Sexual Dysfunction in Women

BASICS

Definition: Female sexual dysfunction (FSD) encompasses sexual concerns related to desire, arousal, orgasm, or sexual pain (DSM-5 criteria: symptoms >6 months, present >75% of the time, and causing distress).
Prevalence: ~43% of women in the US report concerns; 12% report distress.
Types: Lifelong/acquired; generalized/situational; can affect women of all ages.

Age: Highest prevalence in women 45–65 years (15%), but can occur at any age.
Incidence: 74% in gynecologic cancer, 83% in postpartum women (first 3 months).

Multifactorial: Includes biomedical, sexual, and psychosocial factors.
Physiologic: Sex hormones, CNS neuroendocrine circuits, pelvic neurovasculature, pelvic floor function.
Medical: Diabetes, cardiovascular, malignancy, neurologic diseases.
Psychological: Mood disorders, stress, trauma, relationship factors, body image, societal attitudes.
Medications: SSRIs, chemotherapy, hormonal agents.

Menopause (body image, genitourinary syndrome)
Lack of sexual education
Chronic medical illnesses
Gynecologic disorders (endometriosis, fibroids, infections, childbirth, pelvic floor/bladder dysfunction)
Relationship issues, IPV, sexual trauma
Substance abuse/medication side effects

Sexual trauma, psychiatric disorders, menopause, gynecologic malignancy, pelvic pain, incontinence, prolapse.

History: Comprehensive sexual/medical/psychiatric history, including pain, arousal, lubrication, libido, orgasm, safety, and relationship context.
Physical Exam: Trauma-informed; vulvar, speculum, bimanual for lesions, pain, prolapse, pelvic floor tone.
Screening tools: Female Sexual Function Index, Female Sexual Distress Scale.
Labs/Imaging: Only if underlying medical cause suspected—consider FSH, estradiol, thyroid, prolactin, androgens, STI screen, pelvic imaging if structural concern.

Pelvic/uterine: fibroids, endometriosis, infection, pregnancy, prolapse, vaginismus, dyspareunia, orgasmic disorder
Vulvar: genitourinary syndrome of menopause, lichen sclerosis, mutilation
Hormonal: menopause, pregnancy, breastfeeding
Psychiatric: stress, abuse, depression/anxiety
Cardiovascular, neurologic, GI, endocrine, iatrogenic (SSRIs, chemotherapy, surgical menopause)

Identify/address underlying medical/psychiatric conditions and medication side effects.
Education: Vulvovaginal care, pH-balanced lubricants, relationship safety, healthy lifestyle (sleep, nutrition, exercise, reduce alcohol/smoking).

Hormonal:
Low-dose vaginal estrogen for postmenopausal dryness/pain
Transdermal testosterone (postmenopausal libido, trial 3–6 months)
Ospemifene (SERM) for postmenopausal dyspareunia if estrogen contraindicated
Tibolone (synthetic steroid, menopausal symptoms; stroke risk)
Others:
Tizanidine (muscle relaxant—experimental)
PDE5 inhibitors (not recommended except clinical trials)
Bupropion (adjunct for SSRI-induced dysfunction)
Flibanserin (serotonin agonist, for premenopausal hypoactive desire disorder—avoid alcohol)
First Line: Lifestyle/psychosocial interventions, vaginal estrogen for postmenopausal women
Second Line: Tailored to etiology

Pelvic floor physical therapy (self-awareness, strength, confidence, vaginismus)
Vaginal dilators (for vaginismus or stenosis)
Psychotherapy (CBT, psychosexual, couples, mindfulness)
Yoga, relaxation, mindfulness, hypnotherapy

Muscular, structural, social, or psychological etiologies; pelvic floor PT; psychotherapy.

Under investigation (laser, trigger point injections)—not routinely recommended.

Multiple visits may be needed; continue lifestyle, education, and therapy as indicated.
Monitor symptoms and comorbidities.

If untreated, FSD can lead to reduced quality of life, relationship problems, and mood disorders.