Female Sexual Dysfunction

Aka: Female Sexual Dysfunction, Sexual Dysfunction, Female Sexual Arousal Disorder

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II. Epidemiology

  1. Women with sexual concerns: >50%
  2. American women who have never had an orgasm: 8%

III. Types: Disorders of Sexual Desire and Arousal

  1. Female sexual interest/arousal Disorder (DSM5)
    1. Symptoms for >=6 months and associated with significant distress in the individual
    2. Lack or significant decrease in at least 3 of the following
      1. Interest in sexual activity
      2. Sexual or erotic thoughts or fantasies
      3. Initiation of sexual activity and responsiveness to a partner's initiation
      4. Excitement or pleasure during all or almost all sexual activity
      5. Interest or arousal in response to internal or external sexual cues
      6. Genital or nongenital Sensations during sexual activity in nearly all sexual encounters
  2. Hypoactive Sexual Desire Disorder (ICSM/ISSWSH)
    1. Symptoms for >=6 months
    2. Any of the following
      1. Lack of motivation for sexual activity (low sex drive, libido)
        1. Reduced or absent spontaneous desire
        2. Reduced or absent responsive desire to erotic cues and stimulation
        3. Reduced or absent ability to maintain desire or interest through sexual activity
      2. Loss of desire to initiate or participate in sexual activity
        1. Avoidance of situations that could lead to sexual activity
        2. Not secondary to sexual Pain Disorder
  3. Female Cognitive Arousal Disorder (ICSM/ISSWSH)
    1. Symptoms for >=6 months, with problems feeling engaged or sexually aroused
    2. Distressing difficulty to maintain mental excitement associated with sexual activity
  4. Female Genital Arousal Disorder (ICSM/ISSWSH)
    1. Symptoms for >=6 months
    2. Distressing difficulty to maintain adequate genital response (e.g. lubrication, engorgement, sensitivity)
    3. Includes neurovascular injuries or dysfunction
    4. May result in Dyspareunia (due to lack of lubrication)
  5. Persistent Genital Arousal Disorder (ICSM/ISSWSH)
    1. Symptoms for >=6 months
    2. Recurrent genital dysesthesia/distress related to arousal or verge of orgasm
      1. Arousal that is unwanted, intrusive, distressing
      2. Not associated with sexual interest, thoughts or fantasies
    3. Other associations
      1. Aggravation of genital symptoms by sexual activity or other circumstances
      2. Significant secondary emotional distress
      3. Active revulsion from sexual stimulation

IV. Types: Female Orgasmic Disorder (DSM5, ICSM/ISSWSH)

  1. Symptoms for >=6 months, affecting nearly all sexual activity, and associated with significant distress
  2. Persistent or recurrent compromise of orgasm frequency, intensity, timing or pleasure
    1. Orgasm absent (anorgasmy), significantly delayed or infrequent OR
    2. Significantly reduced intensity of orgasmic Sensations

V. Types: Genito-Pelvic Pain and Penetration Disorders (DSM5 and ICSM/ISSWSH)

  1. See Dyspareunia
  2. See Vaginismus
  3. Symptoms >=6 months and with significant distress to the individual
  4. Persistent or recurrent problems with 1 or more of the following
    1. Difficulty with vaginal penetration during intercourse
    2. Marked vulvovaginal or Pelvic Pain during intercourse or penetration attempts
    3. Marked fear or anxiety about vulvovaginal or Pelvic Pain before, during or after vaginal penetration
    4. Marked tensing or tightening of the pelvic floor Muscles during attempted vaginal penetration

VI. Causes: Psychological and Social

  1. Mood Disorder
    1. Major Depression
  2. Guilt about past sexual activities
    1. Masturbation
    2. Premarital and extramarital sex
    3. Sexually Transmitted Infection
    4. Abortion
    5. Multiple partners
  3. Sexual abuse history
  4. Substance Abuse
  5. Relationship problems
    1. Marital distress
    2. Couple mismatch on sexual preferences
      1. Frequency of intimacy
      2. Variety of intimate activities

VII. Causes: Drugs Affecting Sexual Desire Phase

  1. See Antidepressant Induced Sexual Dysfunction (SSRI, SNRI, Tricyclic Antidepressants)
  2. See Sexual Dysfunction from Medications
  3. CNS Depressants
    1. Alcohol
    2. Sedative-Hypnotics (Benzodiazepines, Barbiturates)
    3. Monoamine Oxidase Inhibitors (MAO Inhibitors)
    4. Antianxiety agents
    5. Opioids
    6. Antipsychotics (e.g. Haloperidol, Risperidone)
    7. Lithium
  4. Antiepileptic agents
    1. Carbamazepine
    2. Phenytoin
    3. Topiramate
    4. Valproic Acid
  5. Cardiovascular Medications
    1. Beta Blockers
    2. Clonidine
    3. Methyldopa
    4. Digoxin
    5. Spironolactone
    6. Thiazide Diuretics
    7. Statins
  6. Hormonal Agents
    1. Antiandrogens
    2. Aromatase Inhibitors
    3. GnRH Agonists and analogues
    4. Hormonal contraceptives
    5. Selective Estrogen Receptor Modulator (e.g. Tamoxifen)
  7. Miscellaneous agents
    1. Cancer Chemotherapy agents (e.g. ovary damage)
    2. Cimetidine or Ranitidine (antiandrogen)
    3. Anticholinergic Medications (including Antihistamines)
  8. Chemical abuse (may variably enhance libido)
    1. Cocaine
    2. Amphetamines
    3. Hallucinogens
    4. Marijuana

VIII. Causes: Medical Conditions

  1. Genital anatomy changes
    1. Gynecologic cancer
    2. Hysterectomy
    3. Radiation Therapy
  2. Nerve dysfunction
    1. Diabetes Mellitus
    2. Multiple Sclerosis
    3. Neuromuscular disorders
    4. Parkinsonism
    5. Traumatic Brain Injury
    6. Traumatic Paraplegia
    7. Pituitary tumor (or Hyperprolactinemia)
  3. Decreased Estrogen
    1. Oophorectomy
    2. Premature Ovarian Failure
    3. Menopause
  4. Other gynecologic disorders
    1. Polycystic Ovary Syndrome
    2. Pelvic Floor Disorders
    3. Endometriosis
  5. Disruption of body image
    1. Ostomy
    2. Mastectomy
    3. Urinary Incontinence
  6. Miscellaneous conditions
    1. Coronary Artery Disease
    2. Hypothyroidism
    3. End-stage Renal Disease on Dialysis

IX. History

  1. Sexually Active?
  2. Any sexual concerns?
    1. Do you have any concerns about sexual desire, sexual arousal or orgasm?
  3. Do you have any genital symptoms?
    1. Vaginal Dryness or lack of lubrication?
    2. Vaginal pain or burning (Vaginismus)
    3. Painful Intercourse (Dyspareunia)?

X. Management: General

  1. Entitlement to sexual satisfaction
    1. Permission to initiate sex
    2. Permission to ask for more stimulation from partner
    3. Permission to ask for specific types of stimulation
    4. Permission to refuse sex when not interested
  2. Distribution of Information
    1. Educate (e.g. Women require longer excitement phase)
    2. Dispel myths (e.g. masturbation is abnormal)
    3. Demonstrate on diagrams sexual anatomy and physiology
  3. Specific Suggestions
    1. Privacy from children
    2. Modify sexual behavior for physical Impairments
    3. Consider changing sexual time of day or location
    4. Allow more time for sexual arousal and excitement
    5. Emphasize physical intimacy over the goal of orgasm
  4. Consider changes to medications
    1. See Antidepressant Induced Sexual Dysfunction
    2. See Sexual Dysfunction from Medications
  5. Treat underlying conditions
    1. See Dyspareunia
    2. See Vaginismus
    3. See Chronic Pelvic Pain
    4. See Menopause recommendations below (e.g. Vaginal Dryness)
  6. Consider referral
    1. Sex Therapist (AASECT)
      1. http://www.aasect.org/
    2. Marriage and Family Therapist
      1. https://www.aamft.org/iMIS15/AAMFT/
    3. Chronic Pelvic Pain Specialist
      1. http://www.pelvicpain.org/

XI. Management: Female Sexual Interest/Arousal Disorder

  1. First-Line
    1. Cognitive Behavioral Therapy
    2. Mindfulness
    3. Couples therapy
  2. Second Line: Medications for low sexual desire in premenopausal women
    1. Agents are minimally effective and expensive ($400 to $900 per month in 2019)
    2. Flibanserin (Addyi) oral tablet daily
    3. Bremelanotide (Vyleesi) injected SQ (Abdomen or thigh) prn 45 minutes before sexual activity
      1. Limit to one dose in 24 hours and 8 in one month
      2. Avoid use in Uncontrolled Hypertension or cardiovascular disease
      3. Adverse effects include Nausea and Vomiting (1 in 8 need an Antiemetic)
      4. May result in Hyperpigmentation of possibly irreversible face, Breasts, gums
      5. (2019) Presc Lett 26(8): 54
  3. Third Line (off-label, not FDA approved)
    1. Bupropion
    2. Topical Testosterone (postmenopausal women)

XII. Management: Other Specific Management

  1. Female Orgasmic Disorders
    1. Cognitive Behaviousl Therapy
    2. Sex Therapy (including directed masturbation)
    3. Vibrators
  2. Genito-Pelvic Pain Disorders
    1. See Chronic Pelvic Pain in Women
    2. See Vaginismus
    3. See Dyspareunia)
    4. Comprehensive evaluation
    5. Pelvic Floor Physical Therapy
  3. Pelvic Floor Dysfunction
    1. Pelvic Floor Physical Therapy
    2. Vaginal Dilators (second-line)

XIII. Management: Postmenopausal

  1. General
    1. Sexual interest related to partner's interest in sex
    2. Estrogen Loss may decrease sexual interest
      1. Hot Flashes
      2. Dyspareunia
        1. Vaginal Dryness
        2. Vaginal lubrication requires more stimulation
    3. Weaker orgasmic contractions
  2. First-Line Medications
    1. See Vaginal Dryness
    2. Vaginal Estrogen cream
    3. Water soluble Vaginal Lubricants (e.g. Astroglide)
  3. Second-Line Medications
    1. Vaginal DHEA
    2. Ospemifene

XIV. References

  1. McCartney in Dornbrand (1992) Ambulatory Care, p. 380-3
  2. Clayton (2003) Psychiatr Clin North Am 26:673-82 [PubMed]
  3. Dalrymple (2025) Am Fam Physician 111(5): 433-42 [PubMed]
  4. Faubion (2015) Am Fam Physician 92(4): 281-8 [PubMed]
  5. Philips (2000) Am Fam Physician 62(1):127-36 [PubMed]

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