Until recently, sexual function in women with SCI was relatively understudied. Statistics and demographic studies have consistently shown the incidence of SCI in men is significantly higher (78 percent) than in women (22 percent). The majority of newly injured women are of childbearing age (16 to 30 years old).The impact of SCI on the fertility of women who are in their “prime” childbearing age weighs heavily on their complete adjustment.

Genital Arousal Dysfunction  
Fact #1: Women are sexual beings with a healthy libido. A woman’s expression of a man’s erection is vaginal lubrication. Similar to men, the neurologic level and severity of SCI may predict the ability for women to achieve psychogenic and/or reflexogenic vaginal lubrication. The degree of preservation of sensation at the T11-L2 dermatomes is associated with psychogenic vaginal lubrication. If you have an injury at the T11-L2 spinal cord levels, it is unlikely that you will achieve arousal from erotic thoughts from your brain. In other words, the SCI does not allow these messages to reach this “sexual function center.” Expert researchers recommend that women with SCI check for their ability to feel the groin area when they put their hands in their pants' pockets.

Try this. If you can feel this area, you will likely be able to achieve genital arousal via stimulating thoughts.Alternatively, manual genital stimulation will produce reflexogenic vaginal lubrication if the S2-S4 spinal nerves are intact. Therefore, if you have injury to the lumbar vertebrae or cauda equina, you will not likely achieve arousal through tactile or manual genital stimulation. Clinically, the presence of the bulbocaverosus or anal wink reflexes (mediated by S2-S4) correlates with the capacity of reflexogenic arousal.Caution is advised for women with SCI above T6 as genital stimulation has been reported to induce autonomic dysreflexia.

Treatment
Medications and assisted devices similar to those recommended for men with SCI have been shown to also improve a women’s ability to achieve adequate genital lubrication for sexual intercourse. One study showed that taking Viagra (sildenafil citrate) 60 minutes prior to a sexual encounter with manual stimulation improved genital lubrication by promoting vasocongestion of the women’s erectile tissue. Conceptually, clitoral vacuum pump devices act on local vasocongestion by creating negative pressure, similar to the penile vacuum device. Widely available commercial vibrator stimulators have also assisted women with reflexogenic vaginal lubrication.

Orgasm
The impact of SCI on women’s sexual function is not as well studied or defined when compared to that of men. However, in a controlled lab setting, investigators found that 50 percent of women with SCI (regardless of the level or severity of SCI) were able to achieve an orgasm but had a prolonged time to orgasm when compared to their able-bodied counterparts. Functional MRI studies further suggest that other non-spinal pathways may carry the information from genital stimulation to the brain for an orgasm to occur. But, reports from women with injury to the sacral spinal cord (conus medullaris or cauda equina) note great difficulty in achieving orgasm. Thus, conflicting theories are offered for the physiologic basis for orgasm in women with SCI, which has stimulated a growing body of ongoing research. 

Female Fertility
Fact #2: Unlike men with SCI, a woman’s ability to achieve orgasm does not affect her fertility. With the exception of a transient period of amenorrhea (lack of menstruation) during the acute or subacute period after SCI, a woman’s fertility is not affected by the SCI. 

About 85 percent of women with SCI experience amenorrhea, with 50 percent of women resuming their menses after 6 months post-injury and 90 percent of women resuming their menses by one year post-injury. The level of injury or completeness of SCI does not appear to have any influence on the timing of the resumed menstrual cycle, but 25 percent of women with SCI report increased menstrual cramping, bladder spasms, and autonomic dysreflexia during their menstruation. 

Studies have also shown that SCI has no impact on the onset of menarche in preadolescent girls with SCI nor does SCI alter the onset of menopause. Women with SCI experience menopause at similar ages as women without SCI but report a greater degree of physical and psychologic symptoms.

Contraceptive methods after SCI are challenging for women due to additional risks posed by the SCI. Despite limited studies to support the magnitude of risk for developing deep vein thrombosis (DVT) in chronic SCI, oral contraceptive pills (OCPs) are still cautiously used. 

However, advances in combination hormone OCPs may prove to lessen the DVT risk, and should be explored with a physician. Condoms remain the preferred form of birth control as it provides both contraception and barrier protection from sexually transmitted diseases. Devices such as diaphragms and intrauterine devices (IUDs) also have limitations. Diaphragms may be limited in women with cervical SCIs who may lack sufficient hand dexterity for use. Also, there are concerns in using IUDs, mainly the risk of failing to detect any symptoms for infections in an insensate uterus and improper migration of the device.

Pregnancy
Fact #3: After SCI, women can get pregnant and have healthy babies. For women with SCI, getting pregnant is not the problem. The greatest challenge is managing complex issues during prenatal, perinatal, and postnatal care. 

Since pregnancy in women with SCI is considered “high-risk,” especially if the injury is above T6, it is imperative for women to have collaborative care from an obstetrician and physiatrist. In fact, the American College of Obstetrics and Gynecology has established treatment guidelines for perinatal care in pregnant women with SCI. In the prenatal period, potential SCI-related complications include urinary tract infections, increased spasticity, constipation, pressure ulcers, risk of DVT, and autonomic dysreflexia. During the perinatal period, recognizing premature onset of labor may be difficult. 

Women with a SCI at T10 and below may not sense labor pains. Instead, the onset of labor may be characterized by increased spasticity. For women with SCI above T6, labor may be accompanied by autonomic dysreflexia which may be difficult to distinguish from hypertension due to pre-eclampsia. When compared to able-bodied women, women with SCI are more likely to have low birth weight infants but have a similar incidence of premature births. There is no data to suggest a greater risk of congenital abnormalities. 

During labor, women with SCI are more likely to have forceps delivery or Cesarean section, but no more likely to have a miscarriage or stillbirth. Spinal epidural anesthesia has proven successful and safe for managing autonomic dysreflexia during labor and delivery.