and attempt to advocate from the position of the other person. Or as a couple engage in a free association game in an effort to think of as many solutions to the problem as possible.
• Examine your own motives for the conflict. Are their attitudes or beliefs that may be temporarily suspended to better understand the other's perspective?
• Consider using a consultant. If you become stuck and find it difficult to generate new ideas for reconciliation, perhaps a consultant can provide a perspective that is helpful.

What if we can't get to a solution?

Some problems are not easily resolved. Perhaps the timing, setting, or other circumstances make it difficult to concentrate. Other concerns may have diminished the personal energy and focus necessary to reconcile the differences. Sometimes conflicts also reflect more serious differences in core values or growth on the part of the persons involved. When a solution can not be achieved that contributes to the well-being of the relationship, it is wise to seek consultation. A third party that is objective and caring can often help clarify underlying concerns or assist in identifying an issue that may be causing a blockage. To seek help is a compliment to the value of the relationship. Marriage counselors and other types of therapists provide assistance for couples, partners, or intimates seeking to manage their differences.

Here are the tools you need to be a good communicator in a relationship.

Active Listening

Active listening is an acquired skill that can help people build better relationships and reduce conflicts. Good listening comes from the same place love comes from ... a focus and concentration on the other person. When we are in a conversation, most of the time we just cannot wait until the other person is finished talking so we can tell our tale. In fact, most of the time, we do not wait. If you feel like saying?

"I'm sorry, is the middle of my sentence interrupting the start of yours"?

Then you know what it feels like not to be listened to

Further, we have internal conversations going on that distract us from paying real attention to the conversation. We may also bring our own agendas into a conversation, a preconceived point of view, the need to be right, thus being argumentative. Active listening demands that we're open to the other person's point of view.

Active listening means being aware of both the visual messages as well the auditory. Much of our message is transmitted through body language, gestures, and intonation. Listening is like loving. The focus is off yourself, and on the other person. That person feels good ? knowing that you care enough to listen to them.

An active listener makes us feel important. They make us feel that what we're saying is important.

Better Relationships?

It is usually the case that whenever we are really interested in someone else we become acutely self-conscious about our own performance and appearance. We want to impress them by not being a complete fool. If you really want to impress someone try actively listening to them instead of focussing upon yourself and your own internal dialogue.

So, How Is It Done?

It is simple. Communication is about transmitting meaning and feeling. The active listener is part of making that happen. The main goal, while listening, is to let the speaker know that their message has been received clearly. Now you don't have to make a job of it, and active listening is not needed at all times, but when it is important, here are a few tips:

1. Through gestures or verbally, pick times to let the speaker know that you've gotten their exact meaning.
2. If you are unclear as to their meaning, pick a good spot and ask a question such as, "I'm hearing you say..., is that right?"
3. Contribute to their conversation, their meaning, without espousing your own agenda. Do this by asking questions about their line of thought, about their story, or ideas. However be careful not to be their interpreter. Most of us don't need someone else to tell us what we are thinking or saying.

Keep It Up!

Remember the main job of the active listener is to allow, even encourage, the speaker to talk, to get their meaning across. If they are having some difficulty, as some of us do in being expressive, an active listener attempts to assist by offering words or ideas that may assist in the translation of their meaning.

The frequent use of "who, what, where, and when" is a good idea and will assist in moving the conversation toward better understanding.

The prime rule of active listening is to encourage the speaker to talk, to promote his/her willingness to communicate. A conversation in which one person dominates is not a conversation. That is usually referred to as a lecture

So adhere to a few simple and obvious rules of the road.

1. Do not criticise to the point that conversation is shut down,
2. Do not fake listening, most people are pretty insightful and will spot dishonesty a mile away....
3. Be aware of your internal dialogue that is going on. If it is distracting from listening to the speaker, shut it off. However, if it is about really understanding and personalising the information being spoken, then keep it, and return to the conversation. If you need a moment to do that, then ask for a pause, or ask a question.

Finally, here is one sure fire way to determine if you are being an active listener. Just summarise what the speaker is saying, and if you hear, "that's it...exactly", you know you are right on.

So educate those around you to be active listeners also, then when it is your time to speak in the conversation, you will have the benefit of having your meaning precisely transferred. Good relationships, as well as success in our knowledge based society is largely dependent on good communications skills.

This article is adapted for this site from the Living Large Network (tm).

Female sexual dysfunction is age-related, progressive and highly prevalent affecting 30-50 percent of women^(1,2,3). Based on the National Health and Social Life Survey of 1,749 women, 43 percent experienced sexual dysfunction.⁽⁴⁾ U.S. population census data reveal that 9.7 million American women ages 50-74 self-report complaints of diminished vaginal lubrication, pain and discomfort with intercourse, decreased arousal, and difficulty achieving orgasm. Female sexual dysfunction is clearly an important women's health issue that affects the quality of life of many of our female patients.

Until recently, there has been little research or attention that focuses on female sexual function. As a result, our knowledge and understanding of the anatomy and physiology of the female sexual response is quite limited. Based on our understanding of the physiology of the male erectile response, recent advances in modern technology, and recent interest in Women's Health issues, the study of female sexual dysfunction is gradually evolving. Future advances in the evaluation and treatment of female sexual health problems are forthcoming.

The Female Sexual Response Cycle:

Masters and Johnson first characterized the female sexual response in 1966 as consisting of four successive phases; excitement, plateau, orgasmic and resolution phases⁽⁵⁾. In 1979, Kaplan proposed the aspect of "desire", and the three-phase model, consisting of desire, arousal, and orgasm⁽⁶⁾. However, in October 1998, a consensus panel made up of a multidisciplinary team treating female sexual dysfunction met to create new a new classification system that all professionals treating Female Sexual dysfunction can use.

1998 AFUD Consensus Panel Classifications & Definitions of Female Sexual Dysfunction

• Hypoactive Sexual Desire Disorder: persistent or recurring deficiency (or absence) of sexual fantasies/thoughts, and/or receptivity to, sexual activity, which causes personal distress.
• Sexual Aversion Disorder: persistent or recurring phobic aversion to, and avoidance of sexual contact with a sexual partner, which causes personal distress. Sexual Aversion Disorder is generally a psychologically or emotionally based problem that can result for a variety of reasons such as physical or sexual abuse, or childhood trauma, etc.
• Hypoactive Sexual Desire Disorder may result from psychological/emotional factors or be secondary to medical problems such as hormone deficiencies, and medical or surgical interventions. Any disruption of the female hormonal system caused by natural menopause, surgically or medically induced menopause, or endocrine disorders can result in inhibited sexual desire.
• Sexual Arousal Disorder: persistent or recurring inability to attain, or maintain sufficient sexual excitement causing personal distress. It may be experienced as lack of subjective excitement or lack of genial (lubrication/swelling) or other somatic responses.

Disorders of arousal include, but are not limited to, lack of or diminished vaginal lubrication, decreased clitoral and labial sensation, decreased clitoral and labial engorgement or lack of vaginal smooth muscle relaxation.

These conditions may occur secondary to psychological factors, however often there is a medical/physiologic basis such as diminished vaginal/clitoral blood flow, prior pelvic trauma, pelvic surgery, medications (i.e. SSRI) ^(7,8)

• Orgasmic Disorder: persistent or recurrent difficulty, delay in, or absence of attaining orgasm following sufficient sexual stimulation and arousal, and causes personal distress.

This may be a primary (never achieved orgasm) or a secondary condition, as a result of surgery, trauma, or hormone deficiencies. Primary anorgasmia can be secondary to emotional trauma or sexual abuse, however medical/physical factors can certainly contribute to the problem.

• Sexual Pain Disorders:
  • Dyspareunia: recurrent or persistent genital pain associated with sexual intercourse
  • Vaginismus: recurrent or persistent involuntary spasm of the musculature of the outer third the vagina that interferes with vaginal penetration, which causes personal distress.
• Other sexual pain disorders: Recurrent or persistent genital pain induced by non-coital sexual stimulation. Dyspareunia can develop secondary to medical problems such as vestibulitis, vaginal atrophy, or vaginal infection can be either physiologically or psychologically based, or a combination of the two. Vaginismus usually develops as a conditioned response to painful penetration, or secondary to psychological/emotional factors.

Role of Hormones in Female Sexual Function:

Hormones play a significant role in regulating female sexual function. In animal models, estrogen administration results in expanded touch receptor zones, suggesting that estrogen effects sensation. In post-menopausal women, estrogen replacement restores clitoral and vaginal vibration and sensation to levels close to those of pre-menopausal women⁽¹⁵⁾. Estrogens also have protective effects which result in increased blood flow to the vagina and clitoris ^(15,16). This helps to maintain female sexual response over time.

With aging and menopause, and the decreasing estrogen levels, a majority of women experience some degree of change in sexual function. Common sexual complaints include loss of desire, decreased frequency of sexual activity, painful intercourse, diminished sexual responsiveness, difficulty achieving orgasm, and decreased genital sensation.

Masters and Johnson first published their findings of the physical changes occurring in menopausal women that related to sexual function in 1966. We have since learned that symptoms of low lubrication and poor sensation are in part secondary to declining estrogen levels and that there is a direct correlation between the presence of sexual complaints and low levels of estrogen⁽¹⁵⁾. Symptoms markedly improve with estrogen replacement.

Low testosterone levels are also associated with a decline in sexual arousal, genital sensation, libido, and orgasm. There have been studies that have documented improvements in women's desire when treated with 100 mg testosterone pellets ^(17,18). At this time, there are not Food and Drug Administration (FDA) approved testosterone preparations for women; however clinical studies are underway assessing the potential benefits of testosterone for the treatment of female sexual dysfunction.

Causes of Female Sexual Dysfunction:

Vascular

High blood pressure, high cholesterol levels, diabetes, smoking, and heart disease are associated with sexual complaints in men and women. Any traumatic injury to the genitals or pelvic region, such as pelvic fractures, blunt trauma, surgical disruption, extensive bike riding, for instance, can result in diminished vaginal and clitoral blood flow and complaints of sexual dysfunction. Although, other underlying conditions, either psychological or physiologic may also manifest as decreased vaginal and clitoral engorgement, blood flow, or vascular insufficiency is one causal factor that should be considered.

Neurological

The same neurological disorders that cause erectile dysfunction in men can also cause sexual dysfunction in women. Spinal cord injury or disease of the central or peripheral nervous system, including diabetes, can result in female sexual dysfunction. Women with spinal cord injury have significantly more difficulty achieving orgasm than able-bodied women ⁽²¹⁾. The effects of specific spinal cord injuries on female sexual response is being investigated, and will hopefully lead to improved understanding of the neurological pieces of orgasm and arousal in normal women.

Hormonal/Endocrine

Dysfunction of the hypothalamic/pituitary axis, surgical or medical castration, natural menopause, premature ovarian failure, and chronic birth control pills, are the most common causes of hormonally based female sexual dysfunction. The most common complaints in this category are decreased desire and libido, vaginal dryness, and lack of sexual arousal.

Psychogenic

In women, despite the presence or absence of organic disease, emotional and relational issues significantly affect sexual arousal. Issues such as self-esteem, body image, her relationship with her partner, and her ability to communicate her sexual needs with her partner, all impact sexual function. In addition, psychological disorders such as depression, obsessive-compulsive disorder, anxiety disorder, etc., are associated with female sexual dysfunction. Medications used to treat depression can also significantly affect the female sexual response. The most frequently used medications for uncomplicated depression are the Seratonin Re-uptake Inhibitors. Women receiving these medications often complain of decreased sexual interest.

Treatment Options:

Treatment of female sexual dysfunction is gradually evolving as more clinical and basic science studies are dedicated to evaluating the problem. Aside from hormone replacement therapy, medical management of female sexual dysfunction remains in early experimental phases. Nonetheless, it is crucial to understand that not all female sexual complaints are psychological and that there are possible therapeutic options.

Studies are in progress accessing the effects of vasoactive substances on the female sexual response. Aside from hormone replacement therapy, all medications listed below, while useful in the treatment of male erectile dysfunction, are still in experimental phases for use in women.

• Estrogen Replacement Therapy: This treatment is indicated in menopausal women (either spontaneous or surgical). Aside from reliving hot flashes, preventing osteoporosis, and lowering risk of heart disease, estrogen replacement results in improved clitoral sensitivity, increased libido, and decreased pain during intercourse. Local or topical estrogen application relieves symptoms of vaginal dryness, burning, and urinary frequency and urgency. In menopausal women, or oophorectomized women, complaints of vaginal irritation, pain or dryness, can be relieved with topical estrogen cream. A vaginal estradiol ring (Estring) is now available that delivers low-dose estrogen locally, which may benefit breast cancer patients and other women unable to take oral or transdermal estrogen ⁽²⁵⁾.
• Methyl Testosterone: This treatment is often used in combination with estrogen in menopausal women, for symptoms of inhibited desire, dyspareunia, or lack of vaginal lubrication. There are conflicting reports regarding the benefit of methyltestosterone and/or testosterone cream for the treatment of inhibited desire and/or vaginismus in pre-menopausal women. Potential benefits of this therapy include increased clitoral sensitivity, increased vaginal lubrication, increased libido, and heightened arousal. Potential side effects of testosterone administration, either topical or oral, include weight gain, clitoral enlargement, increased facial hair, and high cholesterol.
• Sildenafil: This medication serves to increase relaxation of clitoral and vaginal smooth muscle and blood flow to the genital area⁽⁷⁾. Sildenafil may prove useful alone or possibly in combination with other vasoactive substances for the treatment of female sexual arousal disorder. Clinical studies evaluating the safety and efficacy of this medication in women with sexual arousal disorder are in progress. Several studies are already published demonstrating the efficacy of sildenafil for the treatment of female sexual dysfunction secondary to SSRI use^(20,23) Another study was recently published describing subjective effects of sildenafil in a population of post-menopausal women. ⁽²⁶⁾
• L-arginine: This amino acid functions as a precursor to the formation of nitric oxide, which mediates relaxation of vascular and non-vascular smooth muscle. L-arginine has not been used in clinical trials in women; however preliminary studies in men appear promising. The standard dose is 1500mg/day.
• Phentolamine (Vasomax)): Currently available in an oral preparation, this drug causes vascular smooth muscle relaxation and increases blood flow to the genital area. This drug has been studied in male patients for the treatment of erectile dysfunction. A pilot study in menopausal women with sexual dysfunction demonstrated enhanced vaginal blood flow and improved subjective arousal with the medication.
• Apomorphine: Initially designed as an antiparkinsonian agent, this short-acting medication facilitates erectile responses in both normal males and males with psychogenic erectile dysfunction, as well as males with medical impotence. Data from pilot studies in men suggests that dopamine may be involved in the mediation of sexual desire as well as arousal. The physiologic effects of this drug have not been tested in women with sexual dysfunction, but it may prove useful either alone or in combination with vasoactive medications. It will be delivered sublingually.

The ideal approach to female sexual dysfunction is a collaborative effort between therapists and physicians. This should include a complete medical, and psychosocial evaluation, as well as inclusion of the partner or spouse in the evaluation and treatment process. Although there are significant anatomic and embryologic parallels between men and women, the multifaceted nature of female sexual dysfunction is clearly distinct from that of the male.

The context in which a woman experiences her sexuality is equally if not more important than the physiologic outcome she experiences, and these issues need to be determined prior to beginning medical therapies or attempting to determine treatment efficacies. Whether Viagra or other vasoactive agents are demonstrated to be predictably effective in women remains to be seen. At very least, discussions such as this will hopefully lead to heightened interest and awareness as well as more clinical and basic science research in this area.

by Laura Berman, Ph.D. and Jennifer Berman, M.D.

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Definition

Female sexual arousal disorder (FSAD) occurs when a woman is continually unable to attain or maintain arousal and lubrication during intercourse, is unable to reach orgasm, or has no desire for sexual intercourse.

Description

The disorder typically affects up to 25 percent of all American women, or an estimated 47 million women. Three-fourths of women with FSAD are postmenopausal. Women describe it as being "unable to get turned on," or being continually disinterested in sex. It is also called "frigidity." Other terms for the disorder include dyspareunia and vaginismus, both of which involve pain during intercourse.

Causes and symptoms

There are numerous causes of this disorder. They include:

• physical problems, such as endometriosis, cystitis, or vaginitis
• systemic problems, such as diabetes, high blood pressure, or hypothyroidism. Even pregnancy or the postpartum period (time after delivery of a child) may affect desire. Menopause is also known to reduce sexual desire..
• medications, including oral contraceptives, anti-depressants, antihypertensives, and tranquilizers
• surgery, such as mastectomy or hysterectomy which may affect how a woman feels about her sexual self.
• stress
• depression
• use of alcohol, drugs, or cigarette smoking

Symptoms vary. A woman may have no desire for sex, or may not be able to maintain arousal, or may be unable to reach orgasm. She may also have pain during sex or orgasm, which interferes with her desire for intercourse.

Diagnosis

To make a diagnosis, a woman's physician - either family doctor, gynecologist, or even urologist -- takes a complete medical history to determine when the problem started, how it presents, how severe it is, and what the patient thinks may be causing it. The doctor will also conduct a complete physical examination, looking for any abnormalities in the genital region

Treatment

The physician should start by providing education about the disorder and recommending various non-medical treatment strategies. These include:

• use of erotic materials, such as vibrators, books, magazines and videos

• sensual massage, avoiding the genitals

• position changes to reduce pain

• use of lubricants to moisten the vagina and genital area

• kegel exercises to strengthen the vagina and clitoris

• therapy to overcome any relationship or sexual abuse issues

Medical treatments include:

• estrogen replacement therapy, which may help with vaginal dryness, pain and arousal

• testosterone therapy in women who have low levels of this male hormone (Side effects, however, may include deepening voice, hair growth, and acne)

• the EROS clitoral therapy device (EROS-CTD), recently approved by the Food and Drug Administration; a small vacuum pump, placed over the clitoris and gently activated to provide a gentle suction designed to increase blood flow to the region, which, in turn, helps with arousal

• using the herb yohimbine combined with nitric oxide has been found to increase vaginal blood flow in postmenopausal women and thus help with some forms of FSAD

Alternative treatmentn

Natural estrogens, such as those found in soy products and flax, may be effective. Herbal remedies include belladonna, gingko, and motherwort. However, there is no scientific evidence to prove these herbs actually help. Some women squirt vitamin E in their vagina to increase lubrication.

Women may also want to see a sexual therapist for additional help.

Prognosis

Generally, once women seek the appropriate help they are quite likely to find a way to resolve their problems. Often, a holistic approach, using physical as well as emotional therapies, is required for success.

Prevention

Maintaining a close and open relationship with a partner is one way to avoid the emotional pain and isolation that can lead to sexual dysfunction. Additionally, women should learn if any medications they take affect sexual function, and should refrain from alcohol and drugs and quit smoking. Women who have anxieties and fears about sexual intercourse, whether because of earlier abuse, rape, or a prudish upbringing, should deal with those issues through therapy.

Key Terms

Dyspareunia

pain in the pelvic area during or after sexual intercourse.

Vaginismus

An involuntary spasm of the muscles surrounding the vagina, making penetration painful or impossible.

Persistent or recurrent aversion to and avoidance of all or almost all genital sexual contact with a sexual partner, causing marked distress or interpersonal difficulties.

Sexual aversion disorder occurs occasionally in males and much more often in females. Patients report anxiety, fear, or disgust in sexual situations. The disorder may be lifelong (primary) or acquired (secondary), generalized (global) or situational (partner-specific).

Etiology and Diagnosis

If lifelong, aversion to sexual contact, especially to intercourse, may result from sexual trauma, such as incest, sexual abuse, or rape; from a very repressive atmosphere in the family, sometimes enhanced by orthodox and rigid religious training; or from initial attempts at intercourse that resulted in moderate to severe dyspareunia. Even after the dyspareunia disappeared, painful memories may persist. If the disorder is acquired after a period of normal functioning, the cause may be partner-related (situational or interpersonal) or due to trauma or dyspareunia. If aversion produces a phobic response (even panic), less conscious and unrealistic fears of domination or of bodily damage may also be present. Situational sexual aversion may occur in persons who attempt to or are expected to have sexual relations incongruent with their sexual orientation.

Treatment

Treatment is aimed at removing the underlying cause when possible. The choice of behavioral or psychodynamic psychotherapy depends on diagnostic understanding. Marital therapy is indicated if the cause is interpersonal. Panic states can be treated with tricyclic antidepressants, selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, or benzodiazepines.