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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