Practical suggestions for aging patients might include taking a warm bath before lovemaking to loosen stiff joints, making love in the morning when the couple is less fatigued, or having neither intercourse nor orgasm as a necessary goal. Local estrogen supplementation can alleviate vaginal dryness, urinary tract symptoms, and dyspareunia, restoring vaginal cell health, decreasing pH, and increasing vulvar and vaginal blood ﬂow. The aging couple can be encouraged to use low-key, more prolonged sexual stimulation because the rate of sexual response is slower.
To relieve sexual symptoms of dyspareunia and lower sexual self-image from estrogen deficiency–associated vaginal dryness and recurrent urinary tract infections, topical vaginal estrogen is recommended. There is some evidence topical therapy may be more effective for sexual symptoms than systemic, and when systemic estrogen is used for nonsexual reasons, additional topical vaginal estrogen may still be required (107).
Ultra low-dose estrogen from a Silastic ring or vaginal cream or vaginal pill is an emerging therapy, to avoid the (albeit) small systemic absorption from current formulations of ring (releasing 7.5 μg estradiol daily) or estradiol tablets (containing 25 μg estradiol daily). These ultra low-dose formulations may prove appropriate for women with past history of breast cancer. Every woman with such history currently is treated individually by her oncologist, taking into account her sexual symptoms, the importance to her of penetrative sex, as well as her particular tumor endocrinology.
Investigational local vaginal DHEA may benefit vulvar vaginal atrophy, in the absence of systemic absorption of either DHEA or the intracellularly produced estrogen or testosterone. Early research shows a generalized sexual benefit in terms of coital comfort, ease of orgasm, and sexual motivation (108).
Increasing numbers of women who underwent female genital mutilation or female genital cutting (FGC) need gynecologic care in Western counties. This ancient tradition from at least 200 B.C. has cultural rather than religious origins and is not restricted to any particular ethnic group or religious sect. Type I FGC involves removing part or all of the clitoris and prepuce, Type II is an excision of part or all of the clitoris and the labia minora with or without excision of the labia majora, Type III is known as infibulation and is the most extreme form, involving narrowing the vaginal orifice and creating a covering of the adjoined labia minora and or labia majora with or without including the clitoris. There are other “lesser” procedures often noted as Type IV, such as pricking of the female genitalia for nonmedical reasons. Although some 85% of FGC are Types I and II and 15% are Type III, recent immigration and refugee resettlement from countries where Type III predominates, including Somalia, resulted in many more women with Type III FGC in North America and Europe.
Sound data are lacking on psychosexual outcome. The taboos against discussing sexual displeasure or pain from FGC limit data collection. Despite this, there is evidence that FGC may not destroy sexual function and prevent enjoyment in all women (109). FGC invariably damages many neural networks associated with the vulvar and perineal areas, potentially altering genital sensation. Neuroplasticity within the brain and spinal cord is thought to account for the fact that some, perhaps even the majority, of women have sexual response, sometimes including that from genital stimulation and other times from stimulation of breasts or other areas of the body.
Results of studies of dyspareunia are somewhat conﬂicting, some suggesting it is only temporary after first intercourse during the initial period of marriage and after reinfibulation (110). Some studies that noted increased prevalence of dysmenorrhea, vaginal dryness, lack of sexual desire, difficulty reaching orgasm, as compared to noncircumcised women, failed to find increased incidence of dyspareunia.