Female sexual dysfunction is very common in women with neurological conditions, including MS.
The majority of women with MS suffer from sexual dysfunction at some stage of the disease. Compared to a general female population, in which 20-50 per cent of women are affected, the prevalence of sexual dysfunction is estimated to be as high as 80 per cent in women with MS. Sexual dysfunction has a major impact on quality of life and interpersonal relationships. For many women it is a physically disquieting, emotionally disturbing and socially disruptive disorder. In spite of its high prevalence, these aspects of an individual's well-being have been considerably neglected until recently, making female sexual dysfunction a very important but often overlooked symptom of MS.
How the body behaves during the sexual response
Two basic physical processes that occur during thesexual response: vasocongestion and myotonia. Vasocongestion refers to the concentration of blood in the blood vessels and the tissues of the genitals and breasts. In women, this inflow of blood causes the clitoris to enlarge, the labia to swell, and the vagina to lubricate.
Myotonia, or neuromuscular tension, refers to the increase of energy in the nerves and muscles.
During sexual activity, myotonia takes place throughout the body, not only in the genital region, but throughout the trunk, particularly in the breast and chest wall.
For women, vasocongestion in the vaginal walls causes vaginal secretion to seep through the vaginal lining, moistening the inner surface of the vagina.
The amount of lubrication or “wetness” present in the vagina does not necessarily coincide with a woman's degree of arousal or desire for intercourse. Swelling of the clitoris and of the labia also occurs in response to vasocongestion during the excitement phase. In addition, the inner two-thirds of the vagina lengthens and expands, the cervix and uterus elevate, and the outer lips of the vagina flatten and separate. Nipples may become erect, breasts slightly enlarged, and the veins in the breasts may appear more visible.
How and why MS can affect sexual functioning
Sexual dysfunction in women has many causes and effects. Abnormalities in blood circulation, hormonal state, nerve functioning and mental well-being may influence sexual functioning. Therefore, one or more of these factors can result in sexual dysfunction.
Lesions in the brain can interfere with the interpretation of sexual stimuli as arousing, while lesions of the spinal cord can interfere in the transmission of arousing nerve signals to the genitals. Lesions in the sacral
| (lower) spinal cord can also cause primary sexual dysfunction, by inhibiting or preventing vasocongestion, resulting in diminished or absent clitoral swelling and/or vaginal lubrication.
In primary sexual dysfunction, MS lesions in the spinal cord may make it difficult to sustain clitoral/vaginal engorgement during the plateau phase (between arousal and orgasm). In addition, sensory changes in the genitals can interrupt or diminish nerve signals that initiate and/or maintain vasocongestion at both the spinal cord and cerebral cortex (brain) levels.
Types and frequencies
Approximately 80 per cent of women with MS experience sexual dysfunction at some time during the course of the disease. Some women stop engaging in sexual relations while others (approximately 40 per cent) have reported that participating in sexual relations is significantly unsatisfactory. Symptoms most commonly reported include reduced genital sensation (48 per cent), reduced vaginal lubrication and difficulty with arousal (35 per cent), and difficulty or inability reaching orgasm (72 per cent). Pain during intercourse is also a frequently reported symptom in women with MS, which may be due to vaginal dryness, spasticity or hypersensitivity.
Assessment
Since the sexual response in women with MS is related to many different factors, a comprehensive assessment of all these aspects must be taken into account. An evaluation should consist of a full medical history, physical examination and pelvic examination. Although sexual dysfunction in women with MS often has a neurological cause, its evaluation is not always included in routine clinical practice. Often it is possible for a clinician to become aware of a problem and begin to evaluate it based on information provided by the individual during the visit, in response to a few relevant questions. Initiating these questions is not always part of the healthcare professionals' routine, with the result that important information is missed by the professional and problems experienced by the person with MS are left unaddressed.
Possible treatments
Oestrogen creams may be useful for women experiencing vaginal dryness, pain or burning. Another treatment for these symptoms is a vaginal suppository, although this form may not be available in all countries. Unfortunately, many of the medications that appear to be effective for the treatment of male sexual dysfunction related to MS have proved either to be ineffective for other symptoms of female sexual dysfunction or have not been studied fully at this time.
Conclusions
Sexual dysfunction is highly prevalent among women with MS. Assessment and treatment of these problems is complicated. Addressing sexual problems during routine visits is important in identifying and managing symptoms that can have a negative impact on an individual's personal life as well as on the life of the couple.
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