Women's sexual dysfunctions correlate most strongly with poor mental health and with negative feelings for the partner, 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, 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 or were recurrent, 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; however, further information is available in the dyspareunia topic.
There is only limited research on persistent genital arousal disorder (PGAD) and its pathophysiology and treatment are not well understood.
History and exam
Key diagnostic factors
- sexual symptoms leading to distress
- absent/reduced sexual/erotic thoughts or fantasies
- absent/reduced sexual excitement/pleasure during sexual activity
- no subjective arousal from erotica
- no awareness of genital response
- no initiation of sexual activity
- orgasm absent or of minimal intensity, or marked delay
- spontaneous, intrusive, unpleasant genital congestion and feeling of impending orgasm
Other diagnostic factors
- current stressors
- absent/reduced interest in sexual activity
- negative emotions during sex
- minimal changes in temperature, muscle tension, heart rate during sex
- vulvovaginal atrophy
- loss of pubic hair
- 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
- mood, affect, and personality
- relationship difficulties
- partner sexual dysfunction
- reduced androgen activity
- estrogen deficiency
- premature ovarian failure
- renal failure
- cardiovascular disease
- polycystic ovarian syndrome (PCOS)
- hypothalamic-pituitary disease
- simple hysterectomy
- lower urinary tract symptoms (LUTS)
- socioeconomic status
- sexual abuse
1st investigations to order
- serum glucose level
- renal function
- serum prolactin level
sexual interest/arousal disorder
female orgasmic disorder (FOD): lifelong
FOD: acquired (antidepressant-induced)
FOD: acquired (not antidepressant-induced)
Rosemary Basson, MD, FRCP (UK)
University of British Columbia
Departments of Psychiatry and Obstetrics/Gynecology
RB is an author or co-author of several references cited in this topic. RB's department has received research funding from the Canadian Institutes of Health Research (CIHR).
Dr Rosemary Basson would like to gratefully acknowledge Dr Lori Brotto, a previous contributor to this topic.
LB is an author or co-author of several references cited in this topic.
Milena Braga-Basaria, MD
Johns Hopkins University
Division of Obstetrics and Gynecology
MBB declares that she has no competing interests.
Philip Kell, MBBS, FRCOG, FRCP
Archway Sexual Health Clinic
PK has undertaken research studies for Boehringer Ingelheim.
- Sexual aversion
- Marital discord
- 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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