Description

• According to the DSM-5, FSD is defined as sexual concerns arising from desire, arousal, orgasm, or sexual pain (1).
  • For diagnosis, symptoms must be present for >6 months, be present >75% of the time, and cause distress.
• The focus of this discussion will be on individuals assigned female at birth, with the understanding that sexual dysfunction can occur across all genders with similar and unique challenges as those described below.
• FSD may arise from a variety of conditions discussed in depth below.

Epidemiology

According to ACOG, 43% of women disclose sexual function concerns, and about 12% of women feel that it causes personal distress.

Incidence

• Sexual dysfunction can occur at any age, but rates vary by age.
• FSD can be lifelong, acquired, generalized, or situational depending on the underlying cause.
• 74% incidence in women with gynecologic cancers
• 83% of women experience problems in first 3 months after childbirth (1).

Prevalence

• Sexual dysfunction prevalence varies by age, with the highest prevalence in women aged 45 to 65 years (15%)
• Prevalence in women aged 18 to 44 years is 10%, whereas prevalence in women aged 65 to 85 years is 9% (2).

Etiology and Pathophysiology

The female sexual response follows a circular model requiring motivation, arousal (physical and subjective), willingness, and neural inputs (2). Thus, pathophysiology of sexual dysfunction is complex and multifactorial, with underlying cause varying between patients. These may include the following:

• Changes in sex hormones: Sex hormones are important in creating a neurochemical sexual response in the central nervous system as well as at the urogenital level, leading to changes in lubrication, clitoral engorgement, neurovasculature to the pelvis, and pelvic floor function.
• Central nervous system: Neuroendocrine circuits impact the emotional and behavioral aspects of sexual function including arousal, orgasm, and desire (3).
• Comorbid illness: Comorbidities such as diabetes, cardiovascular disease, malignancy, or neurologic disease can impact the above processes and alter an individual’s view of themselves.
• Psychological: mood disorders, stress, alcohol/substance use
• Individual factors: sleep, relationship concerns, body image, trauma, societal attitudes toward sexuality

Genetics
Sexual dysfunction in women is a multifactorial issue, often including a combination of biologic and psychosocial causes.

Risk Factors

• Menopause: changing body image, genitourinary syndrome of menopause
• Lack of knowledge about sexual stimulation and response
• Psychological: mood disorders, personality disorders, or psychopathies
• Chronic medical problems: cardiovascular disease; endocrine, dermatologic, and neurologic disorders; malignancy
• Gynecologic issues: childbirth, pelvic floor or bladder dysfunction, endometriosis, uterine fibroids, chronic vulvovaginal candidiasis/vaginal infections, female genital mutilation, breastfeeding
• Relationship factors: safety, intimate partner violence, discrepancies in partners’ expectations, cultural attitudes toward sexuality, sexual trauma
• Medications or substance abuse

General Prevention

Ways to help evaluate for, support, and assist in prevention are to:

• Practice trauma informed care in clinic.
• Perform sexual dysfunction screening in annual wellness visits.
• Assess patient safety at every visit (2)[C].

Commonly Associated Conditions

History of sexual trauma, marital/relationship discord, psychiatric disorders, malignancy, menopause, pregnancy/childbirth, abnormal uterine bleeding, pelvic pain, incontinence, pelvic organ prolapse