PRIMARY SEXUAL DYSFUNCTION IN WOMEN WITH MS

The most frequently described symptoms in women include decreased sexual desire, diminished orgasm, difficulties with vaginal lubrication, and fatigue that interferes with sexual activity. Decreased vaginal lubrication can be treated with water-soluble lubricants, and dysesthesias may be relieved with medication for nerve pain.

Similar to the male anatomy, nitrergic nerves are present in the corpus cavernosum of the clitoris and vaginal wall, so there is good rationale for expecting sildenafil (Viagra®) to have a positive effect. A randomized control trial is currently under way.  Studies of this agent in women with sexual dysfunction suggest that sildenafil may be beneficial in a proportion of patients, particularly when lubrication is an issue.

Decreased Vaginal Lubrication

Vaginal lubrication is controlled by multiple pathways in the brain and spinal cord, similar to the erectile response in men. Decreased vaginal lubrication can be addressed by using generous amounts of water-soluble lubricants, such as K-Y Jelly®, Replens®, or Astroglide®. It is not advisable to use petroleum based jellies (e.g., Vaseline®) for vaginal lubrication due to the greatly increased risk of bacterial infection.

Sensory Changes

Uncomfortable genital sensory disturbances, including burning, pain, or tingling, can sometimes be relieved with gabapentin (Neurontin®), carbamazepine (Tegretol®), phenytoin (Dilantin®) or divalproex (Depakote®) or by a tricyclic antidepressant such as amitriptyline (Elavil®). Decreased genital sensation can sometimes be overcome by more vigorous stimulation, either manually, orally, or with the use of a vibrator. Exploring alternative sexual touches, positions, and behaviors, while searching for those that are the most pleasurable, is often very helpful. Masturbation with a partner observing or participating can provide important information about ways to enhance sexual interactions.

Orgasmic Dysfunction

MS can interfere directly or indirectly with orgasm. In women and men, orgasm depends on nervous system pathways in the brain (the center of emotion and fantasy during masturbation or intercourse), and pathways in the sacral, thoracic, and cervical parts of the spinal cord. If these pathways are disrupted by plaques, sensation and orgasmic response can be diminished or absent.

In addition, orgasm can be inhibited by secondary (indirect physical) symptoms, such as sensory changes, cognitive problems, and other MS symptoms. Tertiary (psychosocial or cultural) orgasmic dysfunction stems from anxiety, depression, and loss of sexual self-confidence or sexual self-esteem, each of which can inhibit orgasm.

Treatment of orgasmic loss in MS depends on understanding the factors that are contributing to the loss, and appropriate symptom management of the interfering problems.