PSAS: A Newly Discovered Pattern of Excessive Female Arousal That Can Continue Unremittingly for Hours, Days, or Weeks. Most physicians are familiar with the common sexual complaints of women (i.e., hypoactive sexual desire, sexual arousal difficulties, an orgasmia, dyspareunia).These problems are quite prevalent, and are reported either spontaneously or after careful sexual inquiry by the physician. Far less common and more puzzling is the complaint by a small number of women of persistent sexual arousal. Although infrequent, this problem is distressing and perplexing not only because of its mysterious onset, but also because of the feelings of shame and discomfort that tend to accompany the phenomenon.

Women who complain of persistent sexual arousal may be young or old, premenopausal or using postmenopausal hormone replacement therapy, married or single. The distinguishing feature of the syndrome is the report of persistent feelings of vaginal congestion and other physical signs of sexual arousal in the absence of any awareness of sexual desire provoking or accompanying this arousal. While the feelings of arousal may lead to a need to masturbate or engage in sexual activity with a partner to relieve the sensation of vaginal congestion, the arousal is only temporarily quelled with orgasm. Indeed, the feeling of arousal may persist for hours, days, or even months.

In the majority of cases in which the woman presents in physician’s office, the feeling of unremitting arousal is experienced as intrusive and unwanted. In some instances, however, the feelings of more or less constant arousal are experienced as pleasurable, if mysterious. In these cases, the woman may not want evaluation or treatment. It is for this reason that the phenomenon may be underreported, even though it is a significant aspect of female sexual response that deserves wider recognition and evaluation.

DISTINGUISHING FEATURES

The distinguishing features of persistent sexual arousal syndrome (PSAS) include the following:

• The physiological responses characteristic of sexual arousal (genital and breast vasocongestion and sensitivity) persist for an extended period (hours to days), and do not subside completely on their own.
• The signs of physiologic arousal do not resolve with ordinary orgasmic experience, and may require multiple orgasms over hours or days to remit.
• These physiologic signs of arousal are usually experienced as unrelated to any subjective sense of sexual excitement or desire.
• The persistent sexual arousal may be triggered not only by sexual activity, but also by seemingly nonsexual stimuli or no apparent stimulus at all.
• The physiologic signs of persistent arousal are experienced as uninvited, intrusive, and unwanted.

When feelings of genital arousal persist for days, weeks, or even months, they can become personally distressing and worrisome. Again, it should be noted that while all the women who presented to the authors were distressed about their symptoms (see Case Reports), it is possible that other women who experience these symptoms do not find them upsetting.

It is important to differentiate between PSAS and hypersexuality, with which it may be confused. Although not a common female complaint, hypersexuality has been reported occasionally in women, where it may manifest as high-frequency masturbation, insistent and intrusive sexual fantasies or thoughts, or very frequent coitus. It is sometimes noted as an occasional symptom associated with various psychiatric or neurologic conditions, or as a result of the drugs used to treat such disorders (eg, levodopa).

Persistent Sexual Arousal Syndrome

Whereas hypersexuality refers to excessive desire with or without persistent genital arousal, PSAS refers to physiologic arousal in the absence of conscious desire, which is what makes it so perplexing. While some women can identify a reliable trigger for the feelings of arousal, other women cannot pinpoint a cause for the unrelenting feelings of vaginal vasocongestion and sensitivity. They worry that they might have a pathologic process that requires medical evaluation. It is sometimes for this reason, rather than the subjective distress, that they seek medical consultation and evaluation.

Although the authors have not been able to find any other reference to this condition in the medical or psychiatric literature, Riley described a case of premenstrual hypersexuality that seems similar to PSAS. The case involved a 22-year old single woman who had lost her job as a result of an intense need to masturbate frequently during the 3 to 4 days prior to menses. She felt the need to masturbate in the lavatory at work up to 12 times daily in addition to sessions at home and even in the car going to work. During these premenstrual days, she reported a continuous state of sexual arousal, with intense tingling in the clitoris and a feeling of vaginal warmth. There was a major increase in genital secretion at this time, which soaked her underclothes and sometimes resulted in a wet patch on her skirt. The genital sensations rose rapidly in intensity, causing her to seek relief through orgasm by self-stimulation; if she did not attain orgasm, the sensations became unbearable. These sensations were not accompanied by sexual fantasies.

In the case reported by Riley, the feelings of continual sexual arousal generally disappeared within 24 hours after the onset of menses, and the patient reported normal sexual needs at other times of the month (ie, she did not actively search for sexual partners, and masturbated only once every 4 to 5 days).

As in the cases the authors have seen, this patient was otherwise healthy and had no demonstrable hormonal abnormalities. She had tried the antianxiety drug lorazepam and evening primrose oil to calm herself, as well as an oral contraceptive, all without success.

When examined during the follicular phase of her menstrual cycle, all appeared normal. However, when examined on the day prior to her period, her labia minora were swollen and dusky purple. The clitoral glands were congested, and palpation of the clitoral shaft revealed substantial tumescence. Genital secretions were oozing freely from the introitus. The uterus was at 100% larger than it was during the follicular phase, and the parauterine structures were thickened and tender to palpitation. During bimanual examination, the patient experienced an orgasm associated with weak vaginal contractions. There was no postorgasmic reduction in uterine size or in the congestion of the parauterine structures. On examination 3 days after menses, the findings had returned to normal. Levels of prolactin, testosterone, sex-hormone – binding globulin (SHBG), and 17-estradiol (luteal phase) were within normal limits.

Riley treated his patient with danazol, 800 mg/d for 2 months. The patient developed acne from the androgenic activity of the drug, so the dosage was reduced to 400 mg/d for 4 months. Menstruation was suppressed, and the patient reported that she was symptom-free. The treatment was then discontinued, and there was no recurrence of symptoms during the 2-year follow-up. In the patients the authors have seen, however, neither etiology nor treatment has been this straightforward.

CASE REPORTS

To date, the authors have interviewed 15 women who presented with PSAS, and have heard of dozens more from OB/GYNs and other primary care physicians.

Case 1

Mrs. B was a healthy 81-year-old woman, 4’11”, 95 lb. who had undergone a hysterectomy. She was married to her third husband, a 91-year-old man. She was referred for psychosexual evaluation by her endocrinologist after consulting a number of physicians for the unrelenting feelings of sexual arousal that plagued her. In the questionnaire mailed to patients prior to consultation, she had written that the complaint “makes me so upset that I cry, as I cannot function normally; I make mistakes, get very hungry, and do not sleep.”? She went on to say that “I would like the sensations to go away. I want to feel I can make plans and not have the strong sexual desire to make me miserable? not knowing if I’ll get satisfied.”

Her genital sensations were almost continuous, but worsened during the night. She initially sought release from the arousal by initiating intercourse with her husband, but he had not been able to engage in coitus for the past 2 to 3 years due to a cardiac condition. Her husband was supportive and loving, however, and willingly stimulated her manually and with a vibrator whenever she could no longer tolerate the feelings of sexual arousal. Although she was initially orgasmic with masturbation and manual stimulation, it was becoming more difficult to reach a climax, and even if she did, the sensations of arousal persisted. She sometimes masturbated with a vibrator for up to 90 minutes without relieving the unwanted feelings of sexual tension.

The problem began 6 years earlier. The patient believed that her sexual appetite had increased following her hysterectomy. She said that she initiated or engaged in coitus between 15 and 22 times per month prior to her husband?s cardiac problems, after which she masturbated 7 to 13 times per month. When she began experiencing PSAS, she kept track of the time spent with vibrator stimulation, and reported that it had increased from a few minutes to 1 hour per session.

The patient found the persistent arousal very distressing, and began to cry during the consultation. She was sometimes awakened in the morning by hot flashes, which had only begun during the past year, and with congestion in her pelvic area. Although she was using low-dose estrogen (Premarin), she reported that her vagina was dry and that she occasionally used estrogen cream or other lubricants. She also noted a loss of sensitivity in her clitoris. She was using no other medications, and had even stopped taking vitamins. She was an intelligent, alert, verbal, fully oriented woman who had kept prodigious and reliable notes about her condition. Although always sexually receptive, she had never engaged in unusual sexual behavior.

She had consulted both an internist and a reproductive endocrinologist. The internist could pinpoint nothing exceptional anatomically, and could not account for her complaint. He referred her to the endocrinologist, who was similarly puzzled. Levels of dehydroepiandrosterone sulfate, 17-hydroxyprogesterone, and testosterone were all within normal limits. She had entered menopause in 1968 after a total abdominal hysterectomy with bilateral salpingooophorectomy secondary to endometriosis. She had been using estrogen replacement since the mid-1970s with no problem. Otherwise, she was in good health. After consulting with a number of colleagues, the authors suggested that the patient undergo neurologic evaluation and magnetic resonance imaging (MRI) to rule out a brain lesion. The endocrinologist supported this recommendation, but Mrs. B. did not comply. When contacted 6 months after the initial consultation, the patient indicated that the arousal continued to “wax and wane” and that she was coping as best she could. She had changed her diet, and was abstaining from all red meat and vitamin pills as well as all medications. She said she was “trying to avoid giving in to it.”

While this case is unusual, it is tempting to ascribe it to some neurologic abnormality given that the authors were unable to rule out this hypothesis. However, the next case illustrates the wide variability in presentation in that the woman is much younger and has had every conceivable medical evaluation with no abnormal findings.

Case 2

Ms. J. was a 52-year-old divorced woman who was a successful editor. She reported having symptoms of PSAS for 6 years, which over time restricted her activities and destroyed her well-being. She was plagued by persistent feelings of genital vasocongestion that were not relieved by masturbation. She said that “Whereas I had always been content with one orgasm, I now have a constant need for release. Immediately after an orgasm, [and] with no?thoughts of sex, my body begins pulsating intensely and persistently?my orgasms are far deeper and [more] exhilarating than usual. The constant need for release is relentless, with relief coming only while I sleep.”?She had come to believe that she was the only person in the world with this problem, and eventually resorted to antidepressants. The problem made it difficult to get through the work day, and prevented her from leaving the house otherwise (written communication, 2001).

Ms. J. had been examined by a family physician, three gynecologists, a urologist, and a psychiatrist. None had ever heard of such a condition. Her blood test results and hormone levels were within norm a limits. There was no history of psychological trauma, and she did not display any obvious psychopathology. Over the previous 6 years, she had tried various antianxiety and antidepressant drugs, including divalp roex, sertraline, buspirone, and fluoxetine without success. She was disheartened by the failure to find a cause or cure for her condition, and said it was only her sense of humor and the support of family and friends that kept her from succumbing to depression. The final assessment of her condition included an MRI, which had normal results. To date, she is still suffering from PSAS, and is discouraged about ever finding an explanation or solution for her complaint.

Case 3

A gynecologist in Australia contacted the authors for advice. The patient was described as a 51-year-old woman with a “continual, distressing feeling of sexual arousal.” Androgen values were within normal limits, and results of abdominal computed tomography were unremarkable, including the adrenal glands, lumbosacral spine, and pelvis. Orgasms did not relieve the patients congestion, and she was unwilling to masturbate. The patient had been using hormone replacement therapy for some years for osteopenia. There was no history of thrush, the vagina and vulva were normal, and the patient was not taking any alternative or herbal medications. The only anomalous finding was mild tenderness in the suprapubic area. Neurologic findings were likewise normal. Again, despite many suggestions from a variety of physicians and therapists, the physician was unable to identify an explanation for the patient?s complaints.

DISCUSSION

{mosbanner:id=1:right:0}In all the cases reported to date, results of extensive anatomic, hormonal, neurologic, and psychiatric evaluation have been normal. The women seen by the authors are psychologically healthy and functional individuals. While in some instances the symptoms may be attributable to psychological hypotheses, this in no way confirms a psychological cause of the problem; psychosomatic explanations can be postulated for many complaints in the absence of an unambiguous physical etiology.

It is unknown whether PSAS is a new, as opposed to a newly recognized, entity. This is an important distinction in the search for a cause because, if PSAS is truly a new phenomenon, then modern environmental factors (eg, food additives, infectious agents, tight jeans, long-distance bicycling) deserve special attention. More research is needed to determine whether PSAS tends to occur in special populations (eg, long-distance cyclists, women who engage in many hours of spin classes).

The prevalence of PSAS is unknown, though it may be more common than supposed because many women may be too embarrassed to report the complaint to their physicians. As indicated, the authors have spoken with some affected women who are not troubled by the feelings of spontaneous arousal, except when they persist unabated for weeks. Physician inquiry can be helpful in identifying the prevalence of this phenomenon and validating the patient’s experience as genuine, disturbing, and not “all in her head.”? Such complaints must be taken seriously if physicians are to identify the causes, sustaining factors, and therapies for this perplexing problem.

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REFERENCES

1. Leiblum SR. Sexual problems and dysfunction: epidemiology, classification and risk factors. J Gend Specif Med. 1999;2(5):41-45.
2. Michael R, Gagnon J, Laumann E, Kolata G. Sex in America: Definitive Surv e y. Boston, Mass: Little, Brown and Company; 1994.
3. Leiblum SR, Nathan S. Persistent sexual arousal syndrome: a newly discovered pattern of female sexuality. J Sex Marital Ther. 2001;27(4):365-380.
4. Carnes P. Out of the Shadows: Understanding Sexual Addiction. Minneapolis: CompCare Publications; 1983.
5. Elmore J, Quattlebaum J. Female sexual stimulation during antidepressant treatment. Pharmacotherapy. 1997;17(3):612-616.
6. Riley A. Premenstrual hypersexuality. J Sex Mar Ther. 1994;9(1): 87-93.

Reprinted with permission from “The Female Patient”

Additional resources on female sexuality are available from MayoClinic.com:

https://www.mayoclinic.org/healthy-lifestyle/womens-health/in-depth/kegel-exercises/art-20045283
https://www.mayoclinic.org/healthy-lifestyle/sexual-health/basics/womens-sexual-health/hlv-20049432
https://www.mayoclinic.org/healthy-lifestyle/womens-health/basics/womens-health/hlv-20049411
https://www.mayoclinic.org/diseases-conditions/low-sex-drive-in-women/symptoms-causes/syc-20374554