Sexuality Across Lifespan: Focus on Women’s Vulnerabilities

Sexuality Across Lifespan I: Women’s Vulnerabilities from Intrauterine Life to Adolescence Women’s sexuality is a multisystemic and multifactorial phenomenon. It is the dynamic expression of biological, psychodynamic, and context-dependent factors continuously interacting in the lifespan. Intrauterine life is emerging as a critical period for human health and specifically for human sexuality. During this phase, the foundations of gender identity are laid. Gestational diabetes, obesity in pregnancy, unhealthy diet, iron deficiency and iron-deficiency anemia, smoke, alcohol, drug abuse, and depression are among the key causes of vulnerability affecting the offspring during intrauterine life, thereby impacting health and sexuality across the lifespan. During childhood, attention must be paid to symptoms suggestive of sexual abuse. Vulvar pain, either intentionally or unintentionally provoked, deserves the highest attention. Adolescence is one of the most critical periods in women’s sexuality, in which female sexual dysfunctions can first manifest themselves. In this chapter, we will discuss a few emerging elements of sexual vulnerability in adolescents such as the impact of social media and pornography on body and genital self-image; the apparently growing phenomena of sexual and gender fluidity and gender dysphoria; and the impact of polycystic ovary syndrome on sexuality. Sexuality Across Lifespan II: FSD Classification and Women’s Vulnerabilities in the Reproductive Age Female sexual dysfunctions (FSDs) have a cumulative prevalence of 40–50%. According to the ISSWSH classification, they include hypoactive sexual desire disorder (HSDD), female arousal disorder (FAD), persistent genital arousal disorder (PGAD), female orgasm disorder (FOD), and sexual pain-penetration disorders (SPPDs). Family physicians and gynecologists should routinely include a few sexual questions in their general clinical history, to give the patient the solid feeling that a respectful listening, a competent multifactorial diagnosis, and a first-line therapeutic recommendation will be offered if indicated. In reproductive-age women, pregnancy and puerperium cause frequent and yet very neglected sexual vulnerabilities, which deserve more committed clinical attention. They are the leading clinical focus of this chapter, besides FSD classification. Key etiologies of sexual vulnerabilities during reproductive age include endometriosis, vulvodynia, infertility, sexual abuse, cancer (in particular gynecological and breast cancers), gynecological surgery, and chronic systemic conditions. A pragmatic approach useful in the daily clinical practice in the office will be privileged in this chapter. Sexuality Across Lifespan III: Women’s Vulnerabilities from Early Menopause to Senescence Aging, loss of sexual hormones, inappropriate or health-destructive lifestyles, and comorbid diseases may impair the key hormonal, nervous, vascular, muscular, and immune-related components of women’s sexual function. Biological stress, triggered by specific menopause-driven symptoms such as insomnia, hot flashes, and joint and muscle pain, may further erode the vital energy, first fuel of sex drive, with a direct effect on the brain, and indirect, through the stress-induced dysbiosis of intestinal microbiota and its effects on the gut brain. Weight gain, abdominal fat, wrinkles, loss of hair, skin thinning, and postural changes may all wound the body shape, affecting body image and body feelings, with variable effects according to the cultural esthetic values of the woman’s cultural background. Male sexual problems may further contribute to FSDs, during the menopausal transition and beyond. Economic difficulties, low education, disadvantaged context, difficulties to obtain appropriate medical diagnosis and treatment of FSDs, and medical comorbidities further complicate the clinical scenario of the individual woman. The chapter focuses on key diagnostic criteria, useful to recognize different clusters of women with FSDs. Appropriate lifestyles, hormone therapy, and rehabilitation of the pelvic floor can synergize to offer a more significant improvement of perimenopausal FSDs. Address of concomitant male sexual dysfunction, if present, is mandatory. Special focus will be finally dedicated to the role of topical genital testosterone to improve different aspects of the genitourinary syndrome of the menopause (GSM), with specific benefits on vulvar and vaginal trophism, clitoral and cavernosal responsiveness, and orgasmic intensity.