Samuel Walker Nickles, MD
Nima Baradaran, MD
Eric S. Rovner, MD, FACS
BASICS
DESCRIPTION
• Sexual dysfunction is a disorder involving sexual desire, orgasm, arousal, or sexual pain in females that results in significant personal distress. It includes the following:
– Hypoactive sexual desire disorder
– Subjective sexual arousal disorder
– Genital sexual arousal disorder
– Combined genital and subjective arousal disorder
– Persistent sexual arousal disorder
– Sexual aversion disorder
– Women’s orgasmic disorder
– Dyspareunia
– Vaginismus
– DSM-IV defines femal sexual dysfunction (FSD) (formerly, inhibited female orgasm) as persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase
• Often multifactorial etiology
EPIDEMIOLOGY
Incidence
25–76% of adult women
Prevalence
N/A
RISK FACTORS
• Age
• Cardiovascular disease
• Depression, alcoholism, or drug abuse
• Diabetes mellitus
• Hyperlipidemia
• HTN
• Menopause
• Pelvic trauma or radiation
• Pelvic surgery for incontinence or prolapse
• Spinal cord injury (SCI)
Genetics
N/A
PATHOPHYSIOLOGY
• Vascular causes: Vascular insufficiency often secondary to atherosclerosis, causes diminished genital blood flow leading to vaginal and clitoral smooth muscle fibrosis (1,2)
• Hormonal influences: Estrogen plays a significant role in regulating sexual function and maintains the vaginal smooth muscle epithelium and lubrication
• Testosterone is the predominant female androgen that also supports sexual arousal and libido. Low estrogen or testosterone levels are associated with sexual dysfunction
• Neurogenic causes: SCI or disruption of the sacral reflex arcs interfere with vaginal sensation or the ability to reach orgasm
• Psychogenic causes: Emotional issues or psychological stressors such as depression, fatigue, or sexual abuse can negatively affect the female sexual response
• Iatrogenic:
– Various medications such as antidepressants can decrease sexual desire and function
– Prior pelvic surgery such as hysterectomy or cystectomy can disrupt the autonomic nerve plexus, thus contributing to sexual dysfunction
– OCP: Exogenous estrogens
ASSOCIATED CONDITIONS
• Depression
• Endometriosis, vulvodynia, etc.
• Urinary incontinence
• Interstitial cystitis
• Menopause
• Multiple sclerosis
• Any disease that causes decreased estrogen or androgens
GENERAL PREVENTION
• Lifestyle modification to reduce CV disease or psychosocial stressors
• Improvements in surgical technique during pelvic surgery have lessened damage to nerves important in sexual arousal
DIAGNOSIS
HISTORY
• Age: Higher prevalence of sexual dysfunction in older women:
– Physical and psychological factors associated with aging affect sexual desire and response
– Decreased estrogen and testosterone after menopause decreases libido and promotes dryness and atrophy
• Sexual history
• Psychosocial history
• Self-administered, validated questionnaires such as the Female Sexual Function Index (FSFI) are useful objection tools to assess sexual function
• Childbirth: Short-term sexual dysfunction is common postpartum (22–86%) with loss of desire and dyspareunia
• Past medical history:
– Hypertension (HTN), hyperprolactinemia (HPL), or diabetes mellitus
– Thyroid disorders can also affect sexual dysfunction
– Previous history of endometriosis, infections, or tumors should also be elucidated
• Past surgical history: Previous pelvic trauma, pelvic surgery, or radiation
• Medications:
– Antidepressants such as seletive serotonin receptor inhibitors (SSRIs) or tricyclics can decrease libido
– Oral contraceptives and tamoxifen can interfere with testosterone binding
– Spironolactone or ketoconazole have antiandrogen properties
– Antihypertensives and chemotherapeutic agents can also contribute to female sexual dysfunction
• Social history: Sexual, alcohol, or drug abuse; pertinent psychosocial factors or interpersonal relationships are also important
PHYSICAL EXAM
• A thorough physical and pelvic/bimanual exam:
– Assess for vaginal atrophy, lichen sclerosis, vaginal depth, genital/perineal sensation
– Examine for trigger points, scarring, or narrowing from prior surgery
– Assess for prolapse, masses
• If neurologic signs are present, a more detailed neurologic assessment is then warranted including anal and vaginal tone, bulbocavernosal reflex, and voluntary tightening of the anus
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Basic chemistry panel, CBC, TSH, and lipid profile to help identify chronic medical conditions, renal failure, diabetes, or hyperlipidemia
• Hormonal profile
• Serum total and free testosterone
• Estradiol level
• LH, FSH, prolactin
• Sex hormone binding globulin (SHBG)
Imaging
Vaginal and clitoral plethysmography, duplex US, and selective pudendal arteriography can be used to assess genital blood flow.
Diagnostic Procedures/Surgery
Genital vibratory sensation threshold testing, genital temperature sensation, and the bulbocavernosal reflex can be evaluated to help rule out associated neurologic dysfunction
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• Desire phase disorders (3)
– Hypoactive sexual desire (low sex drive)
– Sexual aversion disorder: Panic disorder; active repulsion from sexual stimulation
• Impaired female sexual arousal
– Failure to achieve or maintain vaginal lubrication
– Swelling of genitalia; dyspareunia may result
• Orgasmic phase dysfunction
– Orgasm in response to indirect stimulation: kissing, fantasy, breast stimulation
– Orgasm only in response to clitoral stimulation
– Lack of orgasm (Anorgasmy)
• Coital pain problems
– Dyspareunia
– Vaginismus
– Reduced genital sensation
• Others
– Urinary incontinence
– Pelvic organ prolapse
– Vascular causes
– Surgical (Hysterectomy, oophorectomy, etc.)
– Medication related
CNS depressants
Illicit drug abuse
Antihypertensives
Antiandrogens (cimetidine, ranitidine)
Chemotherapy
TREATMENT
GENERAL MEASURES
• Attempt to identify a correctable cause and treat when present.
• Exercise and pelvic floor training/massage can improve sexual function.
• Treat prolapse and incontinence in affected patients, as female sexual dysfunction may be in part related to inhibition due to leakage during sexual relations.
MEDICATION
First Line
• Hormone replacement therapy (HRT) is the mainstay of treatment in postmenopausal women or oophorectomized women (4)
– Oral estrogen or topical vaginal estrogen may improve libido and ameliorate symptoms of dryness or irritation
– Ospemifene is an estrogen agonist/antagonist indicated for the treatment of moderate to severe dyspareunia, a symptom of vulvar and vaginal atrophy, due to menopause
One tablet (60 mg) taken orally once daily with food
Do not use estrogens or estrogen agonist/antagonist or fluconazole concomitantly
– Topical steroids for lichen sclerosis
– Androgen replacement therapy can be considered in patients with androgen deficiency:
Combined estrogen and testosterone replacement therapy can be used or testosterone alone can be applied topically or with a patch (counsel patient on risks of virilization including: Acne, hirsutism, male pattern baldness, and clitoral hypertrophy)
– Testosterone replacement is controversial and not FDA approved despite being one of the most commonly prescribed off label drugs for desire disorders
• Tibolone (synthetic steroid) is commonly used in Europe in postmenopausal women with desire and arousal disorders
Second Line
• Arousal disorders have been treated with several different classes of medications:
– Alprostadil
– Bupropion
– Estrogen
– Phentolamine and yohimbine
– Sildenafil
– Zestra
SURGERY/OTHER PROCEDURES
InterStim therapy is currently under investigation to treat sexual arousal disorders
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Eros Clitoral Therapy Device is a handheld mechanical device that has been FDA approved for the treatment of sexual arousal and orgasmic disorders in women.
• Several other pharmacologic agents are under investigation for treatment of female sexual dysfunction:
• PDE-5 inhibitors are thought to enhance vaginal lubrication and engorgement in postmenopausal women; however, the benefit is not well established.
• α-Adrenergic antagonists such as phentolamine and yohimbine produce vasodilation of the smooth muscle, increasing vaginal blood flow and lubrication.
Complementary & Alternative Therapies
• Education, sex therapy, psychotherapy, and cognitive behavioral therapy are also important in the multidisciplinary management of sexual dysfunction including those with a history of sexual abuse.
• Currently there are limited studies on the effectiveness of herbal remedies to aid female sexual dysfunction.
ONGOING CARE
PROGNOSIS
Outcome is improved if a specific cause can be identified.
COMPLICATIONS
Patients on HRT should be appropriately counseled on its risks and benefits.
FOLLOW-UP
Patient Monitoring
Close monitoring of progress and compliance is necessary.
Patient Resources
Medline Plus. http://www.nlm.nih.gov/medlineplus/sexualproblemsinwomen.html
REFERENCES
1. Jha S, Thakar R. Female sexual dysfunction. Eur J Obstet Gynecol Reprod Biol. 2010;153(2):117–123.
2. Graziottin A, Serafini A, Palacios S. Aetiology, diagnostic algorithms and prognosis of female sexual dysfunction. Maturitas. 2009;63(2):128–34.
3. Female Sexual Dysfunction. Family Practice Notebook: www.fpnotebook.com/Gyn/Psych/FmlSxlDysfnctn.htm. Accessed January 28, 2014.
4. Fooladi E, Davis SR: An update on the pharmacological management of female sexual dysfunction. Expert Opin Pharmacother. 2012;13(15):2131–2142.
ADDITIONAL READING
ACOG Practice Bulletin No. 119: Female sexual dysfunction. American College of Obstetricians and Gynecologists Committee on Practice Bulletins-Gynecology. Obstet Gynec. 2011;117(4):996–1007.
See Also (Topic, Algorithm, Media)
• Dyspareunia, Female
• Erectile Dysfunction/Impotence, General Considerations
• Female Hypoactive Sexual Desire Disorder
• Female Sex Function Index (FSFI)
• Incontinence, Urinary, Adult Female
• Libido, diminished, female
• Pelvic Organ Prolapse (Cystocele and Enterocoele)
• Pelvic Pain, Female
• Vaginal Atrophy, Urologic Considerations
CODES
ICD9
• 302.70 Psychosexual dysfunction, unspecified
• 302.73 Female orgasmic disorder
• 625.0 Dyspareunia
ICD10
• F52.22 Female sexual arousal disorder
• F52.31 Female orgasmic disorder
• N94.1 Dyspareunia
CLINICAL/SURGICAL PEARLS
• FSD is a complex condition with many etiologies.
• A multidisciplinary approach is often necessary.
• Search for reversible cause such as incontinence or prolapse and treat accordingly.