Sexual dysfunction in women

Sexual dysfunction in women of all sexual orientations correlates most strongly with poor mental health and with negative feelings for the partner(s), rather than with any serum hormone (or hormone metabolite) levels.

Normal changes with age and relationship duration must not be mistaken for desire/interest disorder. Desire disorder is diagnosed when there is a lack of anticipatory sexual desire, and desire (along with pleasure, arousal, and excitement) cannot be triggered during sexual activity and results in distress.

The most common syndrome is lack of initial desire, little subjective arousal (mental sexual excitement) such that desire is not triggered during any portion of the sexual engagement, and infrequent or no orgasm.

Given the sensitive nature of the information collected and reluctance or embarrassment to disclose at initial appointments, the clinician should continue to assess relevant information and integrate into treatment throughout contact with the patient.

Treatment includes components of psychoeducation, cognitive behavioral therapy, sex therapy, mindfulness and psychotherapy, mitigation of biologic and pharmacologic risk factors, and occasionally medications.

Women's sexual dysfunctions include a spectrum of disorders that are typically multifactorial in etiology and include sexual interest/arousal disorder (SIAD), female orgasmic disorder (FOD), and genito-pelvic penetration pain disorder (GPPPD), which combines the frequently overlapping diagnoses of vaginismus and dyspareunia.[1]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed, text revision (DSM-5-TR). Washington, DC: American Psychiatric Association; 2022.

There are three criteria for diagnosing a sexual disorder: symptoms need to have persisted for a minimum of 6 months, they need to have been experienced in all or almost all (75% to 100%) sexual encounters, and to have caused clinically significant distress.[1]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed, text revision (DSM-5-TR). Washington, DC: American Psychiatric Association; 2022. Poor mental health, stress, and low levels of emotional intimacy between the partners correlate closely with dysfunction, whereas serum levels of sex hormones do not.[2]Maserejian NN, Shifren JL, Parish J, et al. The presentation of hypoactive sexual desire disorder in premenopausal women. J Sex Med. 2010 Oct;7(10):3439-48. http://www.ncbi.nlm.nih.gov/pubmed/20646184?tool=bestpractice.com [3]Bancroft J, Loftus J, Long JS. Distress about sex: a national survey of women in heterosexual relationships. Arch Sex Behav. 2003 Jun;32(3):193-208. http://www.ncbi.nlm.nih.gov/pubmed/12807292?tool=bestpractice.com [4]Hartmann U, Philippsohn S, Heiser K, et al. Low desire in midlife and older women: personality factors, psychosocial development, present sexuality. Menopause. 2004 Nov-Dec;11(6 Pt 2):726-40. http://www.ncbi.nlm.nih.gov/pubmed/15543025?tool=bestpractice.com [5]Avis NE, Stellato R, Crawford S, et al. Is there an association between menopause status and sexual functioning? Menopause. 2000 Sep-Oct;7(5):297-309. http://www.ncbi.nlm.nih.gov/pubmed/10993029?tool=bestpractice.com [6]Dennerstein L, Dudley E, Burger H. Are changes in sexual functioning during mid-life due to aging or menopause? Fertil Steril. 2001 Sep;76(3):456-60. http://www.ncbi.nlm.nih.gov/pubmed/11532464?tool=bestpractice.com [7]Santoro N, Torrens J, Crawford S, et al. Correlates of circulating androgens in midlife women: the study of women's health across the nation. J Clin Endocrinol Metab. 2005 Aug;90(8):4836-45. http://www.ncbi.nlm.nih.gov/pubmed/15840738?tool=bestpractice.com [8]Davis SR, Davison SL, Donath S, et al. Circulating androgen levels and self-reported sexual function in women. JAMA. 2005 Jul 6;294(1):91-6. http://jama.ama-assn.org/cgi/content/full/294/1/91 http://www.ncbi.nlm.nih.gov/pubmed/15998895?tool=bestpractice.com [9]Erekson EA, Martin DK, Zhu K, et al. Sexual function in older women after oophorectomy. Obstet Gynecol. 2012 Oct;120(4):833-42. http://www.ncbi.nlm.nih.gov/pubmed/22996101?tool=bestpractice.com [10]van Anders SM. Testosterone and sexual desire in healthy women and men. Arch Sex Behav. 2012 Dec;41(6):1471-84. http://www.ncbi.nlm.nih.gov/pubmed/22552705?tool=bestpractice.com [11]Basson R, Brotto LA, Petkau AJ, et al. Role of androgens in women’s sexual dysfunction. Menopause. 2010 Sep-Oct;17(5):962-71. http://www.ncbi.nlm.nih.gov/pubmed/20539247?tool=bestpractice.com

Vaginismus and dyspareunia, now grouped as GPPPD, are specific conditions that will not be covered in this topic. See Evaluation of dyspareunia.

There is only limited research on persistent genital arousal disorder/genito-pelvic dysesthesia (PGAD/GPD) and its pathophysiology and treatment are not well understood.[12]Facelle TM, Sadeghi-Nejad H, Goldmeier D. Persistent genital arousal disorder: characterization, etiology, and management. J Sex Med. 2013 Feb;10(2):439-50. http://www.ncbi.nlm.nih.gov/pubmed/23157369?tool=bestpractice.com [13]Goldstein I, Komisaruk BR, Pukall CF, et al. International Society for the Study of Women's Sexual Health (ISSWSH) review of epidemiology and pathophysiology, and a consensus nomenclature and process of care for the management of persistent genital arousal disorder/genito-pelvic dysesthesia (PGAD/GPD). J Sex Med. 2021 Apr;18(4):665-97. https://www.jsm.jsexmed.org/article/S1743-6095(21)00175-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/33612417?tool=bestpractice.com