DESCRIPTION

• According to the DSM-5, FSD is defined as sexual concerns arising from: desire, arousal, orgasm, or sexual pain (1). To meet diagnostic criteria, symptoms must be present for >6 months, be present >75% of the time, and cause distress.
• FSD may arise from a variety of conditions discussed in depth below
• Note: For purposes of this article, discussion will focus 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

EPIDEMIOLOGY

According to data from the American College of Obstetrics & Gynecology (ACOG), 43% of women disclose sexual function concerns, and about 12% of women feel it causes personal distress.

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 and urogenital level, leading to changes in lubrication, clitoral engorgement, pelvic neurovasculature, 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 as well as psychological view of themselves and their sexuality.
• Psychological: Mood disorders, stress, alcohol/substance use impact the above model of the female sexual response.
• Individual factors: Sleep, relationship concerns, body image, trauma, societal attitudes towards sexuality, and more all impact the above model of female sexual response.

RISK FACTORS

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

• Menopause: changing body image, genitourinary syndrome of menopause
• Education: Lack of knowledge about sexual stimulation and response
• Psychological: mood disorders, personality disorders, substance abuse, or psychopathies
• Chronic medical problems: cardiovascular, endocrine, dermatologic, neurologic, malignancy, medication effects
• 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 towards sexuality, sexual trauma

GENERAL PREVENTION

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

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

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