Sexual Dysfunction in
Women
Lauren Pallis PGY-1
September 2015
Female Sexual Cycle
A.Desire or libido*
B.Arousal - subjective sense of pleasure plus
physiologic changes
C.Orgasm - peak and release with rhythmic
contractions of perineal/reproductive
muscles*
D.Resolution - muscular relaxation and
“general sense of well-being”
Epidemiology
- About 40% of women worldwide complain of sexual
dysfunction
- prevalence highest in Southeast Asia, lowest in
Northern Europe
- PRESIDE study (2008) - largest US study, surveyed >30,000
1
women to estimate prevalence of self-reported sexual
issues, presence of problems that went along with personal
distress
- low desire was most commonly reported (39%) with 10-14% of these
women reporting some kind of personal distress in their lives2
Role of Hormones in Sexual Cycle
Estrogen - decreasing levels of estrogen are
associated with decline in libido and sexual
responsivity
- Lower E levels lead to reduction in
vulvovaginal lubrication, vasocongestion
during arousal; also leads to tissue atrophy,
increases likelihood of pain with intercourse
Role of Hormones in Sexual Cycle
Androgens - likely play a role in female sexual
function
- Conflicting evidence
- Data out of Europe supporting use of
testosterone in treatment of sexual
dysfunction in surgically menopausal
women
Role of Neurotransmitters in Sexual Cycle
Dopaminergic system - increases sexual desire and
excitement
Norepinephrine system - affects arousal and orgasm
Imbalance between these two systems can cause an inability to
begin sexual response cycle
Serotoninergic system - if overactive, can decreased
desire and orgasm
Risk Factors/Comorbidities
Gynecologic
- Pelvic floor dysfunction - 26-47% of women with this
report low sexual desire3
- common issue is urination with sex
- Endometriosis - dyspareunia with penetration is very
common
- Uterine fibroids can cause dyspareunia
- Parity is NOT associated with sexual dysfunction
Risk Factors/Comorbidities
Menopause
- lower levels of estrogen known to cause certain
physiological changes related to female sexual
function
- lower estrogen levels alone may not directly account
for all changes in sexual function
- study of 341 peri- and postmenopausal women, common menopausal
symptoms, including depression, sleep disturbances, and night
sweats, were associated with diminished libido4
Risk Factors/Comorbidities
Psychosocial
Conflict within relationship
Fatigue or stress
Lack of privacy
Issues surrounding prior physical or sexual abuse
Partner’s sexual dysfunction
Relationship factors
- study of over 1800 men and women between the ages of 19 to 32
years in stable relationships  sexual activity and satisfaction
declined as the duration of partnership increased5
Risk Factors/Comorbidities
Depression
- 17-26% of women with low sexual desire
also have depression
2
- Initially can be difficult to distinguish if dysfunction
2/2 depression or side effects of medications
Risk Factors/Comorbidities
Substance Use/Abuse
● Chronic alcohol use - can lead to
hypogonadotropic state
○ Alcohol lowers physiological signs of arousal
● Nicotine - can inhibit arousal
Risk Factors/Comorbidities
Medical Conditions
MS
HTN*
Epilepsy - particularly patients on antiepileptics
Cancer - especially those treated with endocrine
therapies
Risk Factors/Comorbidities
Medications
SSRIs - can decrease desire, cause difficulty with orgasm
benzodiazepines
antipsychotics
beta-blockers*
gabapentin
lamotrigine
topiramate
aromatase inhibitors - profound hypoestrogenemia
Diagnostic Evaluation
- Obtain complete history, assess for risk factors
- When discussing sexual health history ask about:
menopausal status
pregnancy/parity
history of pelvic injury, cancer, surgery
vulvovaginal/pelvic pain
pruritus, dryness, discharge
abnormal bleeding
incontinence
Diagnostic Evaluation
Potential labs/studies:
- Transvaginal pelvic ultrasound
- CG and chlamydia
- Complete blood count
- Prolactin levels - hyperprolactinemia causes gonadal
suppression
- TSH
Making the diagnosis
DSM-V criteria:
- present 75-100% of the time
exception with of substance/medication induced
disorders
- present for at least 6 months
- disorder must cause “significant distress”
Diagnoses
From DSM-V
Female Sexual
Interest/Arousal Disorder
Female Orgasmic Disorder
Genito-pelvic
Pain/Penetration Disorder
Lack of, or significantly reduced
sexual interest/arousal,
demonstrated by 3 or more:
Presence of either symptoms,
experienced all or almost all of
the time:
Persistent or recurrent
difficulties with one or more:
-
-
absent/reduced interest in sex
absent/reduced sexual
thoughts
absent/reduced initiation of
sex, generally uninterested
when partner initiates
absent/reduced sexual
excitement
absent/reduced genital/non
genital sensations during sex
- marked delay
in/infrequency of
orgasam, or complete
absence
- markedly reduced
intensity of oragasm
- penetration
- vulvovagianl or pelvic
pain during sex
- fear/anxiety about pain
during sex
- tensing or tightening of
pelvic floor muscles
during attempted
penetration
Diagnoses
Substance or medicationinduced dysfunction
Other sexual dysfunction,
specified
Other sexual dysfunction,
unspecified
Clinically significant disturbance
in sexual function predominates
- symptoms develop during
or soon after
intoxication/withdrawal or
after taking med
- substance or medication
is known to be capable of
producing symptoms
- disturbance not better
explained by another
cause of sexual
dysfunction
- does not occur solely
during delirium
Patient presents with sexual
dysfunction that causes
distress, but presentation does
not fully meet diagnostic criteria
of other disorders, and
physician chooses to specify
specific reason that criteria are
not met
Same, but clinician does not or
cannot specify reason that
criteria are not met (i.e.
presentations where there is not
enough information to make
diagnosis)
Management
- Should combine pharmacological therapy to
maximize biological factors of sexual
response as well as individualized therapy
or counseling to overcome
personal/relationship difficulties
- principal predictors of sexual satisfaction are
physical and mental health, and the quality of the
relationship with the partner
Non-pharmacologic Treatments
- Sex and couples therapy
- Pelvic physical therapist - subspeciality trained in
pelvic anatomy
- Psychotherapy - for women with comorbid psychiatric
disorders
- Lifestyle changes - reduce stress, fatigue; if possible
make changes to living situation to improve privacy
- Improving body image
- EROS-Clitoral Therapy Device (clitoral suction vacuum
device)- may improve arousal
Hormonal Therapy
Estrogen and estrogen-progesterone therapy
- First line therapy in treating symptoms of
menopause
- Systemic and local estrogen can treat tissue
atrophy, improve dyspareunia
- NO consistent increase in sexual desire or
activity
Hormonal Therapy
Androgens
- Role of testosterone therapy in female sexual function has been
studied since 1950s
- Two recent Cochrane reviews examined benefit of T + EP therapy
vs EPT alone in treating sexual dysfunction in peri- and
postmenopausal women
- Addition of T to hormone therapy regimens improved sexual
function scores and number of satisfied sexual episodes in
postmenopausal women
Hormonal Therapy
Androgen Safety
- Major side effects of testosterone therapy
include hirsutism, acne, decreased HDL
- Seen with oral T therapy
- Side effects do not occur with transdermal T
(bypasses hepatic metabolism)
- Data on long term use is limited
Hormonal Therapy
Androgen Use
- T patch approved in Europe for surgically
menopausal women on concurrent ET
- Androgen therapies not approved by FDA
- Off-label use for treating sexual
dysfunction is increasing
Pharmacologic Treatments
Flibanserin (Addyi)
- Increases DA and NE levels
and induces transient
decreased in 5-HT levels in some areas of brain
- Most commonly reported side effects are
dizziness, nausea, fatigue, sleepiness, trouble
sleeping
Neurotransmitters
Dopaminergic system - increases sexual desire and
excitement
Norepinephrine system - affects arousal and orgasm
Imbalance between these two systems can cause an inability to
begin sexual response cycle
Serotoninergic system - if overactive, can decreased
desire and orgasm
Flibanserin
VIOLET trial
- In premenopausal women with sexual
dysfunction, flibanserin was associated with
significant improvements in satisfying
sexual events, sexual desire, overall sexual
function, as well as reduction of sexual
distress versus placebo
Conclusions
- Lots to take into consideration when making
diagnosis
- Take FULL history, including sexual history
- Optimize therapy - both pharmacologic agents
and behavioral therapies often used
concurrently
- Focusing on patients’ wellness and happiness
with themselves is key
Resources
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Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in United States women:
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Salonia A et al. Sexual dysfunction is common in women with lower urinary tract symptoms and urinary
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Reed SD, Newton KM, LaCroix AZ, Grothaus LC, Ehrlich K. Night sweats, sleep disturbance, and depression
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Resources
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