Women commonly have concerns about sexual function (1). Concerns that cause personal or interpersonal distress are considered a sexual dysfunction disorder. Approximately 12% of women in the United States have a sexual function issue associated with distress (2).
Women access sexual desire (responsive desire) once sexual stimulation triggers excitement and pleasure (subjective arousal) and genital congestion (physical genital arousal). Desire for sexual satisfaction, which may or may not include one or multiple orgasms, builds as sexual activity and intimacy continue, and a physically and emotionally rewarding experience fulfills and reinforces the woman’s original motivations.
References
1. Zhang C, Tong J, Zhu L, et al: A Population-Based Epidemiologic Study of Female Sexual Dysfunction Risk in Mainland China: Prevalence and Predictors. J Sex Med 14(11):1348-1356, 2017. doi:10.1016/j.jsxm.2017.08.012
2. Shifren JL, Monz BU, Russo PA, et al: Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol 112(5):970-978, 2008. doi:10.1097/AOG.0b013e3181898cdb
Physiology
The traditional schema for the sexual response cycle includes the following:
Desire (libido)
Arousal (excitement)
Orgasm
Resolution
Physiology of the female sexual response is incompletely understood but involves hormonal and central nervous system (CNS) factors.
Estrogens influence sexual response. Estrogen helps maintain genital tissue sensitivity, vaginal pH, normal microflora, elasticity, lubrication, and pelvic muscle tone. It is suspected but not proved that androgens are involved and act via androgen receptors and estrogen receptors (after intracellular conversion of testosterone to estradiol).
After menopause, ovarian estrogen production ceases, while ovarian androgen production varies. However, adrenal production of prohormones (eg, dehydroepiandrosterone sulfate [DHEAS]) that are converted to both androgens and estrogens in peripheral cells decreases starting in a woman’s 30s. Ovarian production of prohormones also declines after menopause. Overall, levels of androgen tend to stop decreasing at about age 60. Whether the decrease in sex hormone production plays any role in diminishing sexual desire, interest, or subjective arousal is unclear.
The brain produces sex hormones (neurosteroids) from cholesterol, and production may increase after menopause. Whether this documented increase is universal, whether it facilitates arousal as peripheral production decreases, and whether it is affected by exogenous hormone administration are all unknown.
A woman’s sexual response cycle is strongly influenced by her mental health and by the quality of her relationship with her partner. Initial desire typically lessens with age but increases with a new partner at any age.
Desire (libido)
Desire is the wish to engage in sexual activity. There are many reasons for wanting sexual activity, including sexual interest. Sexual interest or desire may be triggered by thoughts, words, sights, smells, or touch. Desire may be obvious at the outset or may build once the woman is aroused.
Arousal
Brain areas involved in cognition, emotion, desire, and organization of genital congestion are activated. Neurotransmitters acting on specific receptors are involved. Based on known actions of medications and on animal studies, some neurotransmitters appear to be prosexual; they include dopamine, norepinephrine, and melanocortin. Serotonin is usually sexually inhibitory, as are prolactin and gamma-aminobutyric acid (GABA).
This reflexive autonomic response occurs within seconds of a sexual stimulus and causes genital engorgement and lubrication. The brain's appraisal of the stimulus as biologically sexual, not necessarily as erotic or subjectively arousing, triggers this response. Smooth muscle cells around blood spaces in the vulva, clitoris, and vaginal arterioles dilate, increasing blood flow (engorgement) and transudation of interstitial fluid across the vaginal epithelium (lubrication). Women are not always aware of congestion; genital tingling and throbbing are more typically reported by younger women. As women age, basal genital blood flow decreases, but genital congestion in response to sexual stimuli (eg, erotic videos) may not.
Orgasm
Peak excitement occurs; it is accompanied by contractions of pelvic muscles every 0.8 seconds and is followed by slow release of genital congestion. Thoracolumbar sympathetic outflow tracts appear to be involved, but orgasm is possible even after complete spinal cord transection (when a vibrator is used to stimulate the cervix). Prolactin, antidiuretic hormone (ADH), and oxytocin are released at orgasm and may contribute to the sense of well-being, relaxation, or fatigue that follows (resolution). However, many women experience a sense of well-being and relaxation without experiencing any definite orgasm.
Resolution
Resolution is a sense of well-being, widespread muscular relaxation, or fatigue that typically follows orgasm. However, resolution can occur slowly after highly arousing sexual activity without orgasm. Some women can respond to additional stimulation almost immediately after resolution.
Classification of Female Sexual Dysfunction
Female sexual dysfunction can be characterized by at least one of the following:
Pain during sexual activities
Loss of sexual desire
Impaired arousal
Inability to achieve orgasm
Female sexual dysfunction is diagnosed when any of these symptoms result in personal or interpersonal distress.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) (1) includes the following types of female sexual dysfunction, classified based on symptoms:
Substance/medication-induced sexual dysfunction
Other specified and unspecified sexual dysfunction
Persistent genital arousal disorder is a separate, rare disorder not included in the DSM-5-TR. It involves persistent excessive genital arousal that occurs when sexual desire is absent, there is no known cause, and arousal does not resolve with orgasm.
Genito-pelvic pain/penetration disorder can be lifelong or acquired. It is characterized by the presence of ≥ 1 of the following symptoms for ≥ 6 months:
Deep pelvic pain and tension during penetration or superficial burning vulvovaginal pain caused by slight touch
Fear or anxiety before, during, or after penetration, which often leads to decreased sexual desire or avoidance of sexual activity
Reflexive tightening of the vaginal muscles when vaginal entry is attempted, making penetration difficult or impossible
Female sexual interest/arousal disorder is absence of or a decrease in ≥ 3 of the following for ≥ 6 months:
Interest in sexual activity
Initiation of sexual activity and responsiveness to a partner's initiation
Excitement or pleasure during almost all sexual activity
Sexual or erotic fantasies or thoughts
Genital or nongenital sensations during sexual activity
Interest or arousal in response to internal or external sexual or erotic stimuli (eg, written, verbal, visual)
Female orgasmic disorder involves orgasm that is absent, markedly diminished in intensity, or markedly delayed in response to stimulation despite high levels of subjective arousal. Symptoms must occur during almost all sexual activities and must have been present for ≥ 6 months. Acquired orgasmic disorders are frequently related to a new disorder, including psychological and behavioral disorders, or to anatomic changes (eg, due to cancer or surgery).
In substance/medication-induced sexual dysfunction, sexual dysfunction is related to initiation, change in dose, or discontinuation of a substance or medication.
Other specified and unspecified sexual dysfunction includes sexual dysfunction that does not meet criteria for the other categories.
A sexual dysfunction disorder is typically diagnosed when symptoms have been present for ≥ 6 months and cause significant distress. Some women may not be distressed or bothered by decreased or absent sexual desire, interest, arousal, or orgasm.
Almost all women with sexual dysfunction have features of more than one disorder. For example, genito-pelvic pain/penetration disorder often leads to sexual interest/arousal disorder; impaired arousal may make sex less enjoyable or even painful, decreasing the likelihood of orgasm and subsequent sexual desire. However, pain during intercourse due to impaired lubrication may occur as an isolated symptom in women with a high level of sexual desire, interest, and subjective arousal.
Female sexual disorders may be secondarily categorized as lifelong or acquired; situation-specific or generalized; and mild, moderate, or severe based on the degree of distress it causes the woman.
Although research is limited, these disorders probably occur equally in women in heterosexual and homosexual relationships.
Classification reference
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Text Revision (DSM-5-TR). Washington, DC, American Psychiatric Association, 2022.
Etiology of Female Sexual Dysfunction
The traditional separation of psychological and physical etiologies is artificial; psychological distress causes changes in hormonal and neurologic physiology, and physical changes may generate psychological reactions that compound the dysfunction. There are often several causes of symptoms within and between categories of dysfunction, and the cause is often unclear.
Primarily psychological factors
Mood disorders (eg, depression, anxiety) are closely correlated with low interest and arousal. For women with major depression and sexual dysfunction, sexual distress becomes less severe when depression is effectively treated with antidepressants (1). However, some types of antidepressants also cause sexual dysfunction (selective serotonin reuptake inhibitors). Women with an anxiety disorder are also more likely to have sexual dysfunction involving sexual interest, arousal, orgasm and genito-pelvic pain/penetration disorders. Various fears—of letting go, of being vulnerable, of being rejected, or of losing control—and low self-esteem can contribute.
Previous experiences can affect a woman’s psychosexual development, as in the following:
Past negative sexual or other experiences, including sexual trauma, may lead to low self-esteem, shame, or guilt.
Emotional, physical, or sexual abuse during childhood or adolescence can teach children to control and hide emotions—a useful defense mechanism—but such inhibition can make expressing sexual feelings difficult later.
Early traumatic loss of a parent or another loved one may inhibit intimacy with a sex partner for fear of similar loss.
Concerns about a negative outcome (eg, unwanted pregnancy, sexually transmitted infections [STIs], inability to have an orgasm, sexual dysfunction in a partner) can also impair sexual response.
Contextual causes (those specific to a woman’s current situation) include the following:
Intrapersonal context: Low sexual self-image (eg, due to infertility, premature menopause, or surgical removal of a breast, the uterus, or another body part associated with sex)
Relationship context: Lack of trust, negative feelings, or reduced attraction toward a sex partner (eg, due to the partner’s behavior or to a growing awareness of a change in sexual orientation)
Sexual context: For example, surroundings that are not sufficiently erotic, private, or safe
Cultural context: For example, cultural restrictions on sexual activity
Distractions and emotional stress (eg, from family, work, or finances) can interfere with arousal.
Primarily physical factors
Various genital lesions, systemic and hormonal factors, medications, and illicit drugs may lead or contribute to dysfunction (see table Some Physical Factors Contributing to Female Sexual Dysfunction).
Some Physical Factors Contributing to Female Sexual Dysfunction
Category | Factor |
|---|---|
Genital factors | Congenital malformations Sexually transmitted infections Genitourinary syndrome of menopause Vulvar dermatoses (eg, lichen sclerosus, vulvovaginal chronic graft-versus-host disease) Obstetric trauma Postsurgical introital narrowing Radiation fibrosis Recurrent tearing of the posterior fourchette |
Other physical factors | Bilateral oophorectomy in premenopausal women Breastfeeding Physical disability Fatigue Hyperprolactinemia Nerve damage (eg, due to diabetes, multiple sclerosis, peripheral neuropathy, or spinal cord dysfunction) |
Medications and other substances | Certain antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs) Antihistamines Beta-blockers and other antihypertensive drugs Gonadotropin-releasing hormone agonists Opioids |
Genitourinary syndrome of menopause describes symptoms and signs due to estrogen and androgen deficiency, such as
Vulvovaginal atrophy
Vaginal dryness and decreased lubrication during intercourse, which cause pain
Urinary symptoms (eg, urgency, dysuria, recurrent urinary tract infections)
Genitourinary syndrome of menopause affects about half of menopausal women. Low estrogen levels can cause similar symptoms, as occur postpartum or during treatments with certain medications such as aromatase inhibitors.
Selective serotonin reuptake inhibitors (SSRIs) are a particularly common iatrogenic cause of sexual dysfunction. SSRIs may contribute to several types of sexual dysfunction.
Alcohol dependence can cause sexual dysfunction.
Etiology reference
1. Rosen RC, Shifren JL, Monz BU, et al: Correlates of sexually related personal distress in women with low sexual desire. J Sex Med 6(6):1549-1560, 2009. doi:10.1111/j.1743-6109.2009.01252.x
Diagnosis of Female Sexual Dysfunction
Interview with the woman and, sometimes, her partner
Pelvic examination
Most sexual dysfunction disorders are diagnosed based on clinical criteria described by the DSM-5-TR. These disorders include genito-pelvic pain/penetration disorder, female orgasmic disorder, female sexual interest/arousal disorder, and substance/medication–induced sexual dysfunction. For diagnosis of all of these disorders, there must be no more likely alternative explanation for symptoms; for all except substance/medication–induced sexual dysfunction, symptoms must have been present for ≥ 6 months. If sexual dysfunction does not meet criteria for any of these disorders, dysfunction is categorized as other specified or unspecified sexual dysfunction according to DSM-5-TR.
Diagnosis of sexual dysfunction and its causes is based on medical history and physical examination. Clinicians should routinely ask about sexual dysfunction to help decrease any related stigma. Validated questionnaires, such as the Female Sexual Function Index (FSFI), can help facilitate this practice (1).
History can be taken in an interview with the woman and, sometimes, her partner; it begins by asking the woman to describe the problem in her own words and should include specific elements (see table Components of the Sexual History for Assessment of Female Sexual Dysfunction). Clinicians should also obtain a detailed sexual history. Problematic areas (eg, past negative sexual experiences, negative sexual self-image) identified at the first visit can be investigated more fully at a follow-up visit.
Components of the Sexual History for Assessment of Female Sexual Dysfunction
Area | Specific Elements |
|---|---|
Medical history (past and current) | General health (including medical history, endocrinologic conditions, physical energy, level of stress and anxiety, psychiatric history, and mood), medications, substance misuse, gynecologic and obstetric history (eg, procedures, pregnancies, STIs), pelvic trauma, and sexual trauma |
Relationship with partner | Sexual orientation, emotional intimacy, trust, respect, attraction, communication, fidelity, anger, hostility, resentment, history of intimate partner violence |
Current sexual context | Sexual function of partner, activities and behaviors during the hours before attempts at sexual activity, adequacy of sexual stimulation, adequacy of sexual communication, timing (eg, too late at night, too hurried), degree of privacy |
Triggers of desire and arousal | Setting; visual, written and spoken sexual cues; activities (eg, showering together, dancing, listening to music); types of stimulation (nonphysical, physical nongenital, nonpenetrative genital) |
Inhibitors of arousal | Fatigue, stress, anxiety, depression, negative past sexual experiences, fears about outcome (including loss of control, pain, unwanted pregnancy, and infertility), day-to-day distractions, sleep deprivation |
Orgasms | Presence or absence, response to absence (whether the woman is distressed or not), differences in responses with partner and with self-stimulation |
Outcome | Emotional and physical satisfaction or dissatisfaction |
Quality and location of pain in dyspareunia | Burning, tearing, rubbing, stretching, or dull Superficial (introital), intravaginal, or deeper in pelvis |
Timing of pain in dyspareunia | During partial or full entry, deep thrusting, penile movement, or the man’s ejaculation; immediately after penetration; or during urination after vaginal penetration |
Self-image | Self-confidence; feelings about desirability, body, genitals, or sexual competence |
Developmental history | Relationship with caregivers and siblings, traumas, loss of a loved one, abuse (emotional, physical, or sexual), consequences of expressing emotions as a child, cultural or religious restrictions |
Past sexual experiences | Type (whether desired, coercive, abusive, or a combination), subjective experience (how rewarding, varied, and pleasing), outcomes (positive or negative—eg, unplanned pregnancy, STIs, parental or societal disapproval, guilt due to religious teachings) |
Personality factors | Ability to trust, comfort level with being vulnerable, suppressed anger causing suppression of sexual emotions, need to feel in control, unreasonable expectations of self, hypervigilance to self-harm (ie, worry about pain, which inhibits enjoyment), obsessiveness, anxiety, depressive tendencies |
Medications | Specific medications (including over-the-counter medications) and the timing of their use with sexual dysfunction |
STIs = sexually transmitted infections. | |
Physical examination, including the pelvic examination, is done to identify any gynecologic abnormalities that may be causing sexual dysfunction; this examination can often pinpoint the location of pain. The technique may differ slightly from that used in a routine gynecologic examination. Explaining what will occur during the examination helps the woman relax and should be continued throughout the examination. The clinician may ask the woman whether she wants to sit up and view her genitals in a mirror during the examination; doing so may support a sense of control.
During the examination, the clinician should look for signs of low estrogen, particularly thinning of labia minora, loss of the labial fat pad, pale vaginal mucosa, and loss of vaginal folds. A moist cotton swab can be used to identify pain points on the vulva and vulvar vestibule.
Wet-preparation examination of vaginal discharge and Gram stain with culture or DNA probe to detect Neisseria gonorrhoeae and chlamydiae are indicated when history or examination suggests vulvitis, vaginitis, or pelvic inflammatory disease.
Unless an undiagnosed disorder is suspected, the initial evaluation of female sexual dysfunction typically does not require laboratory evaluation. Low estrogen is detected clinically during the examination. Sexual function does not correlate with testosterone levels, regardless of how they are measured. However, if hyperprolactinemia is clinically suspected, the prolactin level is measured. If a thyroid disorder is clinically suspected, appropriate testing is done; it includes thyroid-stimulating hormone if hypothyroidism is suspected, thyroxine (T4) if hyperthyroidism is suspected, and sometimes other thyroid function tests.
Diagnosis reference
1. Rosen R, Brown C, Heiman J, et al: The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther26(2):191-208, 2000. doi:10.1080/009262300278597
Treatment of Female Sexual Dysfunction
Explanation of the female sexual response
Correction of contributing factors
Psychological therapies
Medications
Treatment of sexual dysfunction in women varies by disorder and cause; often more than one treatment is required because disorders overlap. Even if criteria for a particular DSM-5-TR disorder are not completely met, treatment may help.
Sympathetic understanding and careful evaluation may themselves be therapeutic. Teaching women about sexual anatomy and physiology, including what is involved in the female sexual response may also help.
Treatment may require a multidisciplinary team, including sex counselors, pain specialists, psychotherapists, and/or physical therapists.
Contributing factors are corrected if possible, as for the following:
Treating mood disorders
For substance/medication–induced sexual dysfunction, stopping the abused substance or changing a prescription medication
Psychological therapies
Cognitive-behavioral therapy targets negative self-view resulting from illness (including gynecologic disorders) or from infertility.
Mindfulness, an eastern practice with roots in Buddhist meditation, may help. It focuses on nonjudgmental awareness of the present moment. Its practice helps free women from distractions that interfere with attention to sexual sensations. Mindfulness lessens sexual dysfunction in healthy women and in women who have pelvic cancer or provoked vestibulodynia. Women can be referred to community or online resources to learn how to practice mindfulness. Mindfulness-based cognitive therapy (MBCT) combines an adapted form of cognitive-behavioral therapy with mindfulness. As in cognitive-behavioral therapy, women are encouraged to identify maladaptive thoughts, but then to simply observe their presence, realizing that they are just mental events and may not reflect reality. This approach can make such thoughts less distracting. MBCT is used to prevent recurrent depression and can be adapted to treat sexual arousal disorder and sexual interest/arousal disorder as well as the chronic pain of provoked vestibulodynia.
Some women (eg, women with a history of sexual trauma) may need more extensive psychotherapy.
Pharmacologic therapy
Estrogen therapy can be used to treat sexual dysfunction in women with genitourinary syndrome of menopause. The atrophic changes in the vulva and vagina can be treated with low-dose vaginal estrogen (tablets, gels, creams, rings). Low-dose systemic estrogen or estrogen plus progesterone
Androgen therapyTestosterone levels should be measured at baseline and after 3 to 6 weeks. Short-term treatment is recommended, and testosterone should be stopped if there is no response after 6 months of use. Monitoring for adverse effects such as acne, hirsutism, and virilization is indicated. Clinicians should clearly explain that evidence about testosterone therapy is limited, and they should provide detailed information about its harmful effects and benefits. Testosterone therapy should be considered only if other interventions have been unsuccessful and if the woman is generally healthy and has no contraindications. Long-term use of testosterone has not been studied as treatment for sexual interest/arousal disorder, and systemic dehydroepiandrosterone (DHEA) has been shown to be ineffective. Intravaginal prasterone (a DHEA preparation) can be used for postmenopausal women with dyspareunia and genito-pelvic pain/penetration disorder).
Current evidence for using androgens to enhance women's sexual response is weak. Some evidence suggests that testosterone supplementation may modestly benefit women who have low sexual interest but are able to have satisfactory sexual experiences. Total androgen activity (measured as metabolites) is similar in women with or without sexual interest.
norepinephrine-dopamine
Other therapies
Pelvic floor physical therapy is a mainstay of treatment of women with genito-pelvic pain/penetration disorder. Its aim is to teach women to relax the pelvic floor and decrease reflex tightening. Pelvic floor physical therapy includes pelvic floor muscle training, soft-tissue mobilization and myofascial release, trigger-point pressure, electrical stimulation, biofeedback, and therapeutic ultrasonography.
Prescription and nonprescription devices are available for self-dilation in women with tight pelvic muscles, which contribute to dyspareunia in genito-pelvic pain/penetration disorder.
Depending on the type of dysfunction, sexual skills training (eg, instruction in masturbation) and exercises to facilitate communication with a partner about sexual needs and preferences can be implemented.
Various lubricants and moisturizers can reduce vaginal dryness, which causes dyspareunia. These treatments include food-based oils (eg, coconut oil), silicone-based products, and water-based products. Food-based oils should not be used with condoms, but silicone- and water-based lubricants can be used. If lubricants are needed, clinicians and the woman should discuss which kind of lubricant she should use.
Except in small pilot studies, there is scant evidence that devices such as vibrators or clitoral suction devices are effective in women with sexual interest/arousal or orgasmic disorder; however, some of these products are available over the counter and may be tried.
Treatment references
1. Jaspers L, Feys F, Bramer VM, et al: Efficacy and safety of flibanserin for the treatment of hypoactive sexual desire disorder in women: A systematic review and meta-analysis. JAMA Intern Med 176 (4):453–462, 2016. doi: 10.1001/jamainternmed.2015.8565
2. Kingsberg SA, Clayton AH, Portman D, et al: Bremelanotide for the Treatment of Hypoactive Sexual Desire Disorder: Two Randomized Phase 3 Trials. Obstet Gynecol 134(5):899-908, 2019. doi:10.1097/AOG.0000000000003500
3. Clayton AH, Kingsberg SA, Portman D, et al: Safety Profile of Bremelanotide Across the Clinical Development Program. J Womens Health (Larchmt) 31(2):171-182, 2022. doi:10.1089/jwh.2021.0191
Key Points
Female sexual dysfunction includes female sexual interest/arousal disorder, female orgasmic disorder, genito-pelvic pain/penetration disorder, substance/medication–induced sexual dysfunction, and other specified and unspecified disorders.
Psychological and physical factors usually contribute to female sexual dysfunction; they may interact with each other, worsening dysfunction.
Psychological factors include mood disorders, effects of past experiences, concerns about a negative outcome, the woman's specific circumstances (eg, low sexual self-image), and distractions.
Physical factors include genital conditions, systemic and hormonal factors, and medications (particularly SSRIs).
Interview the woman and, sometimes, her partner.
Incorporate psychological therapies (eg, cognitive-behavioral therapy, mindfulness, a combination of the two [MBCT]) into treatment for most types of female sexual dysfunction.
When indicated, use medications (eg, an estrogen) to treat some types of female sexual dysfunction.
Recommend pelvic floor physical therapy, a mainstay of treatment for genito-pelvic pain/penetration disorder, and discuss which kinds of lubricants women should use if lubricants are needed.
