Abstract
Summary
There have been a number of case reports published recently describing women who complain of persistent genital arousal. Most of these papers do not report medical data or observations from genital examination. We report in such detail on six cases of persistent genital arousal disorder (PGAD) in women. We further advance the hypothesis that in many cases the objective genital component may be induced by a variety of psychophysiological and pathological factors such as anxiety, genital prolapses and dermatoses. Genital engorgement so produced may not be continuous but when present may be enhanced and perpetuated by both anxiety focussed on the genitals and masturbation used in an attempt to relieve the sensations. Premorbid affective psychological illness negatively colours the subjective perception of this genital engorgement, leading to either elicitation or maintenance of PGAD. We discuss this hypothesis in relation to our six cases.
INTRODUCTION
The complaint of persistent genital arousal in women continues to baffle clinicians and researchers with the variety of its presentations and the absence of any clear overarching aetiology. Recent web survey research has not been able to document any definitive physical, hormonal or neurological associations. 1 Case reports in the literature have either not commented on the genital appearance, reported clitoral distension, general mucosal hyperaemia or have described the area as normal. 2–4 The only significant factor that differentiates women who are distressed with their spontaneous genital arousal from those who are not distressed is the finding of a higher incidence of depression, anxiety and obsessional thinking among the former group of women. These characteristics seem to predate rather than result from their symptoms. 1
We present six clinical cases of women with complaints of persistent genital arousal and highlight the factors that appeared to precipitate and/or maintain their clinical picture in order to further help understand this enigmatic syndrome.
CASE HISTORIES
Case 1
In Case 1, Ms A was 29 years old and presented with ‘annoying’ and distressing spontaneous genital arousal for a number of years. She said the arousal made her ‘tense’ and usually came unbidden. It would be worse if there was any degree of sexual desire, and lessened a year earlier when she and her boyfriend had argued and separated. Commonly, she would become genitally aroused ‘a few times a day’. If she responded by masturbating, the genital arousal very quickly returned thereby often causing her to remain genitally aroused ‘all day long’. Vaginal sex did not ‘satisfy’ her. Unbidden genital arousal increased in intensity just prior to menstruating.
Psychological background
Ms A had suffered from a moderately severe obsession illness for a number of years that included handbag checking and bedmaking. She also had mild mood swings but no formal manic or depressive illness. From 1999 to 2000 she had taken fluoxetine 20 mg per day for the obsessional illness, which she recalls ‘might have helped’ to reduce the severity of the genital arousal. On stopping this medication, she developed derealization and depersonalization symptoms that lasted three months. However, the genital arousal remained static.
Medical background
She had a past history of genital herpes with no recent recurrences. Genitalia were normal on examination. She had a normal sex hormone profile.
Case 2
In Case 2, Mrs B was a 59-year-old widow from the Middle East whose husband died 12 years ago. She had never been interested in sex, and was relieved to be free of sexual contact since her husband's death. A year ago, she started having an overwhelming urge to masturbate because of persistent genital arousal. This was largely unrelieved by orgasm.
Medical background
She was postmenopausal for the past 13 years and was not on hormone replacement therapy. There was no psychiatric illness. Medications were thyroxine and statins – both for many years. Examination showed a significant rectal and bladder prolapse with engorgement of the vaginal mucosa overlying these areas. Uterine ultrasound revealed a posterior uterine wall subserosal fibroid (27 × 25 mm). Her oestradiol level was unmeasurable, total testosterone 2.4 nmol/L, normal prolactin and thyroxine levels, normal renal and liver function tests, blood picture and unmeasurable C-reactive protein. She also developed urinary symptoms a few months later with no bacterial growth. A bladder biopsy showed ‘chronic inflammation’.
Case 3
In Case 3, Mrs C a 65-year-old married woman who had not had sexual contact with her husband for over 18 years, suffered from lifelong anorgasmia and hence consulted a sex therapist in 2005 who instructed her to use a vibrator on her clitoris. This resulted in ‘violent’ orgasms with painful backarching (hyperextension) and infrequent spontaneous nocturnal orgasms of a similar nature. At the same time she developed ‘constant pressure in the clitoral and vaginal areas’ that occurred unbidden four to five times a day and lasted 10–15 min. Vibrations of train journeys could set it off. Masturbation would sometimes end the arousal but at other times it would persist. She felt ambivalent about the unbidden arousal – sometimes welcoming it and other times finding it distressing.
Medical background
Mrs C had ongoing postviral cardiomyopathy with pulmonary hypertension and chronic fatigue syndrome both of which antedated the onset of the arousal by a number of years. She had a past but not current history of depression. Her medications were bisoprolol, perindopril, spironolactone, bendroflumethiazide, acetylsalicylic acid, orlistat and paracetamol. Examination showed a small bladder prolapse with some vaginal atrophy.
Investigations included normal cervical cytology, total testosterone 1.3 nmol/L, dehydroepiandrosterone sulfate (DHEAS) 1.1 nmol/L. Pelvic ultrasonography showed that the uterus contained ‘multiple prominent vascular channels throughout (measuring up to 2 mm)’. A pelvic magnetic resonance imaging (MRI) scan was reported as normal, as were brain and spinal cord MRIs and an electroencephalography.
Case 4
In Case 4, Ms D was 35 years old with a 15-year history of severe anxiety with obsessional features. She had developed severe genital arousal symptoms two years earlier, which came unbidden and were markedly exacerbated by increased anxiety. Masturbation failed to resolve these feelings. Her anxiety lessened somewhat on venlafaxine and alcohol cessation (she had been drinking 3–4 units per day). Genital examination was entirely normal.
Case 5
In Case 5, Mrs E was 52 years old. Six months prior to consultation, she suddenly developed a loss of sensitivity in the vulval area and symptoms, which she took as menopausal, i.e. exhaustion, depression, weepiness and hot flushes. She was put onto a cocktail of testosterone, progesterone, DHEA and oestrogen in addition to citalopram. At this point, she began complaining of unbidden genital engorgement symptoms in her lower vagina with ‘mini contractions’ of the anal area similar to orgasm. The urge to masturbate was overwhelming but she found this only exacerbated the symptoms, which also came in her sleep. Exercise appeared to relieve the symptoms that were usually highly distressing to her.
Medical background
In the past, she has had increased urinary frequency of undetermined aetiology. Detailed neurological examination was normal, but she did have a small bladder prolapse.
Case 6
In Case 6, Mrs F, a 45-year-old happily married woman who for 20 years, since the birth of her children, has felt an almost continuous uncomfortable feeling on the right side of the clitoral and vulval area that arises without sexual fantasy. She chose to distract herself from these feelings or gently masturbate over the periclitoral area or stimulate the R nipple for 30–40 minutes, which culminated in a 2–3 minute orgasm. Mrs F was able to repeat the whole process frequently so that her whole day can be taken up masturbating in response to the genital feelings. Vaginal sex with her husband was described as ‘relaxing’, but she did not allow him to stimulate her periclitoral area.
Psychological background
She has an obsessional personality with some ritualistic behaviours (tidiness in her home) and anxiety symptoms in relation to work. When she had taken fluoxetine the unbidden arousal considerably decreased. However, she was not happy on this medication.
Medical background
Physical examination, including neurological examination was normal. However, there was marked hypertrophy and fibrosis of the periclitoral hood, which could not be withdrawn so that the clitoris could not be visualized. Clinically, this had the appearance of lichen sclerosis. The patient declined biopsy.
The factors that affected the perception of genital arousal in the six patients are summarized in Table 1.
Factors affecting subjective genital arousal in the six cases
*All factors caused exacerbation apart from exercise which decreased it
DISCUSSION
It is certainly the case that unwanted sexual arousal may be underpinned by purely neurological conditions such as focal epilepsy 5 or withdrawal from antidepressants. 6 In a number of the other anecdotal cases described in the literature 3,4 as well as with the cases described here some degree of genital engorgement is present. We are therefore suggesting that the minimal requirement for the experience of unpleasant symptoms of persistent genital arousal may be a combination of objective genital engorgement (in our cases either physiologically produced or secondary to genital prolapse) or dermatological pathology that is coexistent with significant anxiety. The anxiety, along with catastrophic thoughts about the sensations, narrows the patient's attention to the genital area, further resulting in augmentation of the subjective feeling of genital arousal. 7
Our patients were able to pinpoint masturbation/vibration, menstruation, anxiety and sleep as precipitating factors and one patient asserted that exercise was a relieving factor. Research over the last few years has confirmed that all of these factors can significantly alter objectively observed female genital engorgement in non-clinical samples. Geer and Quartararo 8 and Gillan and Brindley 9 reported that vaginal blood volume can remain at preorgasmic levels for up to 16 minutes postorgasm. Henson et al. 10 found this engorgement to be more focused on the lower vagina rather than the vulva. Vaginal pulse amplitude at REM (repid eye movement) sleep in 20 normal women approached the level recorded while women viewed erotic films. 11 Wylie et al. 12 have reported similar findings recently in a woman who had persistent genital arousal disorder (PGAD). Bradford and Meston 13 found a curvilinear relationship between state anxiety and vaginal pulse amplitude in female volunteers. Therefore, anxiety may enhance both local engorgement and alter perception of that engorgement. A group of Australian workers 14 have demonstrated marginally higher levels of vaginal blood volume at menstruation when compared with other parts of the cycle in response to erotica. Prior exercise decreases vaginal blood amplitude when viewing neutral films but increases when viewing erotica after exercise. 15
The above observations are consistent with other recent research, where a sample of PGAD and non-PGAD women were asked to indicate all the possible factors that may have contributed to the initial development of persistent genital arousal. Two factors emerged as most significant: stress (43% of PGAD women and 33% of non-PGAD women) and intense sexual stimulation (33% of PGAD women and 42% of women with non-PGAD) (Leiblum, unpublished data).
A noteworthy finding with many of our patients is that the distress associated with the condition is quite variable. Some report major distress while others at times characterize the persistent genital arousal as neutral or pleasant. Earlier research has established that not all women with persistent genital arousal find the experience distressing – and for some, it is normative and even pleasurable. 7 Even women who meet the diagnosis of PGAD occasionally regard their sensations as pleasurable. Earlier research found that 45% of women with PGAD indicated that they ‘sometimes’ enjoy their persistent arousal.
We feel it is vital to take a careful and extensive medical and psychological history of women complaining of PGAD and to include a thorough physical examination in order to exclude local pathology, such as genital dermatosis and genital prolapses. This should be complemented with a detailed neurological and psychological screening of all patients with special investigations where necessary to exclude conditions such as cerebral or pelvic pathology. 3,4