Female Sexual Dysfunction

Key Features

• Encompasses several disorders, including

  • Disorders of sexual desire

  • 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

  • Specific sexual dysfunction

Clinical Findings

• 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 with vaginal atrophy may lack both a subjective and physiologic response to sexual stimuli

• 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

Diagnosis

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

Treatment

• 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)