18-11: Female Sexual Dysfunction

GENERAL CONSIDERATIONS

Female sexual dysfunction is a common problem. Depending on the questions asked, surveys have shown that from 35% to 98% of women report sexual concerns. Questions related to sexual functioning should be asked as part of the routine medical history. Three helpful questions to broach the topic are “Are you currently involved in a sexual relationship?,” “With men, women, or both?,” and “Do you have any sexual concerns or any pain with sex?” If the woman is not involved in a sexual relationship, she should be asked if there are any concerns that are contributing to a lack of sexual behavior. If a history of sexual dysfunction is elicited, a complete history of factors that may affect sexual function should be taken. These factors include her reproductive history (including pregnancies and mode of delivery) as well as history of infertility, sexually transmitted infection, rape or sexual violence, gynecologic or urologic disorders, endocrine abnormalities (such as diabetes mellitus or thyroid disease), neurologic problems, CVD, psychiatric disease, and current prescription and over-the-counter medication use. A detailed history of the specific sexual dysfunction should be elicited, and a gynecologic examination should focus on findings that may contribute to sexual complaints.

ETIOLOGY

A. Disorders of Sexual Desire

Sexual desire in women is a complex and poorly understood phenomenon. Emotion is a key factor. Relationship conflict, fear or anxiety related to previous sexual encounters, or history of sexual abuse or violence may contribute to a lack of desire. Physical factors such as chronic illness, fatigue, depression, and specific medical disorders (such as diabetes mellitus, thyroid disease, or adrenal insufficiency) may also contribute. Menopause and attitudes toward aging may play a role. In addition, sexual desire may be influenced by other sexual dysfunction, such as arousal disorders, dyspareunia, or anorgasmia.

B. Sexual Arousal Disorders

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; or medications, such as SSRIs or oral contraceptives. Other women with vaginal atrophy may lack both a subjective and physiologic response to sexual stimuli.

C. Orgasmic Disorders

Despite subjective and physiologic arousal, women may experience a marked delay in orgasm, diminished sensation of an orgasm, or anorgasmia. The etiology of orgasmic disorders is complex and typically multifactorial, but the cause of a particular patient’s orgasmic disorder is usually amenable to treatment.

D. Sexual Pain Disorders

Dyspareunia (female sexual pain) is defined as recurrent or persistent genital pain that is provoked by sexual contact. Vulvodynia is a frequent cause of dyspareunia in premenopausal women. It is defined as vulvar pain of ...