Female sexual dysfunction is a complex and poorly understood condition that affects women of all ages. Sexual function has been reconceptualized as a cyclic (rather than a linear) process that emphasizes social, psychological, hormonal, environmental, and biologic factors.¹ Sexual problems can be classified as sexual complaints, dysfunction, or disorders. Disorders encompass dysfunction associated with personal distress; therefore, abnormal function or sexual discontent can exist without a disorder being present.²

Prevalence

Female sexual complaints are common; the 1992 National Health and Social Life Survey showed a prevalence of 43 percent.³ A more recent international survey of 27,500 men and women 40 to 80 years of age found that 39 percent of sexually active women reported a problem with sexual activity.⁴ It is difficult to accurately determine prevalence because studies use different definitions of normal and abnormal sexual function and use heterogeneous populations.^5,6 The most common sexual complaint in women is decreased desire, followed by orgasmic dysfunction.^3,4 Table 1 presents prevalence data for female sexual dysfunction disorders.^6,7

Definition and Classification

Traditionally, female sexual dysfunction has been classified into four categories by the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV): sexual desire, sexual arousal, orgasmic, or sexual pain disorders.⁷ However, the definition of normal female sexual functioning has been critically examined, and the accepted definition and classification of female sexual dysfunction have subsequently been revised.¹

In 2004, the Second International Consensus of Sexual Medicine accepted revised definitions of female sexual dysfunction (Table 2⁸). Noting whether symptoms, which may meet the definition for a sexual dysfunction, cause distress allows the physician to assess the clinical importance of the symptoms.⁸ Female sexual dysfunction may be further defined as lifelong (primary) or acquired (secondary) and as situational (occurs only in certain circumstances or with certain partners) or generalized (occurs in all situations and with all partners).^8,9

There have been some concerns that female sexual dysfunction, as defined by the DSM-IV and the Second International Consensus of Sexual Medicine, has been created by the pharmaceutical industry to introduce pharmacologic treatment into a nonmedical arena, namely sexual functioning.¹⁰

Biology and Pathophysiology

A number of potential causative and contributing factors to female sexual dysfunction have been identified (Table 3¹¹), reflecting the complex interplay of physiologic, psychological, emotional, and relational components. Normal sexual function is partially dependent on the effects of sex hormones and neurotransmitters on the central and peripheral nervous systems (Table 4^2,11,12). ²

Sexual desire may be the traditional spontaneous desire from sexual thoughts, dreams, and fantasies; or it may be secondary to cognitive motivation.^8,13 In some women, particularly those in long-term relationships, nonsexual motivators (e.g., emotional closeness, feeling loved) may lead to sexual desire.¹

With sexual arousal, the genitals experience vasocongestion, which promotes vaginal lubrication, engorgement, and lengthening; dilation of the vaginal wall; and engorgement of the clitoris and vestibulovaginal bulbs. The physiologic effects of arousal are poorly correlated with subjective arousal. Therefore, a woman with an arousal disorder may have genital vasocongestion in response to sexual stimuli but not experience a subjective sense of arousal.¹ Women can have physical satisfaction without experiencing an orgasm. A positive physical experience promotes future motivation and receptiveness.¹

Evaluation and Diagnosis

Evaluation of sexual complaints may be limited by time constraints, physician or patient discomfort, difficulty with diagnosis, lack of available referral services, and limited treatment options.¹⁴ If time precludes a thorough evaluation at first presentation, the complaint should be acknowledged and the patient should receive follow-up.¹⁵

Physicians are often uncomfortable with and poorly educated about obtaining a comprehensive sexual history,² even though this is an important component of primary health care.¹⁶ There are a number of validated self-report and interview-based tools for assessing female sexual dysfunction, but they are primarily used in research settings.¹⁷ The Brief Sexual Symptom Checklist is a self-report tool that may be useful in the primary care setting¹⁸ as an adjunct to a comprehensive sexual history.¹³ The checklist includes four basic questions to determine the patient's satisfaction with her sexual function, details about specific sexual problems, and the willingness of the patient to discuss these problems with the physician.¹⁸

Discussions about sexuality should begin with open-ended questions. If a sexual concern is elicited, a focused history includes menstrual, obstetric, reproductive, and sexual histories; status of current relationships and sexual activity; family and personal beliefs about sexuality; and history of sexual trauma or abuse.^2,8 Additional elements of the history include medical and surgical history; medication use, including over-the-counter medications and herbal supplements; alcohol, tobacco, and illicit drug use; family history; and birth control method. Several medical conditions and medications are associated with sexual dysfunction.^2,11,19

The PLISSIT (Permission, Limited Information, Specific Suggestions, Intensive Therapy) model is used to initiate discussions about sexual dysfunction and its management.¹⁵ The ALLOW (Ask, Legitimize, Limitations, Open up, Work together) model facilitates completion of the sexual history and initiation of treatment or further evaluation. Table 5 summarizes these models.¹⁵ [ corrected]

Although physical examination findings are often normal,¹⁵ a complete examination, including a focused pelvic examination, can identify pathology and provide patient education about normal anatomy and reassurance that no abnormality is present.¹ The pelvic examination can detect evidence of low hormone levels, infection, hypo- or hypertonicity of pelvic floor muscles, adhesions, and tenderness. The remaining physical examination focuses on mental status; blood pressure and peripheral pulse measurements; and musculoskeletal, thyroid, breast, and neurologic abnormalities. Table 6 presents an overview of abnormal examination findings.^2,13,15 Abnormal findings are more likely in older women, in women with known gynecologic pathology or chronic systemic disease, and in women who have not received regular medical care.¹⁵

Laboratory evaluation is rarely helpful in guiding the diagnosis or treatment of female sexual dysfunction. However, a focused evaluation is appropriate, particularly if the history or examination suggests a medical condition.¹³ Although some experts advocate testing hormone levels in postmenopausal women or in women with decreased desire or arousal,¹¹ there is no reliable correlation between hormone levels and sexual function.^12,13,20

Psychiatric Comorbidities

Sexual dysfunction may be the manifestation of psychiatric illness or an adverse effect of psychotropic medication use.¹¹ If a woman has sexual complaints while taking a psychotropic medication, a detailed history is necessary to identify the etiology.²¹ Use of selective serotonin reuptake inhibitors (SSRIs) is a common cause of medication-induced female sexual dysfunction, although all antidepressant classes can cause dysfunction.²² SSRIs most commonly cause delayed or absent orgasm and decreased libido.²² The incidence of SSRI-induced sexual dysfunction is estimated to be 30 to 50 percent.²³

Treatment of medication-induced sexual dysfunction includes dosage reduction; drug holidays; switching to or adding a medication with a lower incidence of sexual adverse effects (e.g., bupropion [Wellbutrin], mirtazapine [Remeron]); behavior strategies; waiting for tolerance to the medication to develop; delaying medication administration until after sexual activity; and individual and couple therapy.^21,22

Treatment

Treatment of female sexual dysfunction is complicated by the lack of a single causative factor, limited proven treatment options, physician unfamiliarity with available treatments, overlap of different types of dysfunction, limited availability of treatment, and limited expertise in the treatment of female sexual dysfunction.¹⁴ Although patient education and therapy are the foundation of treatment, limited research has demonstrated the benefit of pharmacotherapy ( see online Table A).

PATIENT EDUCATION

Many women consider normal sexual function to be the traditional desire-arousal-orgasm process. Physicians can alleviate sexual concerns by educating patients about what is “normal.” For example, women who expect to feel desire for sexual stimulation may be reassured that desire can encompass a need for emotional intimacy through sexual activity rather than a need for sexual activity itself.¹ Education about normal anatomy is another important component in addressing sexual concerns. Use of a handheld mirror during a gynecologic examination can demonstrate to the patient normal and abnormal physical findings and facilitate a discussion about the physiologic basis of sexual functioning.²⁴ Women may be reassured that normal sexual functioning is widely variable.¹³

HYPOACTIVE SEXUAL DESIRE DISORDER

Hypoactive sexual desire disorder is the most common type of female sexual dysfunction^3,4,15,19 and often has a psychological or physiologic cause. Nonpharmacologic treatment is aimed at education, therapy, and treatment of contributing factors. As understanding about normal female sexual function develops, it is important to educate women about how desire may change with increasing age or relationship duration.⁸ Therapy emphasizes lifestyle changes such as stress management, adequate rest, and regular exercise.¹⁵

Pharmacologic treatment is limited. One of the most commonly studied medications is testosterone. Although decreased androgen levels do not correlate well with hypoactive sexual desire disorder,¹² testosterone (usually 300 mcg daily applied transdermally; transdermal application is not approved by the U.S. Food and Drug Administration [FDA] for use in women) has been shown to benefit sexual desire in postmenopausal women receiving hormone therapy.^25–29 Topical and systemic estrogen improves vaginal lubrication in postmenopausal women with vaginal atrophy, but the therapy has not been shown to consistently increase desire or arousal.^9,13,30 Phosphodiesterase inhibitors have not been shown to improve diminished desire.³¹ One small, poor-quality study demonstrated improved desire with bupropion treatment.³²

SEXUAL AROUSAL DISORDER

Because physiologic and subjective arousal may be unrelated,⁸ education is a key component in the treatment of female sexual arousal disorder.¹⁵ Another treatment option is the Eros Clitoral Therapy Device, made by UroMetric. The device is FDA-approved and is designed to improve arousal by increasing blood flow to the clitoris with gentle suction.^11,33 Two small, short-term studies have shown that the device benefits women with sexual arousal disorder.^33,34 Lubrication may decrease dyspareunia associated with diminished desire.¹⁵

Phosphodiesterase inhibitors have been shown to have limited benefit in subgroups of women with sexual arousal disorder³¹; however, most women do not appear to benefit from the treatment.

ORGASMIC DISORDER

Anorgasmy has been successfully treated with directed masturbation, cognitive behavior therapy, and sensate focus.³⁵ Cognitive behavior therapy focuses on decreasing anxiety and promoting changes in attitudes and sexual thoughts, which increase the ability to achieve orgasm and to gain satisfaction from orgasm.³⁵ Sensate focus is a form of sexual therapy that guides a woman and her partner through a series of exercises, moving from nonsexual to sexual touching.³⁵

Although a few small studies and case reports have suggested that phosphodiesterase inhibitors have a role in the treatment of orgasmic disorder, most studies have not shown a benefit. A pilot study of men and women showed that bupropion was effective for orgasm achievement.³⁶

SEXUAL PAIN DISORDERS

Dyspareunia has many potential etiologies, including infection, vaginal atrophy, and endometriosis.²⁴ Addressing the underlying cause is the first step in treatment. If the cause is unknown or not easily treated, treatment is multidimensional and multidisciplinary and reflects the interplay of physiologic, emotional, and relational factors.^9,24,37

Physiotherapy (e.g., hands-on techniques, biofeedback, pelvic floor electrical stimulation, perineal ultrasonography, use of vaginal dilators) is a treatment option for sexual pain disorders such as vulvar vestibulitis and vaginismus.^9,37 Psychotherapy is tailored to the patient's individual issues, and inclusion of her sex partner should be encouraged.⁹

In the treatment of vaginismus, psychotherapy addresses the patient's fears about vaginal penetration and allows her to gain increasing comfort with her genitals and, eventually, vaginal penetration.⁹ Cognitive behavior therapy (provided in a group setting over six months) that focuses on pain's relationship to anxiety, muscle contractions' relationship to pain perception, and general sexual education has been shown to decrease pain with intercourse and improve sexual satisfaction in women with vulvar vestibulitis.³⁸

An educational pelvic examination may be particularly beneficial in patients with sexual pain disorders. During the examination, the physician gains permission from the patient to continue with each step of the pelvic examination, maintaining a willingness to stop at any point. The physician explains the process of the examination, offers the speculum for the patient to hold or look at, and teaches the patient how to relax her pelvic floor muscles.²⁴ With systematic desensitization, a woman is taught relaxation exercises and is gradually exposed to insertion of a finger or vaginal dilator.^9,38 A Cochrane review of vaginismus treatment determined that there is limited evidence from uncontrolled studies demonstrating the effectiveness of systematic desensitization with vaginal dilators or hypnotherapy.³⁹

Pharmacologic therapy of sexual pain disorders includes treatment of the underlying cause, such as estrogen for vaginal atrophy ^8,25 or medication for vulvovaginal candidiasis. Vulvar vestibulitis is treated with tricyclic and other antidepressants, anticonvulsants, and topical agents; however, there are limited data to support pharmacologic treatment of sexual pain disorders.²⁶