Sexual Dysfunction in Women – Causes, Symptoms, Diagnosis, Treatment and Ongoing care
- Sexual dysfunction may be a lifelong problem or may be acquired.
- Approximately 40% of women surveyed in the US have sexual concerns.
- Female sexual dysfunction may present as a lack of sexual desire, impaired arousal, pain with sexual activity, or inability to achieve orgasm.
The American Psychiatric Association guidelines for establishing a diagnosis of sexual dysfunction require that the problem be recurrent or persistent and that it cause personal distress or interpersonal difficulty.
- 5 major types:
- Disorders of desire: Hypoactive sexual desire with deficient or absent sexual fantasies and desire for sexual activity
- Disorder of arousal: Inability to attain or maintain adequate lubrication/engorgement in response to sexual excitement
- Dyspareunia: Genital pain associated with intercourse
- Vaginismus: Involuntary contractions of the perineal muscles in response to vaginal penetration
- Disorders of orgasm: Delay or absence of orgasm following normal sexual excitement
- System(s) affected: Nervous; Reproductive; Genitourinary; Psychiatric
- Synonym(s): Hypoactive sexual desire disorder; Sexual aversion disorder; Female sexual arousal disorder; Inhibited female orgasm
- In one international study, 40% of women aged 40–80 years reported sexual complaints (1).
- In the largest study of female sexual dysfunction in the US, 43% of over 30,000 women reported sexual dysfunction (2).
- Unfortunately, many studies do not assess whether the sexual issues are associated with distress, which is required to meet the criteria for the diagnosis of sexual dysfunction.
Incidence is highest during the postpartum period and perimenopause.
- Postpartum: In a study of over 400 primiparous women, 83% reported sexual problems at 3 months postpartum; and 64%, at 6 months (3). There was no difference between vaginal versus cesarean delivery.
- Perimenopause: Sexual problems associated with distress are highest in women aged 45–64 years. Though sexual activity decreases with age, so does the distress as well as the perception that it represents dysfunction.
- Overall prevalence of diagnosed sexual dysfunction is 15–30% among US women.
- Orgasmic disorders are the most common: <10% are primary, and 65–80% are secondary.
- Desire disorders are the complaint of 30–55% of individuals and 31% of couples presenting to clinics.
- Arousal disorders are present in 14–48% of patients.
- There are many women who report some degree of dissatisfaction but do not meet clinical criteria for diagnosis for sexual dysfunction.
- 1 out of 5 women report that they are sexually dissatisfied.
- 2 out of 3 women report some degree of sexual dysfunction but do not meet criteria for diagnosis.
- Of women who are anorgasmic, only 1 out of 3 perceive it as a problem causing significant personal distress.
- Advancing age
- Previous sexual trauma
- Lack of knowledge about sexual stimulation and response
- Chronic medical problems (e.g., depression or other psychiatric disorders); cardiovascular disease; endocrine disorders (e.g., diabetes, hypertension); neurologic disorders
- Gynecologic issues such as childbirth, pelvic floor or bladder dysfunction, endometriosis, and uterine fibroids
- Medications such as hormonal contraception, selective serotonin reuptake inhibitors (SSRIs), beta-blockers, and antipsychotic medications
- Relationship factors such as couple discrepancies in expectations and/or cultural backgrounds, attitudes toward sexuality in family of origin
- Substance abuse such as smoking, alcohol, and illicit drugs
The pathophysiology of sexual dysfunction is complex and multifactorial since it can be the result of any etiology that interferes with the normal female sexual response cycle of desire, arousal, orgasm, and resolution.
- Epilepsy: Higher rates of sexual dysfunction
- Diabetes (specifically anorgasmia)
- Anxiety or depression
- Spinal cord damage
- Thyroid disease
- Hormonal imbalance
- Drug use, including prescription medications (e.g., SSRIs, monoamine oxidase inhibitors [MAOIs], tricyclic antidepressants [TCAs], β-blockers)
- Interrelational difficulties and conflict regarding intimacy
- Control issues in the relationships
- Sexual frequency myths
- Survivor of sexual abuse, including incest
- Body image issues
- Proximity of other people in household
Commonly Associated Conditions
- Marital discord
- Female sexual dysfunction is diagnosed by identifying diagnostic criteria through both a medical and a sexual history.
- The diagnosis requires that the sexual problem be recurrent or persistent and cause personal distress or interpersonal difficulty.
- Complaint to health care provider; if the clinician inquires “Do you have any sexual concerns?” more than twice as many are revealed than if clinician waits for the patient to mention).
- Pregnancy/childbirth history
- Menopausal status (natural, surgical, or postchemotherapy)
- Sexually transmitted diseases and vaginitis
- Pelvic surgery, injury, or cancer
- Chronic pelvic pain
- Abnormal genital tract bleeding
- Urinary/anal incontinence
- Marital conflict
- Family dysfunction
Most commonly, patients have a normal physical exam.
- Assess for scars or evidence of trauma.
- Assess for vaginal atrophy, adequate estrogenization.
- Assess for infection.
- Recognize signs of anxiety, apprehension, and pain during the speculum and pelvic exam.
Diagnostic Tests & Interpretation
Neither estrogen nor androgen levels should be used to determine the cause of the sexual dysfunction because there is no established serum hormone range that correlates with sexual dysfunction.
Initial lab tests
As needed to identify infections and other medical causes:
- Wet prep
- Thyroid-stimulating hormone
- Follicle-stimulating hormone
Follow-Up & Special Considerations
Transvaginal ultrasound if indicated
- Medication side effects: SSRIs, TCAs, and other antidepressants; psychotropics; MAOIs; many antihypertensives
- Decreased vaginal lubrication secondary to hormonal imbalance
- Decreased sensation secondary to nerve injury
- Multiple sclerosis
- Anatomic abnormalities
- Abdominal surgery (which can interfere with pelvic innervation)
- Marital dysfunction, including domestic violence
- Pseudodyspareunia (use of complaint of pain to distance self from partner)
- Assess patient goals.
- Treatment should address associated chronic conditions.
- Hormone therapy, alone or in conjunction with other therapies
- An increase in fitness and body image alone can improve libido.
- Consider couples therapy for women who complain of relationship conflicts.
Sexual dysfunction is often a multifactorial psychosocial condition. Using medications does not usually address the cause of the problem and can, in some cases, make the condition worse.
- Bupropion: May be useful in treating sexual dysfunction or as an adjunct for SSRI-induced sexual dysfunction. (4,5) Generally, Bupropion XL 300mg/day is used.
- Premenopausal women:
- Some data suggest that testosterone may be low with decreased libido.
- No clear studies indicate testosterone replacement as beneficial.
- Postmenopausal women:
- Adding testosterone to hormone-replacement therapy may increase sexual desire. (6)[B]. Unfortunately, the FDA has not approved the use of testosterone to treat sexual dysfunction in women. Current testosterone therapy for women must be compounded into an oral or topical form. Typical dosages range from 0.625–1.25 mg/day. Testosterone therapy designed for men should not be used in women.
- Estrogen replacement may help to improve sexual desire, vaginal atrophy, and clitoral sensitivity. Vaginal estrogen therapy is available in cream, vaginal tablet, or ring form (7)[B].
Issues for Referral
Consider referral for marriage or sex therapy counseling.
- Vaginal lubricants
- Aerobic exercise
- Smoking cessation and reduction of alcohol intake
- For childhood trauma: Scripting, psychotherapy, cognitive restructuring
- For anorgasmia: Directed masturbation and “homework” with partners
- For prescription-drug causes: Reduced dosages or change to different medication
- Other: Family therapy, sensate conditioning; referral to specialized sex therapy
Complementary and Alternative Medicine
- Yohimbe: Not recommended, potentially dangerous
- Ginseng and St John’s Wort have no evidence to support treatment of sexual dysfunction.
- DHEA: Androgenic effects; will decrease high-density lipoprotein cholesterol
Weight reduction if needed for either partner
- In the US, sex therapists and counselors can be found through the American Association of Sex Educators, Counselors and Therapists at http://www.assect.org.
- National Women’s Health Resource Center: www.Healthwomen.org
- American Association of Sex Educators, Counselors, and Therapists: www.aasect.org
- Female Sexual Dysfunction Online: www.femlae sexualdysfunctiononline.org
- North American Menopause Society: www.menopause.org
Lack of desire is most difficult type to treat with <50% success.
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- 302.70 Psychosexual dysfunction, unspecified
- 302.71 Hypoactive sexual desire disorder
- 302.72 Psychosexual dysfunction with inhibited sexual excitement
- 302.73 Female orgasmic disorder
- 302.76 Dyspareunia, psychogenic
- 302.79 Psychosexual dysfunction with other specified psychosexual dysfunctions
- 28154007 abnormal female sexual function (finding)
- 270903007 lack or loss of sexual desire (disorder)
- 268637002 psychosexual dysfunction (finding)
- 60103007 inhibited female orgasm (disorder)
- 71315007 dyspareunia (finding)
- Female sexual dysfunction is a complex, multifactorial problem.
- Most commonly, patients with sexual dysfunction have a completely normal physical exam.
- Symptoms of sexual dysfunction peak during perimenopause between the ages of 45–64, even though hormone levels of estrogen and testosterone may fall in the normal range; women often benefit from hormone supplementation with estrogen and/or testosterone.
- Encourage follow-up with counseling for marriage, individual, and/or sex therapy.