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.
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. 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.
Vaginismus and dyspareunia, now grouped as GPPPD, are specific conditions that will not be covered in this topic. See Evaluation of dyspareunia.
History and exam
Key diagnostic factors
- sexual symptoms leading to distress
- absent/reduced interest in sexual activity (SIAD)
- absent/reduced sexual/erotic thoughts or fantasies (SIAD)
- absent/reduced sexual excitement/pleasure during sexual activity (SIAD)
- no subjective arousal from erotic or sexual cues (SIAD)
- absent/reduced awareness of genital or nongenital sensations during sexual activity (SIAD)
- no/reduced initiation of sexual activity (SIAD)
- orgasm absent or of minimal intensity (FOD)
- marked delay in orgasm (FOD)
- marked infrequency of orgasm (FOD)
- spontaneous, intrusive, unpleasant genital congestion and feeling of impending orgasm (PGAD/GPD)
Other diagnostic factors
- current stressors
- negative emotions during sex
- vulvovaginal atrophy
- antidepressant use
- comorbid anxiety disorder
- psychological aspects of cancer
- breast cancer
- gynecologic and other pelvic cancer
- neurologic disease
- radical hysterectomy (non-nerve-sparing)
- cystectomy or proctectomy
- personality factors and attitudes
- relationship difficulties
- partner sexual dysfunction
- reduced androgen activity
- estrogen deficiency
- premature ovarian failure
- renal failure
- cardiovascular disease
- polycystic ovarian syndrome (PCOS)
- medication or substance use
- hypothalamic-pituitary disease
- lower urinary tract symptoms (LUTS)
- socioeconomic status
- sexual abuse and developmental trauma
1st investigations to order
- serum glucose level
- renal function
- thyroid function tests
- serum prolactin level
sexual interest/arousal disorder
female orgasmic disorder (FOD)
substance/medication-induced sexual dysfunction
- Sexual aversion
- Interpersonal factors (e.g., relationship discord, intimate partner violence, other significant stressors)
- Nonsexual mental disorders (e.g., depression)
- Female sexual dysfunction
- The International Society for the Study of Women's Sexual Health process of care for the identification of sexual concerns and problems in women
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