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: Sexual Dysfunction

  1. Desire phase disorders
    1. Hypoactive sexual desire (low sex drive)
    2. Sexual aversion disorder
      1. Panic Disorder
      2. Active revulsion from sexual stimulation
  2. Impaired female sexual arousal
    1. Failure to achieve or maintain vaginal lubrication
    2. Swelling of genitalia
    3. Dyspareunia may result
  3. Orgasmic phase dysfunction
    1. Orgasm in response to indirect stimulation
      1. Kissing
      2. Fantasy
      3. Breast stimulation
    2. Orgasm only in response to clitoral stimulation
    3. Lack of orgasm (Anorgasmy)
  4. Coital pain problems
    1. Dyspareunia
    2. Vaginismus
    3. Reduced genital Sensation

IV. 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 Disease
    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

V. Causes: Drugs affecting sexual desire phase

  1. See Antidepressant Induced Sexual Dysfunction
  2. See Sexual Dysfunction from Medications
  3. CNS Depressants
    1. Alcohol
    2. Sedative-Hypnotics
    3. Monoamine Oxidase Inhibitors (MAO Inhibitors)
    4. Antianxiety agents
    5. Narcotics
    6. Antipsychotics
  4. Chemical abuse (may variably enhance libido)
    1. Cocaine
    2. Amphetamines
    3. Hallucinogens
    4. Marijuana
  5. Antihypertensives
    1. Beta Blockers
    2. Clonidine
    3. Methyldopa
  6. Miscellaneous agents
    1. Cancer Chemotherapy agents (e.g. ovary damage)
    2. Cimetidine or Ranitidine (antiandrogen)

VI. 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. Disruption of body image
    1. Ostomy
    2. Mastectomy
    3. Urinary Incontinence
  5. Miscellaneous conditions
    1. Coronary Artery Disease
    2. Hypothyroidism
    3. End-stage Renal Disease on Dialysis

VII. 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 pain?
    1. Vaginal Dryness?
    2. Vaginal pain (Vaginismus)
    3. Painful Intercourse (Dyspareunia)?

VIII. 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. Medications that may be considered in 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
  7. 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/

IX. 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. Preparations
    1. See Vaginal Dryness
    2. Estrogen Cream
    3. Water soluble Vaginal Lubricants (e.g. Astroglide)

X. References

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

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Related Studies

Ontology: Female sexual arousal disorder (C0015786)

Definition (NCI) A disorder characterized by a recurrent or persistent inability to attain or maintain until completion of sexual activity an adequate physical response of sexual excitement, consisting of vasocongestion in the pelvis, vaginal lubrication and expansion, and swelling of the external genitalia.
Concepts Mental or Behavioral Dysfunction (T048)
ICD10 F52.22
SnomedCT 192466005, 46372006
DSM4 302.72
Italian Disturbo da risveglio sessuale femminile
Japanese 女性の性的興奮障害, ｼﾞｮｾｲﾉｾｲﾃｷｺｳﾌﾝｼｮｳｶﾞｲ
English female sexual arousal disorder, female sexual arousal disorder (diagnosis), Female Sexual Arousal Disorder, [X]Female sexual arousal disorder, [X] Female sexual arousal disorder, Female sexual arousal disorder, Female sexual arousal disorder (disorder), disorder; sexual, arousal, female, sexual; disorder, arousal, female
Czech Porucha pohlavního vzrušení u ženy
Hungarian Női izgalmi szak zavara
Dutch seksueel; stoornis, opwinding, vrouw, stoornis; seksueel, opwinding, vrouw, seksuele opwindingsstoornis bij de vrouw
Spanish trastorno de la excitación sexual en la mujer (trastorno), trastorno de la excitación sexual en la mujer, Trastorno de excitación sexual femenina
Portuguese Afecção da activação sexual da mulher
French Trouble de l'excitation sexuelle chez la femme
German sexuelle Funktionsstoerung der Frau
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Sexual Dysfunction (C0549622)

Definition (CCC) Deleterious change in sex response
Definition (NAN) Change in sexual function that is viewed as unsatisfying, unrewarding, inadequate
Concepts Disease or Syndrome (T047)
ICD10 F52.9 , R37
SnomedCT 65655009, 39894007, 56925008, 231532002, 225723003
DSM4 302.9, 302.70
LNC MTHU013434
English Sexual dysfunction NOS, Sexual Dysfunction, SEXUAL DYSFUNCTIONS, Sexual Disorder NOS, Sexual Dysfunction NOS, SEXUAL FUNCTION ABNORMAL, Sexual dysfunction -RETIRED-, Impaired Sexual Functioning, sexual disorder (diagnosis), sexual disorder, sexual dysfunction (diagnosis), sexual dysfunction, Sexual function abnormal, Sexual disorder NOS, Sexual dysfunction, unspecified, rndx sexual dysfunction (diagnosis), rndx sexual dysfunction, Dysfunction;sexual, Sexual function decreased, Sexual dysfunction (finding), Sexual dysfunction (disorder), Sexual dysfunction, Abnormal sexual function, Sexual disorder, Decreased sexual function, Impaired sexual function, Abnormal sexual function (finding), Decreased sexual function (finding), Sexual disorder (disorder), SEXUAL DYSFUNCTION, Sexual dysfunction, NOS
Italian Disfunzione sessuale, Disturbo sessuale NAS, Funzione sessuale anormale, Funzione sessuale diminuita, Disfunzione sessuale NAS
Dutch verminderde seksuele functie, seksuele disfunctie NAO, afwijkende seksuele functie, seksuele stoornis NAO, seksuele disfunctie
French Trouble sexuel SAI, Dysfonction sexuelle SAI, Fonction sexuelle anormale, Fonction sexuelle diminuée, TROUBLE DE LA FONCTION SEXUELLE, Dysfonction sexuelle
German sexuelle Funktion vermindert, sexuelle Stoerung NNB, sexuelle Funktion anomal, sexuelle Funktionsstoerung NNB, ANOMALIE DER SEXUALFUNKTIONEN, sexuelle Funktionsstoerung
Portuguese Função sexual anormal, Função sexual diminuída, Perturbação sexual NE, Disfunção sexual NE, FUNCAO SEXUAL ANORMAL, Disfunção sexual
Spanish Trastorno sexual NEOM, Disfunción sexual NEOM, Función sexual disminuida, Función sexual anormal, disfunción sexual - RETIRADO -, disfunción sexual (hallazgo), disfunción sexual, disfunción sexual (concepto no activo), disfunción sexual - RETIRADO - (concepto no activo), función sexual anormal (hallazgo), función sexual anormal, función sexual disminuida (hallazgo), función sexual disminuida, trastorno sexual (trastorno), trastorno sexual, Disfunción sexual
Japanese 性機能異常, 性機能低下, 性機能不全, 性障害ＮＯＳ, ｾｲｷﾉｳﾃｲｶ, 性機能不全ＮＯＳ, ｾｲｷﾉｳﾌｾﾞﾝNOS, ｾｲｷﾉｳﾌｾﾞﾝ, ｾｲｷﾉｳｲｼﾞｮｳ, ｾｲｼｮｳｶﾞｲNOS
Czech Abnormální sexuální funkce, Sexuální dysfunkce NOS, Sexuální dysfunkce, Sexuální porucha NOS, Snížená sexuální funkce
Hungarian Szexuális dysfunctio k.m.n., Kóros szexuális funkció, Szexuális dysfunctio, Csökkent szexuális funkció, Nemi betegség k.m.n.
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Female sexual dysfunction (C1112442)

Concepts Mental or Behavioral Dysfunction (T048)
Italian Disfunzione sessuale femminile
English Female sexual dysfunction, dysfunction female sexual, female sexual dysfunction, dysfunction females sexual, dysfunctions female sexual, Female Sexual Dysfunction
Japanese 女性性機能不全, ｼﾞｮｾｲｾｲｷﾉｳﾌｾﾞﾝ
Czech Ženská sexuální dysfunkce
Hungarian Női nemi dysfunctio
Portuguese Disfunção sexual feminina
Spanish Disfunción sexual femenina
Dutch vrouwelijke seksuele disfunctie
French Dysfonctionnement sexuel chez la femme
German Stoerung der sexuellen Erregung bei der Frau
Derived from the NIH UMLS (Unified Medical Language System)

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