Female Sexual Dysfunction

Background

• Female sexual dysfunction is a common problem affecting more than a third of women at some point in their lives.
• Types include:
  • sexual desire and arousal disorders, including hypoactive sexual desire disorder (most common type of female sexual dysfunction)
  • orgasmic disorder (primary or secondary)
  • sexual pain disorders (including dyspareunia and vaginismus)
• Coexisting etiologies and types of sexual dysfunction may complicate diagnosis and treatment.
• Contributing factors also include medical conditions, depression, use of certain medications (especially selective serotonin reuptake inhibitors [SSRIs]), perimenopausal hormonal changes, and relationship or social problems.

Evaluation

• Detailed history and pelvic exam are necessary for accurate diagnosis and treatment.
• Efforts to minimize discomfort and anxiety and to enhance perceived control over the exam are often indicated, especially for women with sexual pain disorders, and may include:
  • asking permission to proceed at all stages of the exam and verbalizing permission for the woman to stop the exam at any point
  • offering detailed description of the exam and handheld mirror
  • allowing the woman to hold the wrist of the examiner
• Careful inspection of external genital structures may reveal factors that if addressed may improve sexual symptoms, such as dermatologic conditions, vulvar or vaginal atrophy, pelvic organ prolapse, or infections.
• Following an external exam, stepwise pelvic exam first using a single gloved finger, then bimanual exam, followed by narrow speculum exam may minimize anxiety and discomfort and avoid confusing vaginal and abdominopelvic pain.

Management

• General management considerations include treating any contributing medical, gynecologic, or psychologic conditions if possible, and counseling and education.
• For treatment of sexual arousal and desire disorders, consider:
  • bupropion sustained-release 150 mg dosed once or twice daily
  • transdermal testosterone for 6 months or less (but associated with adverse effects)
  • systemic and vaginal estrogen for postmenopausal women with atrophic vaginitis
  • mindfulness-based therapy
• For treatment of orgasmic disorder, consider:
  • Elaeagnus angustifolia extract and sildenafil
  • psychological interventions
• For treatment of sexual pain disorders, consider:
  • vaginal estrogen in postmenopausal women with vaginal atrophy
  • ospemifene for postmenopausal women with moderate-to-severe dyspareunia due to vulvar or vaginal atrophy
• Treatment for selective serotonin reuptake inhibitors (SSRI)-induced sexual dysfunction may include:
  • dose reduction, drug holidays, or delaying medication administration until after sexual activity
  • switching to another SSRI with lower incidence of sexual adverse effects
  • adding a medication to treat hypoactive sexual desire, such as bupropion sustained-release
  • behavior strategies or individual and couples therapy