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Female Sexual Dysfunction

Sexual expression and activity are a normal and healthy part of life. Female sexual dysfunction refers to any condition that affects intimate relationships enough to have a negative impact on a woman’s quality of life.

These issues are often overlooked for a number of reasons. Providers may be uncomfortable about sexuality and they may not have the training or time to address the issues.

There is also a perceived lack of treatment options. Often the prevalence of female sexual dysfunction underestimated. It has been reported to be as high as 40 percent in the United States. Many women are uncomfortable discussing the topic. Most will not initiate a conversation about sexual dysfunction, but will discuss concerns if asked.

Background

The first published scientific studies on female sexuality were written in the 1950s by Kinsey and colleagues. This was the first time sexual behavior was studied in an objective way. 

Masters and Johnson followed this work by studying female sexual response through direct laboratory observation. They defined a classic four-stage model of sexual response: excitement, plateau, orgasm, and resolution.

In 1979, Kaplan suggested the category “desire” as the inciting factor of the three phase model: excitement, plateau, and orgasm. Since then other researchers have contributed additional information.

During sexual arousal, blood flow to the clitoris and vaginal tissue increases causing swelling and increased lubrication. Muscles of the pelvic floor and external genitalia also change. Various parts of the brain may be involved in sending signals that affect the muscles of female genitals as well as the blood vessels that supply those tissues. Hormones such as estrogen and testosterone also affect the tissue and blood vessels. Multiple organ systems play a role in normal sexual function as do any number of psychological factors.

The DSM-IV(The Diagnostic and Statistical Manual of Mental Disorders, fourth edition) characterizes female sexual dysfunction as any sexual complaint or problem arising from desire, arousal, orgasm, or sexual pain that causes distress or interpersonal difficulty. 

In 1998, an interdisciplinary consensus panel of 19 experts from five different countries met to evaluate and revise the classification system so that organic causes were included along with psychiatric conditions.

The classification includes four major categories:

  • Disorders of desire
  • Arousal
  • Orgasm
  • Pain

More recent thoughts about female sexual function view female sexual response as a circuit involving libido, arousal, orgasm, and satisfaction. Each aspect can negatively or positively impact the other and conditions affecting one may overlap.

Presentation

Because the term female sexual dysfunction encompasses so many different types of problems, any difficulties or concerns about intimacy should be addressed with a provider. Often a woman will come in at the request of her partner. Annual exams may be a time to address these questions as well. All sexual concerns are considered important if they are significant enough to cause personal distress.

There are two types of sexual desire disorders:

  1. Hypoactive sexual desire disorder
  2. Sexual aversion disorder

Hypoactive sexual desire disorder is the recurrent deficiency or absence of sexual thoughts or fantasies or absence of receptivity to sexual activity enough to cause personal distress.

Hypoactive sexual desire disorder has been reported in 5-13 percent of women and can occur at any age. The peak incidence is between 40 and 60.

Sexual aversion disorder is defined as persistent or recurrent phobic aversion to or avoidance of sexual contact with a partner. It is unknown how many women suffer from sexual aversion disorder partly because these women avoid sexual relationships.

Sexual arousal disorder refers to the recurrent inability to attain or maintain arousal, which may be expressed as lack of lubrication, genital swelling, or excitement.

Female orgasmic disorder has been reported in 3-6 percent of women. It is defined as a difficulty, delay or absence of orgasm after a normal excitement phase. It is a primary disorder in women who have never experienced orgasm with intercourse or masturbation and a secondary disorder when the condition develops over time.

Sexual pain disorders are subdivided into three categories.

  1. Dyspareunia is recurrent or persistent genital pain with sexual intercourse that is not caused by lack of lubrication or vaginismus. Between 8-22 percent of women have complaints of pain with intercourse.
  2. Vaginismus is the persistent or recurrent involuntary contraction of the muscles that surround the lower part of the vagina enough to interfere with penetration.
  3. Non-coital genital pain is recurrent or persistent genital pain that is associated with non-coital sexual stimulation.

Causes/Etiology/Differential Diagnosis

The term female sexual dysfunction encompasses multiple types of medical and psychological issues. Often more than one type of dysfunction occurs.

Psychological trauma, medical conditions, and medications may affect more than one of the four areas of sexual function. Problems in one area may spill over into other areas over time, such as persistent dyspareunia, eventually causing sexual arousal or sexual desire disorders.

Some of the more common causes are:

  • Back injuries
  • Nerve damage
  • Diabetic neuropathy
  • Spinal cord injury

Chronic medical conditions

  • Multiple sclerosis
  • Tumors
  • Tertiary syphilis (rare)
  • Organ failure

Endocrine disorders

  • Thyroid disease
  • Pituitary problems
  • Adrenal gland
  • Sex hormone imbalances

Problems with blood supply

  • High blood pressure
  • Diabetes
  • Vascular disease
  • High cholesterol

Medications

  • Blood pressure medication
  • Antihistamines
  • Medications used to treat anxiety and depression
  • Antipsychotics

Drug use

  • Alcohol
  • Nicotine
  • Narcotics
  • Stimulants

Psychological factors

  • Depression/anxiety
  • Sexual fears or guilt
  • Past sexual abuse or trauma

Gynecologic conditions

  • Endometriosis
  • Ovarian or uterine conditions
  • Pelvic infections
  • Interstitial cystitis
  • Vulvar pain syndromes
  • Chronic pelvic pain
  • Pelvic floor dysfunction

How to Diagnose

The diagnosis involves an open and honest conversation between a patient and a provider. Complete medical, social, and psychological histories are an important part of the evaluation. Often questionnaires are used to help guide additional exams and testing. A thorough physical exam, along with laboratory or radiologic testing may be required, especially if organic (physical) causes play a role.

Treatment Options

Treatment options depend on the patient, her medical conditions, and clinical and psychological findings. Addressing both medical and psychological conditions is crucial. Treatment of any medical illnesses or chronic pain conditions is important.

Physical therapy is appropriate for some patients. Psychotherapy is often a part of the evaluation and treatment plan. Individual or couple therapy may be recommended.

Changing or decreasing medications to determine which might play a role in sexual dysfunction should be undertaken slowly - one step at a time. Hormonal medications may be used for specific conditions. Medications and devices used to improve clitoral blood flow are being studied.


References

ACOG technical bulletin No 119, April 2011

Free medical dictionary: Gale Encyclopedia of Medicine. Copyright 2008 The Gale Group, Inc. All rights reserved.
Accessed 29 Feb 2012

Medline Plus; Sexual problems overview. http://www.nlm.nih.gov/medlineplus/ency/article/001951.htm. accessed 27 Feb 2012.

US Department of Health and Human Services/ National Guideline Clearinghouse/Female Sexual Dysfunction Guideline/ completed 14 June 2011
Berman JR. Physiology of female sexual function and dysfunction.Int J Impot Res. 2005;17(S44-S51)

“Women’s Sexual Function and Dysfunction: Study, Diagnosis, and Treatment.” Goldstein I, Davis SR, Meston CM, Traish AM, 2006 Taylor and Francis Group, Boca Raton, FL