Tag Archives: ascorbic acid vitamin C

WHO HAS PSEUDONYMPHOMANIA- FEMALE RESTLESS GENITAL SYNDROME, AKA PERSISTENT GENITAL AROUSAL?

note that quotations are in italics.

update 14 Sept 2016 neil.burman@gmail.com      having just received a sorrowful posting from Diana below, I now discover that there are a number of similar complaints that I had missed and not posted; so I have now posted them under comments. This condition is such a nightmare for sufferers that I post them as you submitted them, with your name and email if thats how you sent them. I can delete your contacts if you like, but the more you sufferers communicate and exchange ideas the better for sufferers.

Sufferers must surely have tried some nonirritating local anaesthetic cream, or eg virgin coconut oil, or simply massage for relief.

given the risk of even low strength estrogen cream being well absorbed from mucous membranes more than  from skin, and thus (altho beneficial for brains, bones, skin, heart etc) potentially adverse  for endometrium, breast, and many other target organs,   we leave the vascular engorger  estrogen as the last resort- first try anything but topical sex hormonesl then if still desperate,  sparingly up to  3% progesterone cream;   testosterone cream is also healing, but virilizing ie not to be used if arousal, clitoromegally, breast proliferation  is not wanted.

Since my 2009 review, there are some 15 new abstracts in English on Pubmed from USA, Canada, Europe, Israel and Japanese groups. There dont seem to have been any major breakthroughs  in management of this rare and distressing disorder. Antiepileptics may be promising- like cannabinoid oil , and the ketogenic diet are,  in epilepsy.

Since the brain responds so well to more natural dietary  fats (eg animal triglycerides, MCT- coconut oil, fish oil ie EPA, DHA) and withdrawal of excitogenic glucose loading that most people indulge in, and so many patients today are overweight with estrogenizing glucose insulin resistance, in general I encourage patients to think of epilepsy let alone memory loss (including Alzheimers) and mood disorders as brain diabetes, glucose toxicity with  deprivation of good needed dietary  fats;  and thus to  try Banting diet rather than the populist fast food industry-promoted disasterous high carbs low fat low cholesterol  fad of the past 50 years.  This simple dietary advice   is at worst harmless distraction,   and generally beneficial for the unhappy women with  multifactorial PGAD,

Given their ubiquitous benefits in so many disorders, harmless trial is warranted  with:    vigorous vitamin D3 replacement to the commonly optimal level around 100ng/ml  (which may require the average safe 10 000 iu vit D3.day, but perhaps 10 times that with unpredictable vitamin D resistance) seems worth considering for this rare but extremely distressing disorder ie PGAD;

antidepressants;

cannabinoid oil;

lowdose naltrexone LDN;

hypnotherapy has been reported helpful, but potentially hazardous.

If  not obviously due to psychiatric, or  tumour eg  Tarlov cysts, or pelvic venous problems, PGAD may be likened to variant true epilepsy or the only somewhat less common PNES syndrome – psychogenic non-epileptic seizure syndrome  – that like PGAD has been increasingly recognized only this millennium, and which is overall even more of a dis-ease  and psychiatric problem that true epileptic diseases, .

abstracted English refs published  since 2009 review:

Sex Med Rev. 2016 Jul 22. pii: S2050-0521(16)30024-5. Persistent Genital Arousal Disorder: A Review of Its Conceptualizations, Potential Origins, Impact, and Treatment.Jackowich RA1, Pink L2, Gordon A2, Pukall CF3.1Department of Psychology, Queen’s University, Kingston, ON, Canada;Wasser Pain Management Centre, Mount Sinai Hospital, Toronto, , Persistent genital arousal disorder (PGAD) is a condition characterized by symptoms of physiologic (typically genital) sexual arousal in the absence of perceived subjective sexual arousal. The physiologic arousal can last hours or days, or it can occur constantly, and it does not typically remit after orgasm(s). The symptoms are usually described as distressing, intrusive, and unwanted..Much of the research on the potential etiologies and treatments of PGAD is published in the form of case studies. Several etiologies of PGAD have been proposed; however, a cause or causes have not been confirmed. A range of treatments has been explored primarily in case studies, from electroconvulsive therapy to oral medication, with variable success rates. Psychologically based treatments have been suggested but have yet to be evaluated. Online surveys have found initial evidence supporting the negative impact of PGAD on mental health and sexual functioning; however, more research is needed in this area.Although PGAD was first conceptualized 15 years ago, it remains a very under-researched condition. Currently, little is known about its biopsychosocial correlates, etiologies, or successful treatments. Future research directions are identified.   \
Indian J Psychol Med. 2016 Jul-Aug;38(4):341-3..Persistent Genital Arousal Disorder.Aswath M1, Pandit LV1, Kashyap K1, Ramnath R1.Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India.Persistent genital arousal disorder (PGAD) is a phenomenon, in which afflicted women experience spontaneous genital arousal, unresolved by orgasms and triggered by sexual or nonsexual stimuli, eliciting stress. The current case is a 40-year-old female who experienced such orgasms for about a month. Physical examination, investigations, and psychological testing were noncontributory. Carbamazepine (600 mg) was discontinued due to a lack of response. She improved significantly with supportive therapy. Various neuropsychological conditions, pelvic pathology, medications, etc., have been associated with this disorder. Pharmacologic strategies have included the use of antidepressants, antipsychotics, mood stabilizers, and analgesics. Validation, psycho-education, identifying triggers, distraction techniques, and pelvic massage have been tried. Living with PGAD is very demanding. There is a lack of understanding of the problem, shame, and hesitation to seek help. The syndrome has been recently described, and understanding is still evolving.
Orv Hetil. 2015 Apr;156(15):614-8. doi: 10.1556/OH.2015.30131.[Symptomatology and treatment of persistent genital arousal disorder. Case report].[ Hungarian]Erős E1, Brockhauser I1, Pólyán E1.  Persistent genital arousal disorder is a rare condition among women characterized by unwanted and intrusive sexual arousal that can persist for an extended period of time and unrelated to sexual desire or sexual stimuli. Since its first documentation in 2001, numerous studies have been dedicated to investigate its specifics. The persistent genital arousal occurs in the absence of sexual interest and fantasies and it causes excessive psychological suffering. Masturbation, spontaneous orgasm or sexual intercourse can offer only a temporary relief. Researches provide a limited insight into the characteristics of persistent genital arousal disorder. This paper presents a case and summarizes the scientific findings on prevalence, etiology and treatment perspectives.
Case Rep Urol. 2015;2015:465748. First reported case of isolated persistent genital arousal disorder in a male.  Stevenson BJ1, Köhler TS1.Southern Illinois University School of Medicine USA.Introduction. Persistent genital arousal disorder (PGAD) is a newly recognized disorder in women. It is described as unwanted, persistent feelings of genital arousal unrelated to sexual desire and not relieved by orgasm. Its prevalence is estimated to approach 1% of young women. Until now, this has not been described in men. Aim. Here we present a case of a 27-year-old male with symptoms consistent with PGAD and describe successful treatment. Methods. A 27-year-old male presented to urology clinic with the chief complain of persistent feelings of impending orgasm. He reported a sensation similar, but not identical, to sexual arousal that did not occur in the setting of sexual thoughts or desire. Orgasm alleviated the arousal for only a short time after which the symptoms would return. This had become quite bothersome to him. Results. After assessing for a neurological cause and finding none, the patient was started on paroxetine daily with complete resolution of symptoms. Conclusions. PGAD is a disorder previously described only in females. Although symptoms of PGAD have been described in a male as part of another disorder complex, this report describes the first reported isolated case in a male and the successful treatment.
Rinsho Shinkeigaku. 2015;55(4):266-.[A case of Parkinson’s disease following restless genial sensation].[ Japanese] Sawamura M1, Toma K, Unai Y, Sekiya T, Nishinaka K, Udaka F. A 62-year-old woman experienced uncomfortable genial sensation in 2010. Her uncomfortable sensation was exacerbated during rest at night and improved by walking. She exhibited short-stepped gait with postural disturbance and was diagnosed as suffering from Parkinson’s disease (PD) in 2013. Administration of clonazepam and pramipexisole improved her uncomfortable genial sensation. In persistent genital arousal disorder (PGAD)/restless genial syndrome (RGS), abnormal genital sensation occurred without sexual desire, which was relieved by clonazepam administration. PGAD/RGS often coexists with restless legs syndrome (RLS). PGAD/RGS and RLS share common characteristics. This is the first case report of PD following PGAD/RGS, suggesting similar underlying mechanisms between PGAD/RGS and RLS associated with PD.
J Obstet Gynaecol Can. 2014 Apr;36(4):324-30. Persistent genital arousal in women with pelvic and genital pain.   Pink L1, Rancourt V2, Gordon   Wasser Pain Management Centre, Toronto ON.Quebec City QC. Persistent genital arousal disorder (PGAD) has been identified as a condition of often unprovoked genital arousal associated with a significant level of distress. PGAD is not well understood, and no definitive cause has been determined. The aim of this study was to gain a better understanding of the disorder and to seek commonalities between cases of PGAD encountered in a chronic pain management clinic.
We reviewed a cohort of 15 women with PGAD who presented to a chronic non-cancer pain clinic in a large urban tertiary teaching hospital that provides pelvic and genital pain management. We conducted a series of interviews to examine medical history, history of presenting illness, and management. Descriptive statistics were used to examine the data.Findings were largely consistent with previous research on PGAD regarding symptomatology and aggravating and alleviating factors. Symptoms of genital pain, depression, and interstitial cystitis were found in over one half of the patients in this cohort. Previous antidepressant use, restless legs syndrome, and pudendal neuralgia were found in a number of cases. Pelvic varices and Tarlov cysts have been previously identified as possible contributors to PGAD, but these were not a common finding in our cohort\
Case Rep Psychiatry. 2014;2014:529052. Persistent genital arousal disorder: confluent patient history of agitated depression, paroxetine cessation, and a tarlov cyst. Eibye S1, Jensen HM1.Copenhagen NV, Denmark.   report a case of a woman suffering from persistent genital arousal disorder (PGAD) after paroxetine cessation. She was admitted to a psychiatric department and diagnosed with agitated depression. Physical investigation showed no gynaecological or neurological explanation; however, a pelvic MRI scan revealed a Tarlov cyst. Size and placement of the cyst could not explain the patient’s symptoms; thus neurosurgical approach would not be helpful. Her depression was treated with antidepressant with little effect. Electroconvulsive therapy improved the patient’s symptoms though they did not fully resolve. More awareness of PGAD and thorough interdisciplinary conferences are necessary to insure an unequivocal treatment strategy.
Int J Clin Exp Hypn. 2014;62(2):215-23.Hypnotherapy for persistent genital arousal disorder: a case study.  Elkins GR1, Ramsey D, Yu Y. Baylor University , Waco , Texas , USA.Persistent genital arousal disorder (PGAD) is characterized by intrusive sexual arousal that is unresolvable via sexual activity and persists for an extended period of time. PGAD‘s etiology is unknown, and it has no established treatments. This case study reports on a 71-year-old female patient diagnosed with PGAD who received 9 sessions of hypnotherapy. The following measures were administered at baseline and follow-up: Hospital Anxiety and Depression Scale, Center for Epidemiologic Studies Depression Scale, Pittsburgh Sleep Quality Index, and visual analogue measurements of quality of life, intensity of symptoms, and marital interference. At follow-up, there were significant improvements in all measures. Given the currently limited alternatives for treatment, this case study suggests that hypnotherapy may be beneficial for some patients with PGAD.

J Sex Med. 2014 Jan;11(1):136-9. A periclitoral mass as a cause of persistent genital arousal disorder. Bedell S1, Goldstein AT, Burrows L.New York University   describe a woman who developed PGAD in association with a periclitoral mass, a potential physical cause of the disorder that has not been previously described in the medical literature.A postmenopausal woman presented with 6 months of persistent, unrelenting genital arousal and clitoral pain that was unrelated to sexual stimuli. Careful examination revealed a tender, firm, mobile, left-sided mass that appeared to compress the dorsal nerve of the clitoris.Complete excision of the mass resulted in full resolution of her symptoms over several weeks. Localized causes of persistent genital arousal, though rare, should be included in the differential diagnosis PGAD as detection and treatment can lead to a complete recovery.

J Sex Med. 2013 Jun;10(6):1549-58.   Cognitive and emotional determinants characterizing women with persistent genital arousal disorder. Carvalho J1, Veríssimo A, Nobre PJ.  Porto, Porto, Portugal. joana.pereira.carvalho@gmail.com   The aim of this study was to characterize the cognitive and emotional style of women reporting PGAD. More precisely, the content of sexual beliefs, thoughts, and emotions during sexual intercourse was explored.Forty-three women presenting PGAD and 42 controls responded to a web survey. This study was cross-cultural in nature and women worldwide (over 18 years old) were asked to participate.   After controlling for sociodemographic characteristics and psychopathology, findings showed that women reporting PGAD symptoms presented significantly more dysfunctional sexual beliefs (e.g., sexual conservatism, sexual desire as a sin), as well as more negative thoughts (e.g., thoughts of sexual abuse and of lack of partner’s affection) and dysfunctional affective states (more negative and less positive affect) during sexual activity than non-PGAD women.   Notwithstanding the impact of neurophysiological determinants in the etiology of this syndrome, results support the psychological conceptualization of PGAD and highlight the role of cognitive-behavioral therapy (CBT) for PGAD symptomatology. More specifically, cognitive and behavioral strategies would be aimed at targeting maladaptive sexual beliefs and thoughts, as well as regulating negative affective states resulting from a dysfunctional cognitive style regarding sexuality. In all, CBT in association with a medical/pharmacological approach, could be clinically relevant in the management of PGAD.\

J Sex Med. 2013 Feb;10(2):439-501   Persistent genital arousal disorder: characterization, etiology, and management.  Facelle TM1, Sadeghi-Nejad H, Goldmeier D.New Jersey Medical School-Surgery-Urology, Newark, NJ 07103, USA.. Since its first description in 2001, many potential etiologies and management strategies have been suggested.  To review the literature on PGAD, identify possible causes of the disorder, and provide approaches to the assessment and treatment of the disorder based on the authors’ experience and recent literature.PubMed searches through July 2012 were conducted to identify articles relevant to persistent sexual arousal syndrome and PGAD.    PGAD is characterized by persistent sensations of genital arousal in the absence of sexual stimulation or emotion, which are considered unwanted and cause the patient at least moderate distress. The proposed etiologies of PGAD are plentiful and may involve a range of psychologic, pharmacologic, neurologic, and vascular causes. PGAD has been associated with other conditions including overactive bladder and restless leg syndrome. Assessment should include a through history and physical exam and tailored radiologic studies. Treatment should be aimed at reversible causes, whether physiologic or pharmacologic. All patients should be considered for cognitive therapy including mindfullness meditation and acceptance therapy.

Komisaruk BR1, Lee HJ.  Rutgers, The State University of New Jersey, Newark,   Neither consistent etiology nor treatment have been established for Persistent Genital Arousal Disorder (PGAD), which is characterized by uninvited, unwelcome, and distressing genital sensation. Sacral (Tarlov) cysts, which form on dorsal (sensory) roots, most commonly of S2 and S3 in the sacral spine, are reported to produce genital symptoms that bear similarities to those described for PGAD.Women in a PGAD internet support group were asked to submit MRIs of their sacral region to the investigators, who evaluated the MRIs for the presence or absence of Tarlov cysts.  Tarlov cysts were present in 12 of the first 18 (66.7%) MRIs submitted to the investigators by women who suffer from PGAD symptoms. By contrast to this incidence, that of Tarlov cysts reported in the literature for large samples of the population observed for various disorders (e.g., lumbosacral pain) is 1.2-9.0%.Tarlov cysts have been described in the literature as producing paresthesias and genital sensory disturbances. Hence, at least some cases of PGAD might be considered to be a Tarlov cyst-induced paresthesia. Based on the relatively high occurrence of Tarlov cysts currently observed in women who suffer from PGAD symptoms, it would seem advisable to suspect Tarlov cysts as a possible organic etiological factor underlying PGAD
J Sex Med. 2012 Jan;9(1):213-7. .  Persistent genital arousal disorder: successful treatment with duloxetine and pregabalin in two cases.  Philippsohn S1, Kruger TH.Persistent genital arousal disorder (PGAD) is a rare condition in women that causes a lot of suffering. The pathophysiology is not well understood and an approach promising effective treatment has not been established so far.  Treatment of two women–36 and 41 years old–suffering from PGAD with duloxetine and pregabalin, respectively.In both women, the treatment proved to be very successful over a long period of time. One of them experienced full remission (duloxetine) and the other one experienced substantial improvement (pregabalin), over a period now lasting for more than a year.\
Neuroscience. 2010 Apr 28;167(1):88-96.  Persistent genital arousal disorder associated with functional hyperconnectivity of an epileptic focus. Anzellotti F1, Franciotti R, Bonanni L, Tamburro G, Perrucci MG, Thomas A, Pizzella V, Romani GL, Onofrj M.  d’Annunzio University, Chieti, Italy.Persistent Genital Arousal Disorder (PGAD) refers to the experience of persistent sensations of genital arousal that are felt to be unprovoked, intrusive and unrelieved by one or several orgasms. It is often mistaken for hypersexuality since PGAD often results in a high frequency of sexual behaviour. At present little is known with certainty about the etiology of this condition. We described a woman with typical PGAD symptoms and orgasmic seizures that we found to be related to a specific epileptic focus. We performed a EEG/MEG and fMRI spontaneous activity study during genital arousal symptoms and after the chronic administration of 300 mg/day of topiramate. From MEG data an epileptic focus was localized in the left posterior insular gyrus (LPIG). FMRI data evidenced that sexual excitation symptoms with PGAD could be correlated with an increased functional connectivity (FC) between different brain areas: LPIG (epileptic focus), left middle frontal gyrus, left inferior and superior temporal gyrus and left inferior parietal lobe. The reduction of the FC observed after antiepileptic therapy was more marked in the left than in the right hemisphere in agreement with the lateralization identified by MEG results. Treatment completely abolished PGAD symptoms and functional hyperconnectivity. The functional hyperconnectivity found in the neuronal network including the epileptic focus could suggest a possible central mechanism for PGAD.
J Sex Med. 2009 Oct;6(10):2896-900. Persistent genital arousal disorder and trazodone. Morphometric and vascular modifications of the clitoris. A case report.  Battaglia C1, Venturoli S. University of Bologna,  Italy   Persistent genital arousal disorder (PGAD) is an unwanted genital arousal which occurs in absence of sexual interest and desire.A young (29 years old), eumenorrheic (menstrual cycle of >25 and <35 days) woman suffered of unwanted genital arousal and uncontrollable orgasms. In the past, the patient undertook trazodone treatment. ultrasonographic and color Doppler analyses of the clitoral structures prior and after an unwanted orgasm-    The clitoral volume was 1.33 mL before the orgasm and 1.36 mL and 1.33 mL, respectively after 1 minute and 15 minutes from the orgasm. The Pulsatility Index (PI) of the dorsal clitoral artery was 1.05 before the orgasm,  lower after 1 minute (PI = 0.82) and 15 minutes (PI = 0.85) from the orgasm.A subtle and intermittent clitoral priapism may favor the feeling of arousal persistence and elicit unbidden and unwelcomed orgasms. 

posted 2009:

Restless Legs (Ekbom’s) Syndrome, common with iron deficiency, diabetes,  kidney failure etc,  is bad enough. But combination  with restless genitals is an awful prospect. Normally it is men who famously have restless genitals that cannot be sated…

Sandra Leiblum first described persistent genital arousal disorder in women in 2001, and since then has reported on some 171 cases in New Jersey.

Marcel Waldinger now reports on some 23 cases in the Netherlands;  with average age  of onset around 50years ie menopause. His group has now characterized this disorder as having:

restless leg syndrome and/or an overactive bladder, urethral hypersensitivity; involuntary genital arousal with unprovoked orgasms, onset often during early menopause, as well as the 5 diagnostic criteria of persistent genital arousal disorder (PGAD) –  :

  • Persists for an extended period of time (hours, days, and/or months)
  • Does not go away after 1 or more orgasms
  • Is unrelated to subjective feelings of sexual desire
  • Feels intrusive and unwanted; and
  • Causes distress.                                                                                                                                                  They find it is  is “highly associated with pelvic varices (in all on pelvic MRI scan) and with mechanical sensory neuropathy of the dorsal clitoral and pudendal nerves, whose symptoms are suggestive for small fiber neuropathy (SFN).                                    Although all the women reported varying degrees of social withdrawal, desperate feelings, dysthymia, agitation, or depressed mood directly caused by persistent unwanted genital sensations, none were known to have previous psychiatric disorders.”

Leiblum discriminates such disorder from Female Sexual Arousal Disorder on the basis that “FSAD women displayed the greatest problems in desire, arousal, lubrication, orgasm, and pain while women with PGAD reported somewhat more desire than the control group but did not meet the cutoff score for sexual dysfunction.

It is strange that no other gyne or sexual health clinics in the world have  so far reported clusters of such patients as have these two clinics in New Jersey and Den Hage .

Leiblum ea could elicit only perhaps 1 such case (ie 1%) at a sexual health clinic in London UK. From an Internet survey she reported in 2007 that  in the 50% of cases who had all 5 diagnostic criteria, “ they were significantly more likely to be depressed (55% vs. 38% who did not have all 5) and to report panic attacks (31.6% vs. 14.6%). They were more anxious and more likely to monitor their physical sensations. Both groups reported high rates of childhood and adult sexual abuse, although the PGA women reported a higher prevalence of sexual victimization. They were significantly more likely to endorse negative feelings about their genital sensations and also more likely to complain of chronic fatigue syndrome than women without the condition (10% vs. 0%). There were no significant relationships with pharmacologic agents and symptoms.  It is hypothesized that for a subset of women, psychological factors, namely anxiety, reinforce exacerbate and maintain PGAD.”

But they have  anything but nymphomania (origin 1775: Oxford English dictionary), although they may be so mislabeled ie pseudo-nymhomania (Fenichel 1933). Kinsey’s 1948 book on Female Sexual Responsiveness did not even mention, index nymphomania.  Kuperman 1961  in his chapter on Sex Hormones unknowingly  implies the  difference between nymphomania and pseudonymphomania: “nymphomania may occasionally be treated successfully and paradoxically with androgens.. these patients who respond to androgens by a decrease in desire for frequent stimulation are probably those who have been unable to achieve satisfying orgasm, which androgen provides..   in other such patients, progesterone suppositories as an antiandrogen agent may diminish unwanted desire and erotic tendencies. ”

Stuckey ea describe a single case who was cured by coil embolization of pelvic varicose veins- a more realistic therapy than embolization of the clitoris to infarct it, or amputation as was practiced by eminent UK physicians in Victorian times.. .

MANAGEMENT:

Women with  RGS/PGAS do not have either a central  arousal disorder or  craving for love/attention,  but vascular- neuropathic clitoral engorgement; which topical progesterone or anaesthetic eg lignocaine cream  may relieve by treating the endpoint, not the cause.

If varices are the strong associate, perhaps it is worth considering the pathophysiology of varices, which are apparently often associated with sensory neuropathy, presumably through swelling pressure on nerves – local varicose oedema. Vercellini ea note that pelvic varices are one common cause of pelvic pain in women.

Increased pressure and thrombosis  aside, varicose veins are strongly associated with female gender, ie with testosterone:estrogen level about 1/200th of that in middle-aged men, and  loss of collagen  (ie ascorbic acid) in smooth muscle and extracellular matrix.

Higher female estrogen  is associated with stronger bones, and oedema, stress incontinence and vascular relaxation; but it notoriously contributes nothing to muscle growth and strength except in the unique uterus itself – only estrogen  grows the  uterus.  Only androgen grows body muscle mass and strength. From early menopause, testosterone falls gradually;  but especially with fattening, estradiol falls gradually but fat-derived estrone increases, reversing the premenopausal estradiol>estrone dominance. Hence across midlife women mostly shrink their skeletons and lean mass but expand their fat mass steadily- ie couch potatoes develop increasing fatness frailty.

Hence (compression stockings for varicose legs aside), especially in women, apart from raising the legs, the foot of the bed at night, we commonly see varicose vein discomfort and distension in the legs and anus (piles) relieved by a few grams of bioflavinoid – ascorbic acid blend a day. A topical cream may augment this.

And as regards neuropathy of the legs, apart from GABA plus 5HTP for nonspecific relief, we often see significant improvement with a vigorous blend of nerve nutrients including vitamins BCo, zinc and alphalipoic acid.

It may add to understanding of this awful problem if other sufferers contribute their experience. Anonymity will obviously be preserved if their comments are published.