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KatjaKero

Female Sexual Disorders

Essentials

  • Female sexual disorders include hypoactive sexual desire, sexual arousal and orgasm disorders and sexual pain (see article Sexual Pain). See also articles on Female dyspareunia Dyspareunia in Women, Vulvodynia Vulvodynia and Vaginism Vaginism.
  • The causes are often multifactorial, with biological (e.g. diseases and medications), psychological and sociocultural dimensions, as well as dimensions associated with interpersonal relations and various life situations.
  • Find out what the patient wishes from the treatment.
  • Make sure that there is no underlying sexual or other violence (see articles Domestic violence Domestic Violence) and Examination and treatment of a rape victim Examination and Treatment of a Rape Victim). If there is such violence, the treatment of lack of sexual desire should first address securing the patient's safety and treating any trauma.
  • Treatment should address the underlying cause, as far as possible.
  • Sexual counselling and therapy are helpful.
  • Sexual disorders are extremely sensitive and intimate problems requiring particular discretion and listening to the patient.

Causes

  • Sexual disorders are common. One in ten women suffer from hypoactive sexual desire disorder. Orgasmic disorder is the second most common female sexual disorder.
  • Understanding the sexual response cycle is essential for identifying the disorders. In the sexual response cycle described by Basson (Picture 1), sexual desire is divided into spontaneous and responsive desire. Responsive desire can be influenced by the woman herself, and spontaneous desire is not required for a woman to have sex. In women, the experience of intimacy is considered to motivate the reception of sexual stimuli kindling desire and leading to sexual arousal. If the stimulus is sufficiently strong, the response cycle will continue, leading to orgasm or to an otherwise satisfactory result. The response cycle, again, will reinforce the feeling of intimacy. Sexual disorders are due to a dysfunctional response cycle.
  • A normal sexual response cycle requires a connection between body and mind.
    • Stress, anxiety, depression and other factors (such as everyday life in families with children) disrupting the connection between body and mind disturb sexual response.
    • Factors associated with the couple relationship, such as crises, mistrust, hatred, violence or communication problems, may inhibit desire and orgasm, and becoming bored with routines may inhibit desire.
  • Hormonal factors may cause hypoactive desire and arousal disorders.
  • Diseases such as diabetes, vascular disorders, MS and other disorders weakening pelvic floor muscles, sensation or circulation may cause any sexual disorder.
  • Medication (e.g. SSRIs, antipsychotics, anticancer, antihypertensive and cardiac drugs) may affect sexual response.
  • An experience of violence often leads to a feeling of insecurity and need for control, preventing a normal sexual response and orgasm.
  • Sexual inexperience (woman/partner) may lie behind inhibited desire or orgasm disorder.
  • The attitude to sexuality mediated by the nuclear family, cultural norms, and the learned significance of a couple relationship are all involved in a person's experiences of sexuality. Feelings of guilt associated with the experience of pleasure, and a learned ‘moral disgust' may inhibit desire and cause orgasm disorders.
  • Factors associated with gender and sexual orientation disturb the sexual response if the person is not allowed to be their true self.
  • Both sexual arousal and orgasm disorders may be due to insufficient sexual stimulation (Picture 1).

Hypoactive sexual desire disorder

  • Hypoactive sexual desire disorder (HSDD) is considered to be due to insufficient excitatory factors and/or excess inhibitory factors (Bancroft's Dual Control Model).
  • In addition to biological factors, stress associated with sex and a disturbed body image with associated insecurity may affect sexual desire greatly.

Female sexual arousal disorder

  • Female sexual arousal disorder (FSAD) is most commonly due to mucosal atrophy caused by oestrogen deficiency (the menopause, lactation) and insufficient sexual stimulation.
  • Female sexual arousal disorders increase with age; a dry mucosa disturbs arousal and sexual pleasure. Local radiotherapy is associated with thinning of mucous membranes.
  • Sexual pain prevents arousal.
  • Female sexual arousal disorder is often associated with other sexual disorders, such as hypoactive sexual desire, orgasm disorder or sexual pain.

Orgasm disorder

  • Concentrating on sexual intercourse or performance in sex may decrease the chances of having orgasms.
  • Antidepressants (SSRIs) may have individually varying effects on arousal and orgasm. The feeling at resolution may change.

Patient history

Matters to be addressed in the patient history

Sexual historyGynaecological history
Current problemPregnancies and childbirths
Sexual responses and reactionsVulvovaginal trauma, cancers, surgical treatment
Sexual orientation and genderVulvovaginal pain, dryness, itching, discharge and pelvic pain
DiseasesAbnormal bloody discharge
OperationsInability to hold faeces, gas or urine
MedicationGynaecological prolapses
Social situationFibroids
Any sexual or other maltreatment or violenceEndometriosis
Partner's/partners' sexual functioningInfertility

Diagnosis

  • The diagnosis is based on taking the sexual history.
  • The sexual history includes factors such as
    • the patient's current problem and any associated worries or fears
    • any lack of information related to anatomy or to her own body
    • history of sexual pleasure
    • current situation in any couple relationship / intimate relationships
    • beliefs related to sexuality
    • diseases and medications
    • previously or currently experienced sexual or other violence.
  • Gynaecological examination: the condition of the mucosa, any inflammation/infection, any disorders in the genital area (such as lichen sclerosus, tumours, prolapses), the functioning of pelvic floor muscles

Hypoactive sexual desire disorder

  • There are periods in a woman's life when she may experience lack of sexual desire. This is natural. The situation is often transient and desire will be restored.
    • Lack of sexual desire is classified as a disorder if it involves significant subjective distress (hypoactive sexual desire disorder, HSDD).
    • Before treating hypoactive sexual desire disorder, make sure that there is no violence involved in any intimate relationships. If there is sexual or other intimate partner violence, lack of sexual desire can be considered a normal reaction to the situation.
  • Hypoactive sexual desire disorder involves
    1. lacking sexual motivation appearing as decreased or absent spontaneous desire and consequently no sexual thoughts or fantasies
    2. decreased or absent response to external erotic suggestions or stimulation
    3. difficulty maintaining desire or sexual interest for sexual activity
    4. having no desire to begin or to participate in sexual activity.
  • To make the diagnosis the woman must find the lack of desire a significant problem (anxiety, frustration, impotence, loss, sorrow, worry).

Female sexual arousal disorder

  • Classification of female sexual arousal disorders
    1. Female cognitive arousal disorder where the woman does not feel subjectively aroused. A woman may subjectively feel not aroused even though a physiological response can be detected. This is often associated with orgasm disorder and hypoactive sexual desire disorder.
    2. Female genital arousal disorder where the physiological response to arousal (increased blood flow to and lubrication of the genital area) is not appropriate. The woman may suffer from mucosal atrophy and dryness.
    3. Arousal remains a constant, unpleasant feeling. Orgasm and resolution do not alleviate this.
    4. A combination of items 1 and 2.

Orgasm disorder

  • Female orgasm disorder means that a longer time than normally is needed to have an orgasm or the woman does not have orgasms at all.
  • The disorder may be primary, i.e. the woman may never have had an orgasm, or secondary, i.e. she may previously have had orgasms but cannot currently have them or orgasms have become more difficult to reach or less intense.
  • Arousal or sexual desire may occur normally even though having orgasms is disturbed.

Treatment

  • The treatment of sexual disorders targets the underlying cause.
  • Ensure the treatment of any underlying diseases and look at whether it is possible to change any problematic medication.
  • An atrophic mucosa should be treated with topical oestrogen or prasterone. The treatment of menopausal symptoms is important to make sure that the woman also has enough energy for experiencing her sexuality and putting it into practice as she wishes.
  • Sexual counselling and therapy are helpful if there is underlying anxiety, depression, relationship problems or a history of sexual or other violence.
    • Find out about local availability of sexual counsellors.
    • The patient should be provided with sufficient space to become her true self. Her fears and any erroneous beliefs should be discussed with her.
    • To be able to treat the patient well and in the right way, it is necessary to perceive her true underlying human situation.
    • Targeted information should be provided on the patient's problem.
    • Masturbation is an important means of getting to know one's body. Sexual counselling involves providing information about anatomy, about the significance of clitoral stimulation for having an orgasm and about sex aids, as necessary.
    • Variation in sexual practices may increase pleasure even in a longer relationship.
  • Sensate focus exercises
    • Sensate focus exercises are suitable for hypoactive sexual desire and orgasm disorders.
    • The couple can do mindfulness exercises focusing on intimacy, with the aim of establishing a contact between body and mind, first touching each other's bodies generally and later also intimate body areas.
    • Research shows that sensate focus exercises increase trust between the couple and relaxation to enjoy sex and the present moment, which is essential for pleasure and for having an orgasm.

Treatment of hypoactive sexual desire disorder

  • Make sure that there is no underlying sexual or other violence.
  • In addition, you should discuss with the patient what she doesn't want (e.g. not wanting to have sex with a certain partner, not wanting to have sex, not wanting to submit to insulting behaviour, not wanting to perform sex just to ensure her partner's pleasure, whether sex is consenting, etc.). You should use open questions, as they may lead to discussing underlying causes of many kinds and also act as a therapeutic intervention.
  • Drugs developed for lack of sexual desire (flibanserin and bremelanotide) exist but these are not available on all markets.
  • There are international guidelines available for testosterone treatment but, in the absence of testosterone products for women and results of long-term follow-up, testosterone treatment of women is always off label treatment.

Treatment of female sexual arousal disorder

  • Mucosal dryness associated with oestrogen deficiency should be treated with topical oestrogen or prasterone.
  • Sufficient foreplay should be encouraged and instructions given for use of lubricant ointment.
  • Pelvic floor exercises. The patient should be referred, as necessary, for pelvic floor biofeedback therapy to a physiotherapist with the required expertise.
  • Information should be provided about the significance of sufficient stimulation of the genital area. In association with a gynaecological examination, the patient can be informed about the anatomy of the intimate area, particularly about the location of the clitoris.
  • A person suffering from insufficient sexual imagination may learn to feed her world of sexual fantasy visually, through stories and through touch.
  • Various aids possibly involving vibration may help to achieve a sexual response.
  • A constant, unpleasant state of arousal is difficult to treat. Mental support is important. In sexual therapy, mindfulness and cognitive therapy, elimination of factors aggravating symptoms, topical analgesics and physiotherapy have been tried to treat this.
    • Drugs for neuropathic pain can be tried.

Treatment of orgasm disorder

  • Counselling regarding sexual techniques, masturbation, anatomy and the significance of clitoral stimulation for having an orgasm is essential. Few women have orgasms in vaginal intercourse as such. Sufficient clitoral stimulation is essentially important.
  • Calming down the autonomic nervous system to a suitable window of tolerance is also important. Contact between body and mind and letting go of control usually play a central role in treating orgasm disorder.
  • For sensate focus exercises, see above.

    References

    • Basson R. A model of women's sexual arousal. J Sex Marital Ther 2002;28(1):1-10. [PubMed]
    • Parish SJ, Cottler-Casanova S, Clayton AH et al. The Evolution of the Female Sexual Disorder/Dysfunction Definitions, Nomenclature, and Classifications: A Review of DSM, ICSM, ISSWSH, and ICD. Sex Med Rev 2021;9(1):36-56. [PubMed]
    • Giraldi A, Rellini AH, Pfaus J et al. Female sexual arousal disorders. J Sex Med 2013;10(1):58-73. [PubMed]

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