Basics
Description
- Female sexual dysfunction (FSD) can be defined as a disturbance in sexual functioning involving one or multiple phases of the sexual response cycle or pain associated with sexual activity which results in personal distress.
- The phases of the sexual response cycles have been described by the American Psychiatric Association (APA) in the DSM-IV-TR as desire, excitement, orgasm, and resolution.
- Their current classification of sexual dysfunction is based on the first 3 phases of this cycle.
- The American Urological Association (AUA) Foundation has recommended to revise and to expand the definition of women 's sexual dysfunction to include the highly contextual nature of women 's sexuality and the tendency of sexual response phases to overlap and vary in sequence.
- Current diagnostic criteria are under revision for the upcoming publication of DSM-V in 2012. The current DSM-IV-TR definitions, which do not reflect these recommendations, are used in this chapter.
- FSD includes:
- Hypoactive sexual desire disorder (HSDD)
- Sexual aversion disorder
- Female sexual arousal disorder (FSAD)
- Female orgasmic disorder (FOD)
- Sexual pain disorders
Epidemiology
Prevalence
- The overall prevalence of sexual dysfunction is 43% in women.
- Low sexual desire: 22%
- Arousal problems: 14%
- Sexual pain: 7%
Risk Factors
- Neurological disease
- Stroke
- Spinal cord injury
- Parkinsonism
- Genital atrophy
- Genital surgery
- Endocrinopathies
- Diabetes
- Hyperprolactinemia
- Liver and/or renal failure
- Peripheral vascular disease
- Sexual abuse
- Psychological factors, life stressors
- Interpersonal, relationship disorders
- Medications (most common):
- SSRIs
- Oral contraceptive pills
- Antihistamines
- Antihypertensives
- Anticonvulsants
- Anticholinergics
- Drugs of abuse
Pathophysiology
- The phases of the sexual response cycle as described in DSM-IV-TR are:
- Desire: Fantasies about sexual activity and the desire to have sexual activity
- Excitement: Subjective sense of sexual pleasure and accompanying physiological changes, which consist of pelvic vasocongestion, vaginal lubrication, and expansion and swelling of external genitalia
- Orgasm: The peaking of sexual pleasure with release of tension and rhythmic contraction of the perineal muscles and contractions of the wall of outer third of vagina
- Resolution: Sense of muscular relaxation and general well-being
- Disorder of the sexual response may occur at one or more of the phases.
Etiology
Multiple medical, physiological, psychological, and social factors may contribute to FSD.
Associated Conditions
Sexual dysfunction may be associated with mood disorders and anxiety disorders.
Diagnosis
- DSM-IV-TR definitions: These disorders may be due to psychological factors or due to combined factors (when a general medical condition or substance use contributes to condition but is not sufficient to account for dysfunction). All disorders cause marked distress or interpersonal difficulty.
- HSDD
- The persistent or recurrent absence of sexual fantasies and desire for sexual activity
- Sexual aversion disorder
- Persistent or recurrent aversion to and avoidance of genital sexual contact with a sexual partner
- May occur with other sexual dysfunctions such as dyspareunia
- FSAD
- The persistent or recurrent inability to attain or maintain an adequate response of sexual excitement
- The response consists of pelvic vasocongestion, vaginal lubrication, and swelling of the external genitalia.
- FOD
- The persistent or recurrent delay in or absence of orgasm following a normal sexual excitement phase.
- FOD may occur in association with FSAD.
- Vaginismus
- The recurrent or persistent involuntary contractions of the outer third of the vagina as a result of attempted vaginal penetration with penis, finger, tampon, or speculum
- Dyspareunia
- Genital pain that is associated with sexual intercourse
- This disturbance is not caused exclusively by lack of lubrication or vaginismus.
History
- Few women volunteer a history of FSD. Ask open questions during the gynecological review of systems such as:
- "Do you have any sexual concerns that you would like to discuss? "
- "Are you currently involved in a sexual relationship with men, women, or both? "
- "Do you have difficulty with desire, genital or subjective arousal, or orgasm? "
- The history should focus on:
- Past psychosexual development
- Current social context (relationship quality, sources of stress)
- Medical factors including medical illness, surgical history, substance use, and medications
- Ask about a history of sexual or psychological abuse
- When a dysfunction is identified, clarify whether the dysfunction is:
- Lifelong or acquired
- Situational (e.g., with certain types of situations, positions, or partners) or generalized
Physical Exam
- Physical examination should focus on signs of general illness and endocrinopathies.
- A thorough pelvic examination should be performed.
- Inspection of external genitalia
- Speculum exam
- Bimanual
- Abdominal exam
- A rectovaginal exam to assess for endometriosis
Tests
Lab
Laboratory evaluation is needed only as directed by the general medical evaluation or if testosterone therapy is considered.
Differential Diagnosis
- Sexual dysfunction due to a general medical condition
- Substance-induced sexual dysfunction
- Major depressive disorder
- HSDD must be distinguished from dysfunction due to hormonal or endocrine abnormalities such as abnormal testosterone and prolactin levels, which may be responsible for loss of sexual desire.
- FSAD must be distinguished from dysfunction due to reduction in estrogen levels such as in menopause, atrophic vaginitis, diabetes mellitus, lactation, and pelvic radiotherapy.
- Orgasmic dysfunction is commonly found in women with spinal cord lesions or in those who have had removal of the vulva or vaginal excision and reconstruction. It is also a common complaint in women receiving SSRIs for the treatment of depression.
- Genital pain may be due to insufficient lubrication, UTI, endometriosis, adhesions, atrophic vaginitis, autoimmune disorders, or GI conditions.
- Vaginismus may be due to endometriosis or vaginal infection. It may also occur as a result of sexual trauma.
Treatment
Medication
- Sildenafil
- In a small randomized controlled trial (RCT), a single dose of 50 mg sildenafil increased the subjective arousal, genital sensations, and ease of orgasms in women with acquired genital arousal disorders (1)[C].
- No benefit has been reported for treatment of sexual desire disorder.
- In a RCT, sildenafil treatment resulted in reduction of adverse sexual effects in premenopausal women with selective and nonselective serotonin reuptake inhibitor associated sexual dysfunction (2)[C].
- Sildenafil is not FDA approved for treatment of women.
- Vaginal estrogen therapy may be helpful in postmenopausal women to treat vaginal atrophy and dyspareunia (3)[B].
- Conjugated estrogen cream 0.625 mg/g, 0.5 g intravaginally for 3 weeks followed by 1 " 2 times per week for maintenance. Also FDA approved in November 2009 for treatment of moderate-to-severe postmenopausal dyspareunia.
- Vaginal 17B-estradiol ring 7.5 ¼g/day for 90 days
- Vaginal 17B-estradiol cream 2.0 " 4.0 g/day for 1 " 2 weeks followed by 1.0 g/day maintenance
- Synthetic conjugated estrogens-A-cream 1.0 g/day for 1 week followed by 1.0 g/twice weekly maintenance
- Vaginal estradiol tablet 10 ¼g/day for 2 weeks followed by 10 ¼g twice weekly maintenance
- The lowest effective doses for the shortest duration should be used because of potential risks associated with estrogen use and systemic absorption. Abnormal vaginal bleeding should be investigated (3)[C].
- Testosterone replacement may be helpful in patients with known androgen deficiency from premature ovarian failure and natural or surgical menopausal states.
- A transdermal preparation of 300 ¼g/day has been studied in clinical trials.
- In a double-blinded RCT of postmenopausal women with HSDD not on estrogen therapy, treatment with a 300 ¼g patch of testosterone resulted in a modest and significant improvement in sexual function (4)[B].
- Currently, there are no FDA-approved preparations for use in women.
Additional Treatment
General Measures
- Educate the patient and partner regarding normal anatomy and physiological response as well as normal physiological changes that occur with aging and with health problems.
- Encourage open communication between the patient and partner.
- Avoid prescription medications or taper/change medications which are likely to contribute to FSD.
- Treat underlying medical and psychiatric conditions.
- Stop smoking tobacco and drinking alcohol.
- Exercise may improve general sense of well-being and body image.
Issues for Referral
Indications for referral to a sex therapist:
- Long-standing dysfunction
- Multiple sexual dysfunctions
- Comorbid psychological disorders such as depression, anxiety, substance abuse
- Marital problems
- History of sexual abuse
- Lack of response to pharmacotherapies
Additional Therapies
Cognitive behavioral therapy and sex therapy for low desire and arousal disorders may be beneficial (5)[C].
Ongoing Care
Follow-Up Recommendations
- Once a sexual dysfunction is identified upon a clinical visit, it may be necessary for the patient to return at a later time to complete a full sexual assessment.
- A visit with the patient 's partner may also be helpful.
- Follow-up will depend on whether a contributing factor or medical illness is identified or treatment is pursued.
Patient Monitoring
Lipid profile, liver function test, CBC, annual breast exam and mammogram, pelvic exams, and androgenic effects should be monitored in women receiving testosterone replacement (5)[C].
Complications
Testosterone replacement and vaginal estrogen use may have associated risks.
References
1Basson R, Brotto LA. Sexual psychophysiology and effects of sildenafil citrate in oestrogenised women with acquired genital arousal disorder and impaired orgasm: A randomized controlled trial. BJOG. 2003;110:1014 " 1024. [View Abstract]2Nurnberg HG, Hensley PL, Heiman JR. Sildenafil treatment of women with antidepressant-associated sexual dysfunction: A randomized controlled trial. JAMA. 2008;300:395 " 404. [View Abstract]3Krychman ML. Vaginal estrogens for the treatment of dyspareunia. J Sex Med. 2011;8:666 " 674. [View Abstract]4Davis SR, Moreau M, Kroll R. Testosterone for low libido in postmenopausal women not taking estrogen. N Engl J Med. 2008;359(19):2005 " 2017. [View Abstract]5Basson R, Wierman ME, vanLankveld J. Summary of the recommendation on sexual dysfunctions in women. J Sex Med. 2010;7:314 " 326. [View Abstract]
Additional Reading
1 Diagnostic and statistical manual of mental disorders, 4th ed., text revision. Washington, DC: American Psychiatric Association, 2000:535 " 565.2Basson R. Sexual desire and arousal disorders in women. N Engl J Med. 2006;354(14):1497 " 1506. [View Abstract]3Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: Prevalence and predictors. JAMA. 1999;281:537 " 544. [View Abstract]4Lightner DJ. Female sexual dysfunction. Mayo Clin Proc. 2002;77:698 " 702. [View Abstract]
Codes
ICD9
- 302.71 Hypoactive sexual desire disorder
- 302.72 Psychosexual dysfunction with inhibited sexual excitement
- 302.79 Psychosexual dysfunction with other specified psychosexual dysfunctions
- 302.73 Female orgasmic disorder
- 302.76 Dyspareunia, psychogenic
- 306.51 Psychogenic vaginismus
- 625.0 Dyspareunia
ICD10
- F52.0 Hypoactive sexual desire disorder
- F52.1 Sexual aversion disorder
- F52.9 Unsp sexual dysfnct not due to a sub or known physiol cond
- F52.22 Female sexual arousal disorder
- F52.31 Female orgasmic disorder
- F52.5 Vaginismus not due to a substance or known physiol condition
- F52.6 Dyspareunia not due to a substance or known physiol cond
SNOMED
- 28154007 abnormal female sexual function (finding)
- 270903007 lack or loss of sexual desire (disorder)
- 55728007 sexual aversion disorder (disorder)
- 46372006 female sexual arousal disorder (disorder)
- 71315007 dyspareunia (finding)
- 71787009 psychologic vaginismus (disorder)
Clinical Pearls
- Female sexual dysfunction (FSD) is highly prevalent.
- Multiple medical, physiological, psychological, and social factors may contribute to FSD.
- Evaluation should focus on identification of illnesses or factors contributing to FSD.
- Vaginal estrogen therapy may be helpful in treatment of postmenopausal women with vaginal atrophy and/or dyspareunia.
- Testosterone treatment may be helpful for treatment of hypoactive sexual desire disorder but is not FDA approved.
- Referral to a sexual therapist should be considered especially when there is a history of sexual abuse.