Female Sexual Dysfunction

What is normal sexual response? 

• Original landmark studies had a very linear model of “normal sexual response” 

  • Excitement → plateau → orgasm → resolution 

• More contemporary model is non-linear and encompasses a variety of sequences of the original four stages of as well as other stages 

  • Estrogen plays a significant role in female sexual response, including maintenance of genital tissue sensitivity, elasticity, secretions, pH, etc, as well as urinary continence, pelvic floor muscle tone, and joint mobility 

  • Approximately 43% of American women report experiencing sexual problems, with higher prevalence in women aged 45-64

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What are the different types of sexual dysfunction? 

Based on the DSM-V - 5 specific types of female sexual dysfunction:

• Female sexual interest and arousal disorder 

  • Lack of or significant decrease in at least three of the following: 

    • Interest in sexual activity 

    • Sexual or erotic thoughts or fantasies 

    • Initiation of sexual activity and responsiveness to a partner’s initiation 

    • Excitement or pleasure during all or almost all sexual activity

    • Interest or arousal in response to internal or external sexual erotic cues 

    • Genital or nongenital sensations during sexual activity in almost all or all sexuall encounters 

  • Symptoms have persisted for a minimum of 6 months and cause clinically significant distress in individuals 

• Female orgasmic disorder 

  • Marked delay in, marked infrequency of, or absence of orgasm, or markedly reduced intensity of orgamsic sensations in almost all or all occasions of sexual activity 

  • Symptoms have persisted for a minimum of 6 months and cause clinically significant distress in individuals  

• Genito-pelvic pain/penetration disorder 

  • The persistent or recurrent presence of one or more of the following symptoms:

    •  Difficulty having intercourse 

    • Marked vulvovaginal or pelvic pain during intercouruse or penetration attempts 

    • Marked fear or anxiety about vulvovaginal or pelvic pain anticipating, during, or resulting from vaginal penetration 

  • Symptoms have persisted for a minimum of 6 months and cause clinically significant distress in individuals  

• Substance/medication-induced sexual dysfunction 

  • Disturbance in sexual function that has a temporal relationship with substance/ medication initiation, dose increase, or discontinuation and causes clinically significant distress in the individual 

• Other specified or unspecified sexual dysfunction

  • Distressing symptoms characteristic of sexual dysfunction that do not meet the criteria of one of the defined categories. The major distinction between specified and unspecified is whether the clinician specifies reason that the symptoms do not meet criteria for other classes 

  • One specified reason: genitourinary syndrome due to menopause 

How should we evaluate for FSD? 

• Ask about it!

  • During routine visits, can ask questions about sexual function 

  • Ask broad, open-ended questions during routine history gathering 

  • “Many women experience concerns about sex. Are you experiencing any issues?” 

• Initial approach if patient answers yes, or if FSD is a complaint 

  • Comprehensive History 

    • Should ask detailed history about patient’s sexual and gender identity 

    • Nature, duration, and onset of symptoms - also if symptoms cause distress 

    • If patient is using medications 

    • Partner factors (ie. number of current partners, their gender, health problems, sexual function problems) 

    • Relationship quality - communication about sexual concerns with partner, past and current abuse or violence experience

    • Pain/injuries/Body image 

  • Physical Exam

    • Often, there are not specific physical exam findings 

    • However, use of mirror and pointing out female anatomy for education is sometimes helpful 

    • Can also identify if there are areas that are causing pain 

How do we treat FSD? 

• Psychological Interventions 

  • Relationship distress and partner sexual dysfunction can trigger sexual problems in other domains 

  • Options include sexual skills training, cognitive-behavioral therapy, mindfulness-based therapy, and couples therapy 

    • Sexual skills training: can include instructions in masturbation, other erotic stimulation, decrease feelings of guilt and shame with masturbation, as well as learning about anatomy (ie. clitoral stimulation)

    • Couples therapy: exercises to better communication with partner 

    • History of trauma - may need trauma-based psychotherapeutic approach  

  • Can consult or refer to mental health specialists with expertise in this area 

• Medical therapy

  • Estrogen

    • Low-dose vaginal estrogen therapy is the preferred hormonal treatment for FSD due to genitourinary syndrome of menopause  

    • Low-dose systemic estrogen can be an alternative 

    • Other alternatives include Ospemifene for management of dyspareunia due to genitourinary syndrome of menopause 

  • Androgen Therapy

    • Short-term use of transdermal testosterone can be considered for treatment of postmenopausal women with sexual interest andd arousal disorders 

    • Need to appropriately counsel that there are risks (ie. acne, increased hair growth, virilization - may be irreversible) and long-term side effects are not known 

    • Can try for 3-6 months after baseline testosterone is tested and after 3-6 weeks of initial use 

    • Should be discontinued if no effect after 6 months 

  • Flibanserin 

    • Addyi on the market 

    • Serotonin receptor agonist/antagonist and was approved in 2015 by the FDA to treat hypoactive sexual desire disorder in premenopausal women without depression 

    • However, systematic review and meta-analysis of existing studies showed that overall quality of evidence for efficacy and safety were low, and there was minimal to no improvement in hypoactive sexual desire disorder with use 

    • Black box warning against alcohol use - increased risk of syncope and hypotension 

  • Sildenafil (Viagra) 

    • Not efficacious

    • Hypothesized that it may increase pelvic blood flow to clitoris and vagina, but has not been proven to work 

  •  Bupropion 

    • If patient has antidepressant-induced female sexual dysfunction, supplementation with bupropion may improve symptoms 

•  Other 

  • For genito-pelvic pain and penetration disorders:

    • Education to help patient understand anatomy and etiology of their symptoms 

    • Vaginal dilators

    • Physical therapy (Pelvic PT) 

    • Intravaginal prasterone for treatment of postmenopausal women who have dyspareunia 

    • Lubricants and moisturizers 

      • Don’t cure the underlying cause, but may reduce or alleviate dyspareunia that is due to vaginal dryness 

        • Coconut oil is a good option, but do not use with condoms 

        • Tend to counsel more toward silicone-based lubricants because they do not dry out as quickly as water-based lubricants 

    • Vaginal lasers

      • Became a hot topic while we were senior residents and some people raved about them; latest evidence suggesting they’re not effective.

      • Vaginal CO2 fractional laser is inadequately studied for treatment of vulvovaginal atrophy 

      • Cost of treatment is rather high