Sexual Dysfunction in Women

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Basics

  • Very common: ~40% of women surveyed in the United States have sexual concerns.
  • May present as a lack of sexual desire, impaired arousal, inability to achieve orgasm or pain with sexual activity, and may be lifelong or acquired

Description

  • Female sexual interest or arousal disorder—lack of or significantly reduced sexual interest or arousal as manifested by three of the following:
    • Absent or reduced interest in sexual activity
    • Absent or reduced sexual or erotic thoughts or fantasies
    • No or reduced initiation of sexual activity and unreceptive to partner’s attempts to initiate
    • Absent or reduced sexual excitement or pleasure during sexual activity in almost all (75–100%) of sexual encounters
    • Absent or reduced sexual interest or arousal in response to any internal or external sexual or erotic cues
    • Absent or reduced genital or nongenital sensation during sexual activity in almost all (75–100%) of sexual encounters
  • Subjective sexual arousal disorder—absent or diminished feelings of sexual arousal from sexual stimulation, but physical responses, such as vaginal lubrication, occur
  • Genital sexual arousal disorder—subjective sexual excitement occurs with nongenital sexual stimuli; however, there is notable impaired genital sexual arousal, that is, minimal vulvar swelling or vaginal lubrication from genital stimulation
  • Female orgasmic disorder—presence of either of the following in almost all (75–100%) occasions of sexual activity:
    • Marked delay in, marked infrequency of, or absence of orgasm
    • Markedly reduced intensity of orgasmic sensations
  • Genito-pelvic pain or penetration disorder, which can include dyspareunia, vaginismus and sexual aversion disorder—persistent or recurrent difficulties with one or more of the following:
    • Vaginal penetration during intercourse
    • Marked vulvovaginal or pelvic pain during intercourse or penetration attempts
    • Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or because of vaginal penetration
    • Marked tensing or tightening of pelvic floor muscles during attempted vaginal penetration

    ALERT
    Symptoms must be present for ≥6 months; cause clinically significant distress or impairment; and not be better explained by a nonsexual mental disorder, a consequence of severe relationship distress, or other significant stressors

  • System(s) affected: nervous; reproductive; genitourinary; psychiatric
  • Synonym(s): hypoactive sexual desire disorder; sexual aversion disorder; female sexual arousal disorder; inhibited female orgasm

Epidemiology

In two large studies, approximately 40% of women reported sexual problems.

Incidence
Sexual problems are highest in women aged 45 to 64 years and then decline secondary to changes in sexual-related personal distress.

Prevalence
  • Low sexual desire is the most common manifestation, followed by difficulty with orgasm, difficulty with arousal, and sexual pain.
  • Lack of interest in sexual activity is notably greater than the normal decrease experienced with increasing age and relationship duration.

Etiology and Pathophysiology

  • The pathophysiology of sexual dysfunction is complex and multifactorial because it can be the result of any etiology that interferes with the female sexual response cycle (desire, arousal, orgasm, and resolution). The etiology of female sexual dysfunction may encompass biologic, psychological, relational, and sociocultural factors. Phases can vary in sequence, overlap, or be absent during all or some sexual encounters.
    • Biologic
      • Disorders of the hypothalamic-pituitary-adrenal system, hormonal imbalance/disorders of ovarian function, menopause (surgical or natural), chronic illness (vascular disease, diabetes mellitus, and malignancy)
      • Prescription medications (SSRIs, MAOIs, TCAs, β-blockers)
      • Thyroid disease
      • Neuromuscular disease (multiple sclerosis, spinal cord damage, disorders of central or peripheral nervous system)
      • Musculogenic disorders causing hyper- or hypotonicity of pelvic floor muscles
      • Malignancy
    • Psychological
      • Anxiety/depression
      • Maladaptive thoughts/behaviors
      • Interrelational difficulties
      • Body image issues
      • Drug and alcohol abuse
      • Sexual abuse
  • There are a multitude of sex hormones and neurotransmitters involved in sexual functioning with different effects:
    • Positive effects on desire, arousal: dopamine, estrogen, norepinephrine, serotonin, testosterone
    • Negative effect on desire, arousal: prolactin, serotonin
    • Vasocongestion of clitoral tissue: nitric oxide, vasoactive intestinal peptide
    • Receptivity, orgasm: oxytocin, progesterone

Genetics
Sexual dysfunction in women is a multifactorial issue, often including a combination of biologic and psychosocial causes. However, genetics can affect certain medication responses and medical conditions. As psychoactive medications can affect sexual desire, the genetic differences of neurotransmitter receptor profiles can affect how SSRIs influence levels of sexual desire. Other medical conditions affected by genetics may also result in sexual dysfunction in women.

Risk Factors

  • Advancing age/menopause
  • Previous sexual trauma
  • Lack of knowledge about sexual stimulation and response
  • Chronic medical problems
    • Depression, anxiety, chronic pain syndromes, and other psychiatric disorders
    • Cardiovascular disease
    • Endocrine disorders
    • Dermatologic disorders
    • Neurologic disorders
    • Cancer
  • Gynecologic issues
    • Childbirth
    • Pelvic floor or bladder dysfunction
    • Endometriosis
    • Uterine fibroids
    • Chronic vulvovaginal candidiasis/vaginal infections
    • Female genital mutilation
  • Relationship factors such as couple discrepancies in expectations and/or cultural backgrounds and attitudes toward sexuality in family of origin
  • Medications or substance abuse

General Prevention

  • Typically, sexual health is usually not discussed until or unless a problem arises. Effective sexual health care, through thorough sexual history can not only assist with control of fertility and prevention of sexually transmitted diseases but also with detection of psychosocial problems associated with sexual dysfunction. Additionally, eliciting a sexual history may aid in the early diagnosis of chronic disorders such as diabetes or depression.
  • To take a detailed sexual history, consider using the 5 P’s model to shape the interview:
    • Partners: How do partners identify, how many, how satisfied, any changes in sexual desire or frequency of sexual activity?
    • Practices: What types of sexual activities?
    • Past history/protection from sexually transmitted diseases/infections
    • Pregnancy plans: interest in pregnancy, contraception
    • Pleasure: any pain with intercourse, difficulty with orgasm, difficulty with lubrication, asking about concerns or questions about sexual function

Commonly Associated Conditions

  • Marital/relationship discord
  • Depression
  • Anxiety

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Basics

  • Very common: ~40% of women surveyed in the United States have sexual concerns.
  • May present as a lack of sexual desire, impaired arousal, inability to achieve orgasm or pain with sexual activity, and may be lifelong or acquired

Description

  • Female sexual interest or arousal disorder—lack of or significantly reduced sexual interest or arousal as manifested by three of the following:
    • Absent or reduced interest in sexual activity
    • Absent or reduced sexual or erotic thoughts or fantasies
    • No or reduced initiation of sexual activity and unreceptive to partner’s attempts to initiate
    • Absent or reduced sexual excitement or pleasure during sexual activity in almost all (75–100%) of sexual encounters
    • Absent or reduced sexual interest or arousal in response to any internal or external sexual or erotic cues
    • Absent or reduced genital or nongenital sensation during sexual activity in almost all (75–100%) of sexual encounters
  • Subjective sexual arousal disorder—absent or diminished feelings of sexual arousal from sexual stimulation, but physical responses, such as vaginal lubrication, occur
  • Genital sexual arousal disorder—subjective sexual excitement occurs with nongenital sexual stimuli; however, there is notable impaired genital sexual arousal, that is, minimal vulvar swelling or vaginal lubrication from genital stimulation
  • Female orgasmic disorder—presence of either of the following in almost all (75–100%) occasions of sexual activity:
    • Marked delay in, marked infrequency of, or absence of orgasm
    • Markedly reduced intensity of orgasmic sensations
  • Genito-pelvic pain or penetration disorder, which can include dyspareunia, vaginismus and sexual aversion disorder—persistent or recurrent difficulties with one or more of the following:
    • Vaginal penetration during intercourse
    • Marked vulvovaginal or pelvic pain during intercourse or penetration attempts
    • Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or because of vaginal penetration
    • Marked tensing or tightening of pelvic floor muscles during attempted vaginal penetration

    ALERT
    Symptoms must be present for ≥6 months; cause clinically significant distress or impairment; and not be better explained by a nonsexual mental disorder, a consequence of severe relationship distress, or other significant stressors

  • System(s) affected: nervous; reproductive; genitourinary; psychiatric
  • Synonym(s): hypoactive sexual desire disorder; sexual aversion disorder; female sexual arousal disorder; inhibited female orgasm

Epidemiology

In two large studies, approximately 40% of women reported sexual problems.

Incidence
Sexual problems are highest in women aged 45 to 64 years and then decline secondary to changes in sexual-related personal distress.

Prevalence
  • Low sexual desire is the most common manifestation, followed by difficulty with orgasm, difficulty with arousal, and sexual pain.
  • Lack of interest in sexual activity is notably greater than the normal decrease experienced with increasing age and relationship duration.

Etiology and Pathophysiology

  • The pathophysiology of sexual dysfunction is complex and multifactorial because it can be the result of any etiology that interferes with the female sexual response cycle (desire, arousal, orgasm, and resolution). The etiology of female sexual dysfunction may encompass biologic, psychological, relational, and sociocultural factors. Phases can vary in sequence, overlap, or be absent during all or some sexual encounters.
    • Biologic
      • Disorders of the hypothalamic-pituitary-adrenal system, hormonal imbalance/disorders of ovarian function, menopause (surgical or natural), chronic illness (vascular disease, diabetes mellitus, and malignancy)
      • Prescription medications (SSRIs, MAOIs, TCAs, β-blockers)
      • Thyroid disease
      • Neuromuscular disease (multiple sclerosis, spinal cord damage, disorders of central or peripheral nervous system)
      • Musculogenic disorders causing hyper- or hypotonicity of pelvic floor muscles
      • Malignancy
    • Psychological
      • Anxiety/depression
      • Maladaptive thoughts/behaviors
      • Interrelational difficulties
      • Body image issues
      • Drug and alcohol abuse
      • Sexual abuse
  • There are a multitude of sex hormones and neurotransmitters involved in sexual functioning with different effects:
    • Positive effects on desire, arousal: dopamine, estrogen, norepinephrine, serotonin, testosterone
    • Negative effect on desire, arousal: prolactin, serotonin
    • Vasocongestion of clitoral tissue: nitric oxide, vasoactive intestinal peptide
    • Receptivity, orgasm: oxytocin, progesterone

Genetics
Sexual dysfunction in women is a multifactorial issue, often including a combination of biologic and psychosocial causes. However, genetics can affect certain medication responses and medical conditions. As psychoactive medications can affect sexual desire, the genetic differences of neurotransmitter receptor profiles can affect how SSRIs influence levels of sexual desire. Other medical conditions affected by genetics may also result in sexual dysfunction in women.

Risk Factors

  • Advancing age/menopause
  • Previous sexual trauma
  • Lack of knowledge about sexual stimulation and response
  • Chronic medical problems
    • Depression, anxiety, chronic pain syndromes, and other psychiatric disorders
    • Cardiovascular disease
    • Endocrine disorders
    • Dermatologic disorders
    • Neurologic disorders
    • Cancer
  • Gynecologic issues
    • Childbirth
    • Pelvic floor or bladder dysfunction
    • Endometriosis
    • Uterine fibroids
    • Chronic vulvovaginal candidiasis/vaginal infections
    • Female genital mutilation
  • Relationship factors such as couple discrepancies in expectations and/or cultural backgrounds and attitudes toward sexuality in family of origin
  • Medications or substance abuse

General Prevention

  • Typically, sexual health is usually not discussed until or unless a problem arises. Effective sexual health care, through thorough sexual history can not only assist with control of fertility and prevention of sexually transmitted diseases but also with detection of psychosocial problems associated with sexual dysfunction. Additionally, eliciting a sexual history may aid in the early diagnosis of chronic disorders such as diabetes or depression.
  • To take a detailed sexual history, consider using the 5 P’s model to shape the interview:
    • Partners: How do partners identify, how many, how satisfied, any changes in sexual desire or frequency of sexual activity?
    • Practices: What types of sexual activities?
    • Past history/protection from sexually transmitted diseases/infections
    • Pregnancy plans: interest in pregnancy, contraception
    • Pleasure: any pain with intercourse, difficulty with orgasm, difficulty with lubrication, asking about concerns or questions about sexual function

Commonly Associated Conditions

  • Marital/relationship discord
  • Depression
  • Anxiety

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