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
®, 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.
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.
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.
Diminished libido is much more common in women with MS than men. To date, there are no published clinical trials of medications that restore libido in MS. Hormone replacement therapy has helped in some post-menopausal women without MS. Testosterone replacement in persons with abnormally low physiological levels has been tried in non-MS populations. However, there is research currently underway that is evaluating medicines that enhance sympathetic arousal, to see if this impacts libido in women with MS. Also, there is research evaluating clitoral vacuum devices and vibrators to see if blood flow, libido, and sensation are enhanced in women with MS.
Pelvic floor or Kegel exercises are sometimes prescribed to enhance female sexual responsiveness. However, in women with significantly reduced sensation, EMG biofeedback is required to help them identify and contract the appropriate pelvic floor muscles in the prescribed manner. The rationale for Kegel exercises is that sensation and contraction of the muscles around the vagina are important parts of the female sexual response.
When loss of desire is due to secondary sexual dysfunction (for example, as a result of fatigue) or tertiary sexual dysfunction (for example, as a result of depression), treatment of the interfering secondary or tertiary symptoms frequently restores libido. When a person's libido is diminished by MS, he or she may begin to avoid situations that were formerly associated with sex and intimacy. Sexual avoidance serves as a source of misunderstanding and emotional distress within a relationship. The partner may feel rejected, and the person with MS may experience anxiety, guilt, and reduced self-esteem. Misunderstandings arising from sexual avoidance tend to increase the loss of desire and diminish emotional intimacy in relationships.
Some men and women who have sustained loss of libido report that they continue to experience sexual enjoyment and orgasm even in the absence of sexual desire. They may initiate or be receptive to sexual activities without feeling sexually aroused, knowing that they will begin to experience sexual pleasure with sufficient emotional and physical stimulation. This adaptation requires developing new internal and external "signals" associated with wanting to participate in sexual activity. In other words, instead of experiencing libido or physical desire as an internal "signal" to initiate sexual behaviors, one can experience the anticipation of closeness or pleasure as an internal cue that may lead to initiating sexual behaviors and the subsequent enjoyment of sexual activity.
Intimacy and Sexuality in MS by Rosalind C. Kalb, Ph.D.
© 2008 National Multiple Sclerosis Society.
Assessment and Treatment of Sexual Dysfunction in Multiple Sclerosis by Frederick W. Foley, PhD.
Clinical Bulletin / Information for Health Professionals.
© 2008 National Multiple Sclerosis Society[Original publication date: 2006]
For Further Information:
CH Polman, AJ Thompson, TJ Murray, AC Bowling, and JH Noseworthy.
Multiple Sclerosis: the Guide to Treatment and Management, 6th edition.
New York: Demos Medical Publishing, 2006.
(updated online, 2008).
How to Manage MS-Related Sexual Dysfunction Series: Part One: Understanding How MS Can Affect Sexual Function
Part Two: Primary Sexual Dysfunction in Men with MS
Part Three: Primary Sexual Dysfunction in Women with MS Part Four: Secondary Sexual Dysfunction in Men and Women Part Five: Sexuality, Intimacy, and Multiple Sclerosis Part Six:
Multiple Sclerosis: Sex Toys, Tips, and Tools