Abstract
Abstract
Keywords
Introduction
Discharge per vagina is a common issue faced by women. In India, four community-based studies showed the prevalence of this condition to be ranging from 22% to 57%. 1 Vaginal discharge is among the most common symptoms of reproductive tract infection.2, 3 However, some studies recently showed that vaginal discharge can be present even in the absence of reproductive tract infection,4, 5 with psychiatric illnesses associated to a larger extent with the vaginal discharge. In the absence of any organic cause, this type of vaginal discharge can be termed as non-pathological white discharge per vagina (NPWDPV).
In the Indian subcontinent, genital secretions are considered to be one of the fundamental elements that make up the body, and their loss leads to progressive weakness of the body and the mind. Hence, loss of semen is believed to lead to weakness, fatigue, sleeplessness, loss of appetite, guilt, sexual dysfunction, and many other symptoms.6– 8 This condition is known as Dhat syndrome. It is typically seen in young and poorly educated males. It is a widely recognized illness and many cases have been reported from Europe, Americas, Russia, China, Sri Lanka, Pakistan, Japan, Malaysia and other Asian countries.9– 11 That there is a possibility for a similar syndrome in women has long been debated.12– 14 In as early as 1918, an article presented a report about an African woman with multiple somatic complaints of having white discharge without an organic cause. 15 Bili hoguvudu, bili batte, ujla, swetha pradara, dhatu, and safed paani are some of the common terms used by the women to refer to white discharge per vagina. The belief that the passage of white discharge from vagina is associated with weakness, tiredness, exhaustion, anxiety, pain and other somatic symptoms is supposed to be widely prevalent among certain groups of women. 16 This is known as psychaesthenic syndrome and this term was first used by Santhosh K. Chaturvedi. 12 This syndrome has been mentioned in DSM-5 48 under “Cultural Concepts of Distress”. There is also a belief that somatic complaints themselves cause white discharge per vagina. Ayurvedic practitioners routinely ask about passage of vaginal discharge. It is possible that concepts of Ayurveda, which say that a hundred drops of blood make one drop of safed paani, are highly entrenched in the minds of the people, hence leading to apprehension about passage of vaginal discharge. On the other hand, there are other perceived causes of vaginal discharge such as ingesting spicy meals, melting of bones, tubectomy, abortion, supernatural causes, and sometimes just fate. 17
Review of Literature
A study conducted by Santhosh K. Chaturvedi in the psychiatric outpatient department showed that 32% of the patients who presented with somatic complaints attributed their symptoms to NPWDPV. 12 In a different study by the same author, it was found that women in the index group were 3.5 times more likely to attribute the symptoms to NPWDPV than women in the control group. 16
A community-based survey was conducted in Goa, India, by Patel V. with 2494 women participants aged 18-50 years. Out of these, 14.5% reported vaginal discharge. Among them, 82.5% had white discharge per vagina. Commonest causes, in descending order, were stress and emotional factors, excess heat in the body, and infection. A major finding of this study was that psychosocial factors, mainly the presence of common mental disorders and somatoform disorder symptoms, were most strongly associated with the complaint of vaginal discharge. 18
This syndrome is not unique to India. A study published in 2012 shows that women presenting with vaginal discharge as the chief complaint to gynecology OPD in Pakistan were significantly more likely to have a common mental disorder as compared to women presenting with other gynecological problems with an odds ratio of 2.38. 19
A study done by Kaur J. et al in an urban slum in Delhi showed that 97% of the 391 participants were aware of white discharge per vagina. Out of these, 32.7% reported having the complaint. About 2.4% reported having sexual problems as a result of the discharge per vagina. However, this study did not elaborate on the type of sexual problems. 20
Female Sexuality
Female sexuality is not understood as well as male sexuality. 21 Studies in this area also are comparably lesser in number. Most of the understanding of psychophysiological basis of sexuality comes from the extensive work done by William H. Masters and Virginia E. Johnson who gave a linear model of sexual response in both men and women. This model includes the four stages of excitement/arousal, plateau, orgasm, and resolution and theorizes that one stage progresses into the next. 22 Kaplan then modified the model to the phases of desire, arousal, and orgasm. 23 Based on the same model, the sexual dysfunctions were divided into sexual desire disorders, sexual arousal disorders, and orgasmic disorders. However, evidence started mounting against this model as most women often did not go through all these phases. 24 The model also did not take into account the non-physiological aspects of sexuality in women such as relationship and prior sexual experiences. Research also showed that female sexual response was far more complex than male sexual response.25, 26 This led to a nonlinear model explanation of sexual response by Basson which included emotional intimacy, well-being, sexual stimuli, and cognitive processes.27– 29
According to this model, the response cycle starts with willingness to become receptive after processing sexual stimuli, subjective arousal which leads to expression of desire, followed by satisfaction even without orgasm.
Current understanding is based on the incentive motivation model which states that sexual desire is the result of a complex interaction between the sexual response system and stimuli that act on the system. From this theory, sexual desire does not precede arousal but is either a consequence of arousal or a simultaneous occurrence, especially in women in a long-term relationship. This theory also emphasizes on the fact that for the activation and maintenance of sexual arousal response, various cognitive processes are involved in the processing of the sexual stimuli. Negative connotations to sex such as a prior bad sexual experience or sexual abuse lead to decreased desire, whereas prior enjoyable sexual experiences lead to increased desire for sex.
In women, there is a component of subjective sexual arousal which is different from genital arousal. The subjective arousal is based on the appraisal of and reaction to the sexual situation. It is possible for a woman to have genital arousal without subjective sexual arousal. Hence, even if there is a genital response with lubrication and vasocongestion, a woman need not be subjectively aroused and willing for sexual activity. 27 This finding plays a very important role in her sexuality.
Female sexual dysfunction is a common yet an inadequately discussed problem in the population.30, 31 Hypoactive sexual desire disorder and sexual arousal disorder are amongst the most common sexual dysfunction disorders seen in women.32– 35 DSM-5 has now come up with female sexual interest/arousal disorder as one entity which has the criteria that there should be absent or reduced interest in sexual activity and thoughts, absent or reduced sexual excitement, and arousal with decreased sensations which have persisted for a period of at least 6 months. Inclusion of both desire (sexual interest) and arousal together brings into focus the difficulty involved in delineation of phases in female sexual response.25, 26 This has implications even in management of sexual dysfunction in women. This issue has been discussed with reference to the newer approved drug Flibanserin for the management of female sexual dysfunction. 36 However, ICD-10 49 still describes it to be comprised of two entities—lack or loss of desire and failure of genital response. DSM-5 has dissolved the use of the term sexual aversion disorder due to the fact that there was little evidence for the same. There were also objections that sexual aversion disorder has more similarities to phobic disorder and hence should be placed under the spectrum of anxiety disorders rather than in sexual dysfunctions.37, 38
The factors that play a role in the sexual system include biological and psychosocial factors. Under biological factors, hormones play a very important role. Hormonal disorders such as thyroid disorders and diabetes mellitus have a correlation with decreased sexual desire and arousal.39, 40 Decreased estrogen levels as in menopause lead to vaginal atrophy and vaginal dryness but do not impede the genital arousal response. 41 Low testosterone levels caused by pituitary, gonadal or adrenal dysfunction in women lead to decreased sexual desire.
Psychosocial factors include the importance of the stimuli in sexual desire and arousal. The processing of the stimuli involves cognitive functions. Positive association of the stimuli will lead to increased sexual desire and arousal while negative influence and connotations will diminish the desire and arousal. If there is anxiety and pain during sex, it will lead to negative outcomes and this will form a vicious cycle.
The relation between psychiatric illnesses and sexual desire and arousal is bidirectional. 42 Psychiatric morbidities such as depression and anxiety are associated with decreased sexual interest and response.43, 44 They have an inhibiting effect on both genital and subjective arousals. On the other hand, it has been found that women who came with reduced sexual desire and arousal as complaint were three times more likely to have episodes of depression. 45
Interplay Between Psychaesthenic Syndrome and Female Sexual Arousal
In psychaesthenic syndrome, the discharge per vagina causes much distress to the women. She will not be comfortable participating in sexual activity due to various reasons. One reason is the physical discomfort itself caused by the NPWDPV. Another reason is the association of discharge per vagina with sexually transmitted infections. This will lead the woman to have the idea that the discharge per vagina has occurred due to the infidelity of her partner. 46 On the other hand, the woman might also fear that her partner might accuse her of infidelity. With focus on such nonsexual negative thoughts instead of on the sexual stimuli, adequate sexual arousal response is prevented as cognitive distraction during the processing of sexual stimuli will lead to weaker sexual arousal.
Many women present with multiple somatic complaints in this syndrome which include generalized body ache and burning sensation all over the body and/or in external genitalia. If the women are preoccupied with these symptoms, there will be lesser appreciation of the sexual stimuli which will again lead to diminished sexual arousal. This negative association will lead to further reduced arousal in future sexual activities.
In women, there is a strong reciprocal association between sexual desire and relationship satisfaction. 47 More sexual contact and desire for the same is usually observed on days with more positive interactions between the woman and her partner. Sexual dysfunction in one partner will lead to problems in the relationship due to dissatisfaction. If NPWDPV causes a conflict in the relationship, it is likely for the woman to have attenuated sexual arousal.
The most common psychiatric manifestations of NPWDPV are depression and anxiety. Women suffering from depression tend to have decreased interest in sex. They also have decreased self-esteem which includes a negative sexual image of the self. This can affect sexual arousal in a negative manner. Anxiety on the other hand is characterized by decreased attention and concentration on the sexual stimuli. This leads to impaired cognitive processing of the stimuli, hence diminishing the sexual arousal. Thus, there is also an indirect correlation between depression and anxiety and sexual arousal.
So when managing a case where the woman is presenting with multiple somatic complaints, one has to keep psychaesthenic syndrome in mind as a differential diagnosis. This is truer in a case where there have already been repeated medical consultations. We should also assess the psychological factors in play here, such as internal and external environmental factors. When dealing with psychaesthenic syndrome as such, a thorough evaluation should be carried out, especially looking out for depressive and anxiety symptoms. In the same vein, sexual function should also be assessed as part of the treatment process, for example in psychiatry, medicine, and gynecology. It should be brought up by the treating doctor or therapist as the women would not be comfortable talking about the same by themselves. If there are conflicts and interpersonal issues between the partners in the relationship, they should be addressed. Masters and Johnson believed that the couple, rather than one of the partners, should be assessed and treated in sexual dysfunctions. They also advocated that the treating team should consist of therapists of both sexes to make the process more comfortable for the patients. This belief governs the concept of Masters and Johnson’s co-therapy of dual sex teams and conjoint therapy of addressing both the partners in the relationship. Thus, the whole process will be easier if it is a female therapist who is dealing with the patients. Most of the cases of psychaesthenic syndrome present to a specialist in obstetrics and gynecology (OBG). Hence, they should be trained to bring up these issues during a consultation. Every effort should be made by an OBG specialist to counsel the patients, and where intensive intervention is needed, the patients should be referred to a psychiatrist or sexologist for further evaluation and treatment. This approach will lead to a comprehensive management of a case of psychaesthenic syndrome.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.