Sexual Health, Arousal disorder

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 (ie, hypoactive sexual desire, sexual arousal difficulties, an orgasmia, dyspareunia).These problems are quite prevalent, and are re p o rted 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.


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

{mosbanner:id=1:right:0}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.