**By Una Lee, MD**
If the female sexual response seems mysterious and complicated, it is – like anything that involves both mental and physical systems. To shine a light on a few of these mysteries, let’s discuss some of the latest research and what it has taught us about female sexual function.
Sexual arousal and the mind-body connection. When our sexual organs are stimulated, our brains process sexual pleasure. But imaging studies show that just thinking about stimulating the clitoris, nipples, and vagina activate the same sites in the brain that light up during actual physical stimulation of sexual organs. Studies using MRI have also shown that a woman’s perception of the sexual experience plays a key role in orgasm and reported sexual satisfaction.
The G-spot is not so much a “spot.” About 84 percent of women believe that a highly sensitive spot exists in the vagina, and most women report its location as the anterior (front) wall of the vagina, a few centimeters from the vaginal opening. During studies of women who report achieving vaginal orgasms, the women were asked to press on their G-spot while ultrasound was performed. Consistently they pointed to a location related to the clitoral body. Ultrasounds during sexual intercourse also identified an area near deep structures of the clitoris as the perceived G-spot. This tells us the G-spot is not an isolated spot on the vaginal wall, but is actually able to help stimulate the recessed parts of the clitoris via the vagina (a light bulb moment!)
If this still seems a little mysterious, think of a woman’s clitoris like the tip of a man’s penis: both are part of a larger sexual organ. The clitoris has several parts. The glans, which is the tip of the gland, and the body, which divides into two branches called crura or crus (which resemble the roots of a tree). The corpus cavernosum is the erectile tissue. Both men and women have erectile tissue that extends inside the body. During sexual arousal the clitoris can become engorged and increase in size 50 to 300 percent. For women, the front wall of the vagina (the location of the G-spot) is connected with the internal parts of the clitoris, which can be stimulated through the vagina. The “roots” of the clitoris can become engorged during sexual arousal, sending signals to the brain, and play a key role in orgasm.
The truth about female ejaculation. Female sexual arousal and response involves increased blood flow and dilation of the genital organs. For some women, this increase in pressure leads to the release of vaginal lubrication, also called “squirting” or “gushing.” This so-called “female ejaculation” has created some debate, as the phenomenon isn’t well understood. Women can expel fluid, anywhere from 1 to 900 cc, as part of the sexual response. This fluid is thought to come from the vagina, and possibly vaginal glands called the Skene’s glands. This fluid is generally not urine, but rather clear fluid containing proteins and enzymes. Some women can be worried or confused about this phenomenon if they have never experienced it before. So why don’t all women release this fluid? It’s just another facet of the complexity of the female sexual response. And speaking of female sexual response …
The “little pink pill” has arrived. After years of development and two earlier unsuccessful bids for FDA approval, in August 2015 the drug flibanserin, sold under the trade name Addyi, became the first FDA-approved medication for treating female sexual dysfunction. Specifically the drug is intended to treat hyposexual disorder, or low libido in pre-menopausal women. While it’s been called “the little pink pill,” it has a dramatically different function than “the little blue pill,” or Viagra, for men. Flibanserin works on the brain by altering the balance of neurotransmitters (dopamine and serotonin), and was originally developed as an antidepressant. By comparison, Viagra works to enhance erections by increasing blood flow to the penis.
Questions about efficacy and side effects complicated getting flibanserin to market. Studies show about 10 percent of women achieved an average of one more “sexually satisfying event” per month on flibanserin versus placebo. Meanwhile women must totally abstain from alcohol while taking flibanserin, which can cause a serious drop in blood pressure. While a half million prescriptions were written in the first month of Viagra’s release, there were only 200 prescriptions filled in the first 30 days for the little pink pill.
There are strategies for the dry season. Many women know that menopause can bring on bothersome vaginal dryness, though the problem can occur at any age. The culprit is typically falling estrogen levels, causing dryness that can lead to itching, discomfort, and painful intercourse. For mild symptoms, over the counter lubricating products are effective, including longer acting vaginal moisturizers. Some women have success with natural remedies, such as cold-pressed coconut oil.
Vaginal estrogen applied locally is another option that can be effective and safe. Vaginal estrogen is a prescription medication that comes in the form of a cream, vaginal suppository, or small ring that dispenses the medication over time. These treatments are inserted into the vagina and can improve the vaginal tissues to help treat atrophy, a condition causing thinning and decreased elasticity. An added bonus: studies have also shown that increasing hormone levels in the vaginal tissues can help boost one’s natural defenses against urinary tract infections. Additionally, a newer oral medication called ospemifene (brand name: Osphena) is approved for treating painful sexual intercourse due to vaginal atrophy.
Having sex is good for women’s health. In women, sexual activity boosts feel-good chemicals called endorphins, activating pleasure centers in the brain which help stave off things like anxiety and depression. Research also shows that having sex can boost certain antibodies that help fight illnesses like colds and flu. And how about a youthful glow? Sex promotes the release of hormones, like estrogen and testosterone, which can help women look younger and more vital. In fact, people who have fulfilling sex lives tend to live longer and report greater happiness. So ladies, consider reaping the full benefits of a fulfilling sex life. Doctor’s orders.
Una Lee, MD, is board certified in Urology and subspecialty certified in Female Pelvic Medicine and Reconstructive Surgery at Virginia Mason.