Michael Sand, William A Fisher, Raymond C Rosen, Irwin Goldstein
Couples share their sexual dysfunctions. In this chapter, the issue of female sexual dysfunction that is associated with male sexual dysfunctions will be reviewed.
Studies such as that by Riley et al. in 2002 have noted a high prevalence of sexual problems in women whose men also had sexual problems. In this specific investigation, Riley et al. found, regarding men with erectile dysfunction, that women had frequent sexual concerns about their own function. The problem included relationship dissatisfaction, fear of intimacy, diminished sexual desire, and dyspareunia.1 Is the association between female sexual dysfunction and male sexual dysfunction related to aging factors within each member of the couple? Can a woman who is otherwise sexually functional and healthy develop a sexual dysfunction because her male partner has a sexual dysfunction?
There are limited data on the topic. This chapter will review the evidence supporting the potentially strong association between female sexual dysfunction and sexual dysfunction in the male partner.
Women with men who have erectile dysfunction
Women with men who have erectile dysfunction may have their own sexual function adversely affected. In particular, a woman’s sexual attitudes, sexual beliefs, sexual experiences, sexual function (desire, arousal, and orgasm) and sexual quality of life may be impaired by her partner’s erectile dysfunction. Furthermore, among women with male partners, it is not known whether the woman’s sexual function and sexual quality of life are altered when her partner is successfully treated for erectile dysfunction with safe and effective agents such as selective phosphodiesterase type 5 inhibitors.
While substantial investigation has taken place on the effects of selective phosphodiesterase type 5 inhibitors on men with erectile dysfunction, little attention has been given to the sexual responses of their female partners. A typical inclusion criterion in the selective phosphodiesterase type 5 inhibitor trial on such couples was the existence of a stable heterosexual relationship. Participation of the woman was voluntary and limited to assessments of treatment satisfaction. The female partners of men with erectile dysfunction were thought to support unconditionally their partners’ sexual treatment. The perspective of the woman, her well-being, quality of life, sexual function, and sexual satisfaction, either in relation to existing erectile dysfunction or successfully treated erectile dysfunction, were not taken into consideration.
What are the scientific data available concerning changes in the woman’s sexual function among women whose partners have erectile dysfunction? Clinically, it has been frequently anecdotally observed that women have discontinued their sexual activity if their male partners develop erectile dysfunction. Unfortunately, there are limited investigations on the subject. In one study, Blumel et al. examined a sample of 534 otherwise healthy women who had ceased sexual activity with their male partners.2 It was noted that, among the cohort under age 45, erectile dysfunction was the most frequently cited reason for cessation of the woman’s sexual activity.
There have recently been a series of studies investigating the effects of a woman’s sexual function when her male partner has erectile dysfunction. Initial studies were, however, obtained with data from the man’s perspective. Past research in this area involved inquiries of the men with erectile dysfunction about the effect their sexual problem had on their women partners. For example, in 2001, Paige et al. hypothesized that since erectile dysfunction could have a significant influence on the lives of the couple, the restoration of erectile function should then be associated with an enhancement of health-related quality of life in the couple.3 Focusing on the relationship involving women whose men had erectile dysfunction, this study showed that significant improvement in the marital interaction score was noted when men with erectile dysfunction used a selective phosphodiesterase type 5 inhibitor. Moreover, when the men were asked whether using the selective phosphodiesterase type 5 inhibitor improved the relationships with their women partners, 29% indicated that it definitely had.3
Contemporary research has finally begun to address the issue from the woman’s perspective. Current investigations have begun to shed light on the previously poorly explored effects of erectile dysfunction and its treatment among women whose partners experience this sexual dysfunction.
In the following five investigations, data are derived from the woman herself, as her own study subject. In the first study, Cayan et al. recently reported on a prospective study assessing the sexual function of women with men who had erectile dysfunction.4 All women in the trial completed a Female Sexual Function Index score. The study involved 38 women whose men had erectile dysfunction and 49 women whose men did not have erectile dysfunction. Women’s sexual function, including sexual arousal, lubrication, orgasm, satisfaction, pain, and total score, was significantly diminished among women with men who had erectile dysfunction in comparison with women in the control group. Among those women whose male partners received treatment (penile prosthesis insertion, oral phosphodiesterase type 5 inhibitor treatment) for their erectile dysfunction, significant improvements in sexual arousal, lubrication, orgasm and satisfaction in the women were identified.4
In the second study, Ichikawa et al. evaluated the sexual function and satisfaction of women with men who received treatment (phosphodiesterase type 5 inhibitor) for erectile dysfunction.5 Of the 98 women who were invited to participate, only 30 (31%) accepted. Of these, most women (90%) reported that the treatment was effective, and a majority of women (60%) reported improvement in their quality of life. Interestingly, 20% of women whose men’s erectile dysfunction was treated with phosphodiesterase type 5 inhibitors were concerned about adverse events. A significant number of women disappointed with the erectile dysfunction treatment had female sexual dysfunction.5
In the third study, Montorsi et al. investigated thoughts, views, and intercourse satisfaction in 930 women whose male partners were taking a selective phosphodiesterase type 5 inhibitor to manage erectile dysfunction.6 Women with men using a selective phosphodiesterase type 5 inhibitor had significantly higher intercourse satisfaction than women whose men used a placebo.6
In the fourth study, Chevret et al. developed and validated the Index of Sexual Life to measure women’s sexual function in relationships with men who had erectile dysfunction.7 Women partnered with men with erectile dysfunction were found to have significantly diminished sexual drive and sexual satisfaction compared with women whose male partners did not have erectile dysfunction.7
In the fifth study, Oberg et al. examined data from a nationally representative cross-sectional population investigation of sexual life, attitudes, and behavior in Sweden.8 A total of 926 women, aged 18-65 years, were sexually active in a steady, heterosexual relationship during the 12 months prior to the investigation. Data from women who claimed personally distressing sexual dysfunctions quite often, nearly all the time, or all the time were compared with data from women that had no distressing sexual dysfunction. Women distressed by low sexual interest or orgasmic dysfunction were very likely to have a partner with an erectile dysfunction (odds ratios 47.6 and 20.0, respectively).8
There are two additional data sets that have been utilized to investigate the sexual function of women whose male partners have erectile dysfunction. One new source of scientific data has been obtained from a large observational study, the Female Experience of Men’s Attitudes to Life Events and Sexuality study.9-11 In this investigation, data were analyzed from 283 women in eight countries whose male partners had erectile dysfunction. Women with men who had erectile dysfunction were asked multiple questions comparing their sexual activity, sexual function, and beliefs about sexuality before and since their partners experienced difficulty with their erections. Data from the women were stratified by the man’s selfreported degree (mild, moderate, or severe) of erectile dysfunction.9 In the Female Experience of Men’s Attitudes to Life Events and Sexuality study, women whose partners had erectile dysfunction reported a lower frequency of sexual activity currently compared with before their partner developed erectile difficulties.9,10 Significantly fewer women reported that they experienced sexual desire, sexual arousal, orgasm, or sexual satisfaction (“almost always” or “most times”) currently compared with before their partners developed erectile difficulties. There was a significant correlation between the reduction in frequency of the woman’s orgasm, the reduction in her sexual satisfaction, and the degree of her partner’s selfreported erectile dysfunction (mild, moderate, severe).
Women had the lowest frequency of orgasm and the lowest satisfaction with the sexual experience when their partners had severe erectile dysfunction.
The diminished sexual response in these women was analyzed by current-use versus nonuse of phosphodiesterase type 5 inhibitors by the male partner.10 Women whose partners were current users of phosphodiesterase type 5 therapy reported significantly greater frequency of desire (54% vs 43%), arousal (56% vs 40%), and orgasm (46% vs 30%) than did women whose partners were not current phosphodiesterase inhibitor type 5 users.
This study showed that a woman partnered with a man who had erectile dysfunction had significant negative sexual experiences compared with before her partner developed erectile dysfunction, and that the woman’s loss of orgasm and satisfaction with the sexual experience correlated with the man’s perception of the severity of his erectile dysfunction.10
The second source of scientific data has been obtained from a double-blind, multicenter, 3-month, randomized trial involving men with erectile dysfunction in heterosexual couples who were in a stable relationship for at least 6 months.11 In this trial, women whose male partners had erectile dysfunction were asked at initial screening to complete the validated Female Sexual Function Index. Couples in which the female partner did not have sexual dysfunction, based on their baseline responses, were enrolled in the trial. Male partners with erectile dysfunction received placebo or selective phosphodiesterase type 5 inhibitor for 1 month, with an option to adjust the dose higher or lower based on erectile response after each of two consecutive, 1-month intervals. One outcome variable was the improvement of the woman’s sexual quality of life. This was determined objectively by the woman’s response to the quality of life domain of the modified Sexual Life Quality Questionnaire as well as other patient responses to that questionnaire.11
The selective phosphodiesterase type 5 inhibitor significantly improved the erectile quality of the men with erectile dysfunction compared to placebo. Compared with those men with erectile dysfunction treated with placebo, women whose partners were randomized to receiving active drug had significantly higher (1) sexual quality of life, (2) sexual confidence, (3) sexual pleasure, and (4) orgasm satisfaction.11
In summary, accumulating scientific evidence indicates that there are adverse effects on the sexual function of women whose male partners have erectile dysfunction. In addition, accumulating data support the hypothesis that there is an independent improvement in the sexual quality of life of women whose partners have erectile dysfunction and receive successful erectile dysfunction treatment. This supports the theory that that there is a close relationship between women’s sexual response and the quality of the erectile responses of their male partners.
Women with men who have premature ejaculation
Women with men who have premature ejaculation may have their own sexual function adversely affected. Since premature ejaculation is the most common male sexual dysfunction,12 affecting approximately 25% of men, it is likely that many women experience a sexual relationship with a man with premature ejaculation. In addition, since only 5-10% of men receive treatment for premature ejaculation,13 it is likely that women with men with premature ejaculation will have to deal with his sexual problem on a long-term basis. Premature ejaculation is objectively determined with a stopwatch to record intravaginal ejaculatory latency time defined as the time between vaginal intromission and intra vaginal ejaculation. It has been suggested that an intravaginal ejaculatory latency time of 2 min or less may serve as a criterion for defining premature ejaculation.14 Note that the diagnosis of premature ejaculation is somewhat controversial.15
Women with men who have premature ejaculation may have significant distress, interpersonal difficulties, and dissatisfaction with sexual intercourse. The woman’s distress is a common reason for the man to consult a clinician about premature ejaculation.
Byers et al. investigated the effect of premature ejaculation on 152 couples’ sexual function.16 Concerning the couple’s perceptions of whether the premature ejaculation was a problem, reports of women and men were only moderately correlated. Women saw less of a problem for the men than the men reported for themselves. For both the women and the men, having more premature ejaculation characteristics was related to lower sexual satisfaction. The results suggest that, for most couples, the premature or early timing of ejaculation adversely affects sexual satisfaction.16
Patrick et al. carefully selected patients with and without premature ejaculation based on stopwatch testing.15 The mean intravaginal ejaculatory latency time was 1.8 min in the 207 men with premature ejaculation. This was significantly lower than the time (7.3 min) in the 1380 men without premature ejaculation. Women whose men had premature ejaculation were found to differ significantly from women whose men did not have premature ejaculation in terms of decreased satisfaction with sexual intercourse and increased interpersonal difficulty and distress (p <0.0001). More women partners of men with premature ejaculation than women whose partners did not have premature ejaculation claimed “poor” or “very poor” for satisfaction with sexual intercourse (28% vs 2%, respectively) and gave worse ratings (“quite a bit” or “extremely”) for personal distress, couple relationship (44% vs 3%, respectively), and interpersonal difficulty (25% vs 2%, respectively) (p <0.0001).16
Women whose partners experience premature ejaculation are adversely affected by the men’s sexual dysfunction.
Both members of a couple experience aspects of the sexual dysfunction of the affected individual. Initial findings suggest that the woman whose male partner has erectile dysfunction or premature ejaculation often has concerns and distress about her own sexual function. It is important for clinicians to recognize that sexual dysfunction and its treatment are likely to have an effect on both members of the affected couple.
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9. Fisher W, Rosen R, Sand M et al. Is there a correlation between ED severity and level of sexual concerns in the female partner? The FEMALES study. Abstract presented at 20th EAU Congress, Istanbul, Turkey, 2005.
10. Rosen R, Eardley I, Fisher W et al. Effect on the Sexual Function of Female Partners of PDE5 use in Men with ED: The F.E.M.A.L.E.S. Study. J Sex Med 2005; Suppl 1.
11. Fisher W, Rosen R, Brock G et al. Vardenafil improves treatment satisfaction and sexual pleasure in men with erectile dysfunction and their Partners. Abstract presented at 20th EAU Congress, Istanbul, Turkey, 2005.
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