Persistent Genital Arousal Disorder in Women: What is Known and What is Unknown

Persistent Genital Arousal Disorder (PGAD) is a relatively newly identified and perplexing condition characterized by high levels of unrelenting genital arousal occurring in the absence of subjective interest or desire. This arousal can persist for hours, days or even weeks, despite attempts to relieve it with sexual activity or orgasm which at best provide only brief attenuation of the symptoms. The PGAD diagnosis is made based on the presence of four features (persistent genital arousal, genital arousal unrelated to subjective desire, arousal which persists despite one or more orgasms, arousal feels intrusive). Subjective distress is rated as at least moderate or severe (a score of 2 or 3 on a scale where 0= no distress and 3= extreme distress). The shame and embarrassment attached to the symptoms most likely has contributed to the phenomenon going unrecognized nd underreported until recently. Complaints by sufferers can include clitoral tingling, irritation, vaginal congestion, vaginal contractions, throbbing, pressure and pain, as well as spontaneous orgasms in some cases. Attempts to quell the genital arousal by engaging in masturbation or sexual activity often leads to brief relief, no relief, or even more arousal and activation. Compared to non-PGAD women, PGAD patients exhibit overall lower levels of sexual satisfaction, lower desire and greater pain on the Female Sexual Functioning Inventory (FSFI). They also evidence a higher incidence of anxiety, depression and obsessive symptoms than non-PGAD women. These conditions seem to pre-date rather than result from their symptoms No definitive physical, hormonal or neurological associations have been identified as causing the disorder and there is no evidence of any particular medical condition associated with PGAD with the exception that women complaining of PGAD are more likely to report chronic fatigue. A relatively high percentage of women with PGAD than non-PGAD women report having used selective serotonin reuptake inhibitors, atypical anti-depressants or tricyclic antidepressants either in the past or currently although there is no clear evidence linking the use or discontinuation of these agents with the syndrome. Although psychological factors are clearly implicated in the maintenance, if not always the genesis of the condition, there is evidence that there are brain changes associated with the report of genital arousal. Specifically, preliminary fMRI data on a small pilot sample of women indicate that there is a high level of brain activity in and extending into the posterior cingulated cortex, a region of the brain that is reported to respond to pain and itch. The fact that these fMRI findings occur in the absence of direct physical stimulation of the genitalia suggest that the symptoms of PGAD are “real” and “physiological” rather than “imaginary.” At this time, there are many unknowns about PGAD: prevalence figures are uncertain, although it is likely that there are more cases than are reported. The etiology is unknown although there are many hypotheses including a) central neurological changes (e.g., post-injury, specific brain lesion anomaly), b) peripheral neurological changes (e.g., pelvic nerve hypersensitivity or entrapment), c) vascular changes (e.g., pelvic congestion), d) mechanical pressure against genital structures, e) medication-induced changes, and f) psychological changes (stress) or some combination of all of the above. There is no generally accepted treatment for PGAD and current interventions focus largely on symptom management. Anesthetizing agents may be used initially to numb the area and pelvic massage or stretching exercises may help reduce or eliminate pelvic tension and disrupt connective tissue strictures that may contribute to the condition. Medication treatment is largely achieved by trial and error, as certain medications may be associated paradoxically with either alleviation or exacerbation of the symptoms. Cognitive-Behavioral interventions have been used to enhance coping skills and assist in interrupting the cycle of anxiety and catastrophizing of the symptoms. This cycle plays a significant role in PGAD, for anxiety worsens the symptoms by leading to increased autonomic activation, which may, in turn, lead to greater genital arousal. More research is clearly needed to clarify the prevalence, etiology and treatment of this perplexing and distressing condition.