Female Sexual Dysfunction

Encompasses several disorders, including

• Sexual desire disorder

• Sexual arousal disorders

• Orgasmic disorders

• Sexual pain disorders (see Dyspareunia [Painful Intercourse])

Obtain reproductive history (including pregnancies and mode of delivery)

In addition, obtain a history of

• Infertility

• Sexually transmitted diseases

• Rape or sexual abuse

• Gynecologic or urologic disorders

• Endocrine abnormalities (such as diabetes mellitus or thyroid disease)

• Neurologic problems

• Cardiovascular disease

• Psychiatric disease

• Current prescription and over-the-counter medication use

Disorders of sexual desire

• Emotion is a key factor in sexual desire

• Lack of desire may be attributed to such physical factors as

  • Chronic illness

  • Fatigue

  • Depression

  • Specific medical disorders (such as diabetes mellitus, thyroid disease, or adrenal insufficiency)

• Attitudes toward menopause and aging may play a role

• In addition, sexual desire may be influenced by other sexual dysfunctions

Sexual arousal disorders

• May be both subjective and objective

• Sexual stimulation normally leads to genital vasocongestion and lubrication

• Some women may have a physiologic response to sexual stimuli but may not subjectively feel aroused because of factors such as

  • Distractions

  • Negative expectations

  • Anxiety, fatigue, depression

  • Medications, such as selective serotonin reuptake inhibitors (SSRIs) or oral contraceptives

• Other women may lack both a subjective and physiologic response to sexual stimuli related to vaginal atrophy

Orgasmic disorders

• In spite of subjective and physiologic arousal, women may experience a marked delay in orgasm, diminished sensation of an orgasm, or anorgasmia

Sexual pain disorders

• See Dyspareunia (Painful Intercourse)

Gynecologic examination should focus on findings that may contribute to sexual complaints

Disorders of sexual desire

• In the absence of specific medical disorders, the focus of therapy is psychological (eg, cognitive behavioral therapy, sexual therapy, and couples therapy)

• Pharmacologic therapy, particularly with dopamine agonists or testosterone with estrogen, may be successful but data are lacking

Sexual arousal disorders

• May respond to psychological therapy

• Some evidence suggests a role for sildenafil in women with sexual dysfunction due to multiple sclerosis, type 1 diabetes mellitus, spinal cord injury, and antidepressant medications, if other, better established, approaches fail

• Flibanserin (Addyi)

  • Effective for treatment of hypoactive sexual desire disorder in premenopausal women

  • Must be used long-term to be effective

  • Has significant risks that require specific certifications of providers and pharmacies before dispensation to patients in the United States

Orgasmic disorders

• Counseling or sex therapy may be adequate therapy

• There is an FDA-approved vacuum device that increases clitoral blood flow and may improve the likelihood of orgasm

Sexual pain disorders

• See Dyspareunia (Painful Intercourse)