Comportamentul

sexual

Conf. Dr. Daniel Grigorie

Catedra de Endocrinologie,
UMF Carol Davila,
Institutul C.I.Parhon, Bucureti

ISTORIC

Kamasutra primul tratat explicit de sexologie umana

Kinsey variabilitatea practicilor sexuale la americani
Masters si Johnson : la ambele sexe exista raspunsuri
fiziologice previzibile dupa stimularea sexuala si au
descris ciclul raspunsului sexual normal pe baza caruia
se clasifica disfunctiile sexuale
Freud atribuie problemele sexuale ale adultului
dificultatilor maturarii sexuale in copilarie si dezvoltarii
relatiilor parinte-copil
1980 elucidarea mec. fizico-chimice ale erectiei, care
este consecinta relaxarii muschilor cavernosi si a
cresterii fluxului sg. penian, mediate de NO

INTRODUCERE

Endocrine disease and its treatment can frequently

disturb sexual function in men and women.
In addition, patients may believe, often incorrectly,
that their sexual dysfunction must necessarily be due
to hormonal imbalance and seek management from
endocrinologists.
Patients consider their sexual lives to be important;
recognizing the importance of sexual function as a
determinant of quality of life, the World Health
Organization declared sexual health a fundamental
right of men and women

FAZELE CICLULUI SEXUAL

The traditional model of human sexual response

stemming from the research of Masters, Johnson, and
Kaplan envisioned a linear progression from desire to
arousal to a plateau of high arousal followed by
orgasm/ejaculation, followed by a phase of resolution.
In marked contrast to this earlier model depicting a
linear invariable progression of discrete phases, recent
research conceptualizes sexual response as a
motivation/incentive-based cycle comprising phases of
physiologic response and subjective experience.
The phases of the cycle overlap and their order is
variable

RASPUNSUL SEXUAL ESTE CIRCULAR

Poate incepe cu stimuli nu neaparat sexuali

Dorinta si excitatia co-exista si se potenteaza
reciproc.
In both men and women, the relationship
between desire and arousal is variable and
complex, and both are often unable to
separate the two.
Excitatia subiectiva este mai importanta
decat congestia genitala

Prcesarea cerebrala e esentiala

Even with sufficient sexual motivation and the

presence of adequate stimuli, the arousal and
pleasure may not occur if attention is not focused.

Sexual information is processed in the mind both

automatically and consciousl.The sexual nature of the
stimuli is processed by the limbic system, allowing
genital congestion (observed to be quick and
automatic in women and slower but still involuntary in
men).

Conscious appraisal of the sexual stimuli and the

contextual cues can lead to subjective arousal.

MOTIVATII/STIMULI

The motivations and incentives for sex are multiple and

varied and enhance emotional intimacy between the
partners is important for both men and women.
Depression is a major cause of reduced sexual motivation
in otherwise healthy persons and in those with endocrine
disease: repeatedly, comorbid depression has been
identified as a factor underlying increased sexual
dysfunction in women with diabetes.
Even in the absence of clinical depression, low sexual
interest is associated with having more depressed and
more anxious thoughts and lower sexual self-image than
that in control subjects.
Endocrine disorders can markedly lessen sexual self-image
especially when associated with altered appearances,
infertility, or ability to be gainfully employed.

Physiology of Desire and Arousal

Functional Brain Imaging of Sexual
Arousal in Men and Women

S-au identificat arii activatoare (cortexul orbitofrontal)

si arii inhibitoare

Brain imaging in hypogonadal men before and after

treatment suggests that the left OFC might exert a
testosterone-dependent inhibitory tonic control on
sexual arousal and that this control decreases upon
visual sexual stimulation.

Also the response of the right anterior insula to visual

sexual stimulation was found to depend on the level of
plasma testosterone.

Neurotransmitters and Hormones

Involved in Sexual Desire and
Subjective Arousal

The role of testosterone in desire and arousal is

better documented in men than in women .
Serum levels of testosterone do not correlate with
womens sexual function according to large
epidemiologic studies
A link between low desire and low androgen activity as
reflected by serum testosterone levels or androgen
metabolites has not been identified to date
In animal models, steroid hormones modulate sexual
arousal by directing synthesis of the enzymes and the
receptors for a number of neurotransmitters, including
dopamine, noradrenalin, melanocortin, and
oxytocin.

Modele animale- cai stimulatorii si

inhibitorii

It is thought that dopamine transmission in the

medial preoptic area (MPOA) and the nucleus
accumbens focuses the persons attention on sexual
stimuli (the incentives or motivations for sexual activity) .
It is postulated that the behavioral pattern stimulated by
those systems and the subjective feelings that
accompany them constitute the phenomenon commonly
referred to assexual desire or arousal when genital
sensations triggered by these systems are subjectively
felt
Brain pathways for sexualinhibitioninclude opioid,
endocannabinoid, and serotonin neural transmissions
feeding back to various levels of the excitatory pathways.
It is thought that the behavioral pattern stimulated by
the inhibitory pathways includes both sexual reward
and satiety refractoriness.

Modele animale

Endogenous opioids modulate the feedback effects of sex

steroids on the hypothalamus and pituitary.-Endorphin is
synthesized in the anterior pituitary, the hypothalamus,
and the nucleus of the tractus solitarius in the brainstem.
The sexual inhibiting effects of opioids occur mainly
through their action in the MPOA and the amygdala.
Administration of melanocortin receptor agonists has
been associated with an increase in spontaneous
erections in healthy men and in men with ED, and with
increased desire, but not genital responses, in women.
Oxytocin levels increase close to orgasm. This hormone
is known to be involved in pair bonding in some animal
species, but its relevance in humans is unclear.

Rolul prolactinei

The physiologic role of prolactin in the human sexual

response remains uncertain.
Because a generalized reduction of dopamine activity
in the hypothalamus results in increased prolactin
secretion, it has been difficult to distinguish between
the effects of raised prolactin itself and the possible
effects of the reduced dopamine transmission.
High levels of prolactin are associated with
impaired sexual function in men and women

Genital Sexual Congestion and

Arousal

Men and women differ substantially with respect to the

correlation between genital congestion and subjective
sexual arousal (excitement). Whereas subjective
arousal is typically concordant with genital
congestion in men, there is a poor correlation
between subjective arousal and measures of
genital congestion in women.
There are some exceptions in men: sleep-related
erections are mostly dissociated from erotic dreams or
from subjective sexual arousal.
Also psychophysiologic studies have found that men
can get erections in response to films of assault or rape
while experiencing no subjective arousal.

Physiologic Mechanisms of Penile

Erection

The MPOA of the hypothalamus serves as the

integration site for the central nervous system
control of erections; it receives sensory input from the
amygdala and sends impulses to the paraventricular nuclei
of the hypothalamus and the periaqueductal gray matter.
Neurons in paraventricular nuclei project onto the
thoracolumbar and sacral nuclei associated with
erections.The parasympathetic input to the penis is
proerectile, and sympathetic input is mainly inhibitor
Penile erection results from a series of biochemical and
hemodynamic events that are associated with activation of
central nervous system sites involved in regulation of
erections, relaxation of cavernosal smooth muscle,
increased blood flow into cavernosal sinuses, and venous
occlusion resulting in penile engorgement and rigidity.

The Role of Testosterone in Regulating

Sexual Function in Men

Although androgen-deficient men can achieve penile erections in

response to visual erotic stimuli, their overall sexual activity is
decreased. Spontaneous but not stimulus-bound erections are
testosterone-responsive .Testosterone promotes sexual
thoughts and desire and increases sexual arousal and
attentiveness to erotic auditory and other stimuli . Nocturnal
erections, temporally related to peaks of nighttime testosterone
secretion, are of lower amplitude and duration in androgen-deficient
men, and testosterone therapy increases the frequency, fullness,
and duration of nocturnal penile tumescence. Maximum rigidity
may require a threshold level of androgen
activity.Testosterone regulates nitric oxide synthase (NOS) in the
cavernosal smooth muscle,exerts trophic effects on cavernosal
smooth muscle and ischiocavernosus and bulbospongiosus muscles,
and is necessary for the veno-occlusive response. Androgendeficient men show delayed orgasm and low ejaculatory
volume.

Physiology of Physical Sexual Arousal in

Women: Genital Congestion

A number of physical changes accompany womens

sexual excitement (i.e., their subjective sexual arousal),
including genital swelling, increased vaginal lubrication,
breast engorgement, and nipple erection; increased skin
sensitivity to sexual stimulation; changes in heart rate,
blood pressure, muscle tone, breathing, and temperature;
and mottling of the skin with a sexual flush of
vasodilatation over the chest and face.
These changes are reflexive, mediated by the autonomic
nervous system.
As the clitoris becomes more swollen, it elevates to lie
nearer the symphysis pubis. The vagina lengthens and
dilates during arousal, elevating the uterus. The labia
become swollen and darker red, and the lower third of the
vagina swells.

Physiology of Physical Sexual Arousal in

Women: Genital Congestion

The correlation between genital congestion and

subjective arousal are found to be highly variable.This
is true in sexually healthy women and in women
reporting a lack of desire or arousal or sexual pain.
The physiology of nongenital physical changes and
their correlation with subjective excitement remain
poorly understood.

Physiology of Orgasm

Orgasm is a brain event, triggered typically by genital

stimulation but also by sleep, stimulation of other parts of the
body (including breast and nipple), fantasy, certain
medications, and in women with spinal cord injury,
vibrostimulation of the cervix.
Orgasm is a subjective experience in both men and women,
and it has been difficult to determine an objective marker. In
healthy men, there is the associated ejaculation and, in both
genders, involuntary (reflexive) muscular contractions of the
striated perineal muscles.
The role of oxytocin and prolactin in orgasm is unclear. Both
hormone levels increase at the time of orgasm: PET scanning
has confirmed increased pituitary blood flow in women, but
not in men, at the moment of orgasm. Both hormones can
cause uterine and vaginal smooth muscle contraction, which
may contribute to the sensations of orgasm.

The Revised Definitions of Sexual

Dysfunction in Men

a. Male hypoactive sexual desire disorder

b. ED
c. Premature ejaculation
d. Delayed ejaculation

Male Hypoactive Sexual Desire

Disorder

Androgen deficiency is an important, treatable cause

of HSDD and should be excluded by measuring serum
total testosterone levels.

Erectile Disorder

ED, previously referred to asimpotenceormale ED, is

the inability to attain or maintain an erection or to
achieve penile rigidity sufficient for satisfactory sexual
intercourse.
CVD and ED share common risk factors, such as
diabetes mellitus, obesity, hypertension, smoking, and
dyslipidemia
Recent surveys have revealed an association of lower
urinary tract symptoms (LUTS) with ED

Ejaculatory disorders

Ejaculatory disorders include premature ejaculation,

delayed ejaculation, retrograde ejaculation,
anejaculation/anorgasmia, and painful ejaculation.
Ejaculatory disorders are at least as prevalent and
may be even more prevalent than ED.
Premature ejaculation, defined as ejaculation
associated with lack of or poor ejaculatory control that
causes distress in one or both partners, is the most
prevalent sexual disorder in men 18 to 59 years of age.
Delayed ejaculation refers to inability to ejaculate in a
reasonable period that interferes with sexual or
emotional satisfaction and is associated with distress.

Current Definitions of Sexual

Disorders in Women

Sexual Interest/Arousal Disorder

Female Orgasmic Disorder
Genitopelvic Pain/Penetration Disorder
Persistent Genital Arousal Disorder

Sexual Dysfunction in the Context of

Endocrine Disease

In healthy women, factors such as attitudes toward

sex, feelings for the partner, past sexual experiences,
duration of relationship, and mental and emotional
health have been shown to more strongly modulate
desire and arousability than do biologic factors.
Contrary to gender stereotypes:
-mens physical sexual pleasure was more closely
linked to relational factors than was the case for
women.
-men rated the importance of sex for closeness and
intimacy to their partner more highly than did their
female partners

Androgen Deficiency Syndromes

The testosterone levels required to maintain sexual function

are close to the lower limit of the normal male range.
Androgen deficiency is an important treatable cause of male
HSDD. Therefore, the men diagnosed with HSDD should be
evaluated for androgen deficiency by measurement of
testosterone levels, preferably in an early morning fasting
blood sample.
Although ED and androgen deficiency in men are distinct
disorders with separate pathophysiologic mechanisms, the
two can coexist in the same patient. Testosterone levels
should be measured in men presenting with any form of
sexual dysfunction because androgen deficiency is treatable,
and furthermore, androgen deficiency may be a
manifestation of another underlying disease, such as a
pituitary tumor.

Diabetes and Sexual Dysfunction in

Men

The men with diabetes have significantly lower scores

for sexual desire, activity, arousal, and satisfaction,in
part due to the medical and psychological factors
associated with diabetes, such as the variations in
glycemic control, reduced energy, altered self-image,
and interpersonal difficulties regarding dietary
compliance, glucose monitoring, and medications.
Diabetes also is associated with increased risk of low
testosterone levels.
Endothelial and smooth muscle dysfunction, autonomic
neuropathy, and psychological and interpersonal issues
contribute to sexual dysfunction in men with diabetes

Sexual Dysfunction Associated with

Therapies for Benign Prostatic
Hypertrophy

Benign prostatic hypertrophy is frequently associated

with LUTS and sexual dysfunction

Hyperprolactinemia and Sexual

Dysfunction

Prolactin lowers testosterone levels through its

inhibitory effects on GnRH secretion and on the
pituitary response to GnRH. Most, but not all, men
with sexual dysfunction and hyperprolactinemia have
low testosterone levels.
Whether and how hyperprolactinemia directly affects
erectile function through target organ effects is not
well understood. Erectile function generally improves
in hyperprolactinemic men following treatment with
dopamine agonists.

Sexual Dysfunction in Patients with

Thyroid Disease

Hypothyroidism has been associated with increased

risk of hypoactive sexual desire and ED
Hyperthyroidism has been observed in a small fraction
of men with ED.

Natural Menopause

A majority of women who discontinue postmenopausal

estrogen supplementation develop signs of vulvovaginal
atrophy, which is a risk factor for sexual dysfunction
The traditional notion that maintaining sexual activity
will prevent symptomatic vulvovaginal atrophy has been
refuted. Subjective symptoms and objective signs of
vulvovaginal atrophy correlate poorly.
Epidemiologic studies have not shown an increase in the
prevalence of dyspareunia with age. Clearly not all
postmenopausal women develop sexual symptoms of
estrogen deficiency: of 1525 women followed from age
47 to 54 years, the vast majority were not affected by
the major hormonal shifts.

Natural Menopause

It is likely that multiple factors contribute to sexual symptoms,

including variations in the production of estrogen from adrenal
precursors, the number and sensitivity of estrogen receptors,
and the degree of sexual arousal or excitement at the time of
vulval stimulation and vaginal entry.
Psychological factors rather than estrogen levels were shown
to moderate symptoms when vulvovaginal atrophy is present.
Most studies report a decrease in sexual desire with advancing
age that is not easily explained by hormonal deficiency
The negative association between age and sexual desire was
particularly pronounced in women experiencing little intimacy.

Surgical Menopause

Surgical menopause is a state of both androgen and

estrogen depletion of sudden onset and has often been
viewed as a risk factor for sexual dysfunction. However,
most women undergoing bilateral BSO for benign clinical
indications do not develop sexual dysfunction. Three pro
spective studies found that women choosing BSO plus
hysterectomy for benign indications did not develop sexual
dysfunction over the next 1 to 3 years.
In women undergoing nonelective surgery, the thematic
context of bilateral oophorectomy may impair sexual desire
and function. For example, women who are treated for
malignant disease or those who desire to preserve their
fertility may experience greater distress about low sexual
desire after BSO than those who undergo BSO for benign
conditions.

Hormonal Contraceptives

The estrogen in combined systemic contraceptives

increases SHBG and thus decreases available free
testosterone. The decrease in sexual desire and
subjective arousability in some women receiving oral
contraceptives has been attributed to the decrease in
free testosterone levels.

Polycystic Ovary Syndrome

Limited research has shown that women with

polycystic ovary syndrome may be less sexually
satisfied and may regard themselves as less attractive
than control subjects.
The presumption is that obesity and androgen-related
symptoms may contribute to poor body image, which
may increase the risk of sexual dysfunction.
Recent studies show little evidence that polycystic
ovary syndrome (as opposed to obesity) is a risk
factor for sexual dysfunction.