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Sexual Dysfunction in Women
Amanda M. Carnes, MD
Lisa M. Harris, DO
image BASICS
  • Very common: ˜40% of women surveyed in the United States have sexual concerns.
  • May present as a lack of sexual desire, impaired arousal, pain with sexual activity, or inability to achieve orgasm, and may be lifelong or acquired
DESCRIPTION
  • Female sexual interest or arousal disorder—lack of or significantly reduced sexual interest or arousal as manifested by three of the following:
    • Absent or reduced interest in sexual activity
    • Absent or reduced sexual or erotic thoughts or fantasies
    • No or reduced initiation of sexual activity and unreceptive to partner's attempts to initiate
    • Absent or reduced sexual excitement or pleasure during sexual activity in almost all (75-100%) of sexual encounters
    • Absent or reduced sexual interest or arousal in response to any internal or external sexual or erotic cues
    • Absent or reduced genital or nongenital sensation during sexual activity in almost all (75-100%) of sexual encounters
  • Female orgasmic disorder—presence of either of the following in almost all (75-100%) occasions of sexual activity:
    • Marked delay in, marked infrequency of, or absence of orgasm
    • Markedly reduced intensity of orgasmic sensations
  • Genitopelvic pain or penetration disorder— persistent or recurrent difficulties with one or more of the following:
    • Vaginal penetration during intercourse
    • Marked vulvovaginal or pelvic pain during intercourse or penetration attempts
    • Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or because of vaginal penetration
    • Marked tensing or tightening of pelvic floor muscles during attempted vaginal penetration
EPIDEMIOLOGY
In two large studies, approximately 40% of women reported sexual problems.
Incidence
Sexual problems are highest in women aged 45 to 64 years, then declines secondary to changes in sexual-related personal distress.
Prevalence
Low sexual desire is the most common manifestation, followed by difficulty with orgasm, difficulty with arousal, and sexual pain.
ETIOLOGY AND PATHOPHYSIOLOGY
The pathophysiology of sexual dysfunction is complex and multifactorial because it can be the result of any etiology that interferes with the nonlinear model of female sexual response cycle (emotional intimacy, sexual stimuli, psychological factors, and relationship satisfaction).
  • Physiologic
    • Prescription medications
      • SSRIs, MAOIs, and TCAs
      • &bgr;-Blockers, ACE inhibitors, and calcium channel blockers
      • GNRH agonists
      • Injectable progestins
      • Antiepileptics
      • Gabapentin
  • Endocrine
    • Disorders of the hypothalamic-pituitary-adrenal system, hormonal imbalance/disorders of ovarian function, menopause (surgical or natural)
    • Thyroid disease
    • Diabetes
  • Neurologic
    • Spinal cord damage
  • Psychologic
    • Maladaptive thoughts/behaviors
    • Interrelational difficulties
    • Body image issues
    • Drug and alcohol abuse
    • Sexual abuse
RISK FACTORS
  • Advancing age/menopause
  • Previous sexual trauma
  • Lack of knowledge about sexual stimulation and response
  • Chronic medical problems
    • Depression, anxiety, chronic pain syndromes, and other psychiatric disorders
    • Cardiovascular disease
    • Endocrine disorders
    • Dermatologic disorders
    • Neurologic disorders
    • Cancer
  • Gynecologic issues
    • Childbirth
    • Pelvic floor or bladder dysfunction
    • Endometriosis
    • Uterine fibroids
    • Chronic vulvovaginal candidiasis/vaginal infections
    • Female genital mutilation
  • Relationship factors such as couple discrepancies in expectations and/or cultural backgrounds and attitudes toward sexuality in family of origin
  • Medications or substance abuse
COMMONLY ASSOCIATED CONDITIONS
  • Marital/relationship discord
  • Depression
image DIAGNOSIS
  • Female sexual dysfunction is diagnosed by utilizing a validated sexual function screening instrument and a structured interview, including detailed medical and sexual history, to confirm diagnosis.
    • Female Sexual Function Index
    • Brief Index of Sexual Functioning for Women
    • Brief Sexual Symptoms Checklist
    • Decreases Sexual Desire Screener
  • The diagnosis requires that the sexual problem be recurrent or persistent and cause personal distress rather than be due solely to partner or relationship issues.
PHYSICAL EXAM
  • Most commonly, patients have a normal physical exam (1)[C].
    • Assess for anatomic abnormalities.
    • 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.
  • General physical exam, signs of chronic disease
DIFFERENTIAL DIAGNOSIS
  • Medication side effects
  • Vaginitis
  • 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)
  • Depression
  • Marital dysfunction, including domestic violence
  • Pregnancy
  • Pseudodyspareunia (use of complaint of pain to distance self from partner)
DIAGNOSTIC TESTS & INTERPRETATION
Laboratory studies are rarely helpful. There are no reliable correlations between serum hormone levels and sexual dysfunction.
Initial Tests (lab, imaging)
As needed to identify infections and other medical causes (1)[C]
P.965

image TREATMENT
  • Set realistic goals and expectations (2)[C].
  • Address underlying medical and psychiatric conditions (3)[C].
  • Review basic sex education, sexual response, heterogeneity of normal response, and sexual activity other than intercourse (2,4)[C].
  • Education on communication (4)[C]
  • Educate on healthy lifestyle, including diet, exercise, sleep, avoidance of tobacco, and reduced alcohol use (2,4)[C].
  • Vaginal moisturizers and lubricants (5)[C]
  • Cognitive-behavioral therapy (CBT) (individual or couples) to target maladaptive thoughts and behaviors and to disrupt the dysfunctional cycle (3,4)[C]
  • Mindfulness-based CBT (2,4)[C]
  • Sex therapy: sensate focus, systematic desensitization exercises, homework exchanging physical touch with partner, or directed masturbation alone (3,4)[C]
  • Physical therapy/biofeedback (4)[C]
MEDICATION
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 (2,4)[C]: adjunct for SSRI-induced sexual dysfunction. Improves sexual arousal and orgasm but not desire. Dose: bupropion SR 150 mg orally once or twice daily.
  • Flibanserin (3)[C]: possible improvement in sexual desire. Mechanism of action: 5-HT1A agonist and 5-HT2A antagonist.
  • Estrogen replacement with or without progestins (2,5)[C],(6)[A]: may improve sexual desire, vaginal atrophy, and clitoral sensitivity. Vaginal estrogen therapy is available in cream, vaginal tablet, or ring form.
  • Ospemifene (2)[C]: selective estrogen receptor modulator FDA approved for dyspareunia due to vulvo or vaginal atrophy in postmenopausal women. Dose: ospemifene 60 mg orally once daily.
  • Testosterone (2,3,4)[C]
    • Use in premenopausal women not supported by data.
    • In naturally or surgically postmenopausal women, adding short-term testosterone to hormone replacement may increase desire.
    • Use >6 months contingent on clear improvement and no adverse effects.
    • Side effects: hirsutism, androgenic alopecia, acne, decreased HDL, liver dysfunction; not FDA approved for sexual dysfunction in women
    • Contraindicated in breast or endometrial cancer, thromboembolic disease, or coronary artery disease
    • Dose: oral methyltestosterone 1.25 to 2.5 mg/day (1/10 of men's dose) or topical (patch, gel)
  • DHEA and tissue-selective estrogen complexes (TSECs) (3,4,5)[C]: may improve vaginal atrophy, dryness, and dyspareunia. Not FDA approved. Additional studies needed
  • PDE-5 inhibitors (4)[C]: not recommended
ISSUES FOR REFERRAL
Consider referral for CBT, marriage/couples counseling, or sex therapy.
ADDITIONAL THERAPIES
  • Smoking cessation and reduction of alcohol intake
  • For childhood trauma: scripting, psychotherapy, cognitive restructuring
  • For prescription-drug causes: reduced dosages or change to different medication
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Zestra for Women botanical feminine massage oil: Small trial showed increased arousal, desire, genital sensation, ability to have orgasm, and sexual pleasure.
  • Yohimbine: not recommended, potentially dangerous
  • Ginseng and St. John's wort: No evidence to support treatment of sexual dysfunction.
image ONGOING CARE
DIET
Weight reduction if overweight or obese
PATIENT EDUCATION
  • American Association of Sex Educators, Counselors, and Therapists: www.aasect.org.
  • National Women's Health Resource Center: www.healthywomen.org
  • North American Menopause Society: www.menopause.org
  • National Vulvodynia Association: www.nva.org
PROGNOSIS
Lack of desire is most difficult type to treat with <50% success.
REFERENCES
1. Latif E, Diamond MP. Arriving at the diagnosis of female sexual dysfunction. Fertil Steril. 2013;100(4):898-904.
2. Kingsberg SA, Woodard T. Female sexual dysfunction: focus on low desire. Obstet Gynecol. 2015;125(2):477-486.
3. Kingsberg SA, Rezaee RL. Hypoactive sexual desire in women. Menopause. 2013;20(12):1284-1300.
4. Basson R, Wierman ME, van Lankveld J, et al. Summary of the recommendations on sexual dysfunctions in women. J Sex Med. 2010;7(1, Pt 2):314-326.
5. Tan O, Bradshaw K, Carr BR. Management of vulvovaginal atrophy-related sexual dysfunction in postmenopausal women: an up-to-date review. Menopause. 2012;19(1):109-117.
6. Nastri CO, Lara LA, Ferriani RA, et al. Hormone therapy for sexual function in perimenopausal and postmenopausal women. Cochrane Database Syst Rev. 2013;(6):CD009672.
Additional Reading
&NA;
  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
  • Basson R. Women's sexual function and dysfunction: current uncertainties, future directions. Int J Impot Res. 2008;20(5):466-478.
  • Buster JE. Managing female sexual dysfunction. Fertil Steril. 2013;100(4):905-915.
  • Carey JC. Pharmacological effects on sexual function. Obstet Gynecol Clin North Am. 2006;33(4):599-620.
  • Meston CM, Bradford A. Sexual dysfunctions in women. Annu Rev Clin Psychol. 2007;3:233-256.
  • Palacios S. Hypoactive sexual desire disorder and current pharmacotherapeutic options in women. Womens Health (Lond Engl). 2011;7(1):95-107.
  • Safarinejad MR. Reversal of SSRI-induced female sexual dysfunction by adjunctive bupropion in menstruating women: a double-blind, placebo-controlled and randomized study. J Psychopharmacol. 2011;25(3):370-378.
  • Safarinejad MR, Hosseini SY, Asgari MA, et al. A randomized, double-blind, placebo-controlled study of the efficacy and safety of bupropion for treating hypoactive sexual desire disorder in ovulating women. BJU Int. 2010;106(6):832-839.
  • Shifren JL, Davis SR, Moreau M, et al. Testosterone patch for the treatment of hypoactive sexual desire disorder in naturally menopausal women: results of the INTIMATE NM1 study. Menopause. 2006;13(5):770-779.
  • Shifren JL, Monz BU, Russo PA, et al. Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol. 2008;112(5):970-978.
  • Silverstein RG, Brown AH, Roth HD, et al. Effects of mindfulness training on body awareness to sexual stimuli: implications for female sexual dysfunction. Psychosom Med. 2011;73(9):817-825.
  • Simonelli C, Eleuteri S, Petruccelli F, et al. Female sexual pain disorders: dyspareunia and vaginismus. Curr Opin Psychiatry. 2014;27(6):406-412.
  • Sungur MZ, Gündüz A. A comparison of DSM-IV-TR and DSM-5 definitions for sexual dysfunctions: critiques and challenges. J Sex Med. 2014;11(2):364-373.
  • Taylor MJ, Rudkin L, Bullemor-Day P, et al. Strategies for managing sexual dysfunction induced by antidepressant medication. Cochrane Database Syst Rev. 2013;(5):CD003382.
  • Woodis CB, McLendon AN, Muzyk AJ. Testosterone supplementation for hypoactive sexual desire disorder in women. Pharmacotherapy. 2012;32(1):38-53.
Codes
&NA;
ICD10
  • R37 Sexual dysfunction, unspecified
  • F52.0 Hypoactive sexual desire disorder
  • N94.1 Dyspareunia
Clinical Pearls
&NA;
  • Female sexual dysfunction is a common, complex, multifactorial problem.
  • Usually patients with sexual dysfunction have a normal physical exam.
  • Symptoms of sexual dysfunction peak during perimenopause between the ages of 45 and 64 years.
  • Several therapies exist for treating sexual dysfunction in women, including behavioral therapy and medications.