Sheila Ann Medina Sexual health plays an integral role in overall health, yet it is often overlooked and undertreated. Sexual dysfunction is an important aspect of sexual health that may affect a woman’s self-esteem and quality of life. Several large-scale studies have confirmed that sexual satisfaction in women is strongly associated with life satisfaction and general well-being. Sexual health concerns should be taken seriously because they can lead to serious distress and interfere with relationships.1 Sexual problems are highly prevalent, affecting between 40% to 45% of women in the United States in their lifetime.2 The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies female sexual dysfunction (FSD) into three major categories: (1) female sexual interest/arousal disorder; (2) female orgasmic disorder; and (3) genito-pelvic pain/penetration disorder.3 FSD is further classified as to duration (lifelong versus acquired), as generalized versus situational, and by etiologic origin and/or treatment. American Psychiatric Association guidelines specify that for the diagnosis of a female sexual disorder to be established, all of the sexual dysfunctions (except substance/medication induced sexual dysfunction) now require a minimum duration of approximately 6 months, and more precise severity criteria. The sexual problem must be recurrent or persistent, cause personal distress or interpersonal difficulty, and not be better accounted for by another mental disorder, drug-related cause, or medical condition.3 The presence of distress is an essential criterion for the diagnosis; therefore a diagnosis of sexual disorder is not indicated unless the sexual dysfunction is associated with distress. Distress may be experienced because of a lack of sexual interest or arousal or as a result of significant interference with a woman’s life and well-being. Female sexual interest/arousal disorder is defined as diminished or absent sexual interest or arousal manifesting with at least three of six indicators for a minimum duration of approximately 6 months. Female sexual interest/arousal disorder is frequently associated with problems in experiencing orgasm, pain experienced during sexual activity, infrequent sexual activity, and couple-level discrepancies in desire.3 Five factors must be considered during the assessment and diagnosis of the patient, in addition to the subtypes “lifelong/acquired” and “generalized/situational.” These factors may be relevant to the cause and/or treatment and include (1) partner factors (e.g., partner’s sexual problems, partner’s health status); (2) relationship factors (e.g., poor communication, discrepancies in desire for sexual activity); (3) individual vulnerability factors (e.g., poor body image, history of sexual or emotional abuse), psychiatric comorbidity (e.g., depression, anxiety), or stressors (e.g., job loss, bereavement); (4) cultural or religious factors (e.g., inhibitions related to prohibitions against sexual activity; attitudes toward sexuality); and (5) medical factors relevant to prognosis, course, or treatment.3 Female orgasmic disorder is defined as the persistent or recurrent inability of a woman to achieve orgasm, markedly diminished intensity of orgasmic sensations, or marked delay of orgasm during any kind of sexual stimulation despite self-reported high sexual satisfaction and arousal. The prevalence rates for female orgasmic disorders in women range from 10% to 42% and are varied based on multiple factors (e.g., age, culture, duration, and severity of symptoms). Genito-pelvic pain/penetration disorder is defined as persistent or recurrent difficulties involving one (or more) of the following: (1) difficulty with intercourse, (2) genitopelvic pain, (3) fear of pain or vaginal penetration, and (4) tension of the pelvic floor muscles. This diagnosis is frequently associated with other sexual dysfunction, particularly sexual interest and arousal disorders. The five factors discussed under sexual dysfunction must also be considered during the assessment and diagnosis of genito-pelvic pain/penetration disorder because they may be relevant to the cause and/or treatment.3 Epidemiologic studies have yielded widely varied estimates of the prevalence of FSD, depending on the definition used as well as the population and specific dysfunction studied. The prevalence of female sexual interest/arousal disorder as defined in DSM-5 is unknown. Low sexual desire and problems with sexual arousal as defined by the the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and International Classification of Diseases, Tenth Revision (ICD-10) may vary markedly in relation to age, cultural setting, duration of symptoms, and presence of distress. Low desire is a common sexual problem in women across all age groups worldwide; however, some older women report less distress about low sexual desire than younger women, although sexual desire may decrease with age.3 Studies reveal that the prevalence rate for dysfunction tends to increase as women become older, with approximately 40% to 45% of adult women revealing at least one sexual dysfunction.4 Women also corroborate low levels of sexual interest, and report that with age sexual desire decreases. In general, arousal and lubrication problems are prevalent in 8% to 15%, although three studies have reported this at a higher level of 21% to 28% in sexually active women. In the United States, Australia, Canada, and Sweden, the prevalence of manifest orgasmic dysfunction is about 16% to 25% in 18- to 74-year-old women.5 Estimates from multiple studies suggest that the prevalence of problems with women who experience difficulties with arousal or pain may range up to 28% for each.5 Prevalence rates are affected by a variety of factors including age, partner’s age, duration of marriage, medical illness, menopause, family planning, and frequency of sexual intercourse had significant association with FSD. Studies have shown that prevalence of most sexual dysfunctions is higher in clinical than in community samples.6 Female sexual response is a complex interaction of psychological, interpersonal, environmental, genetic, biologic, and physiologic factors that change throughout the life cycle. Thus, the pathophysiologic mechanism of a sexual complaint is typically multifactorial and complex, involving organic, functional, etiologic, and psychological factors. Vascular, neurogenic, hormonal, anatomic, medication-induced, and emotional factors have been implicated as major contributors to the development of FSD (Box 168-1).3,7 Any disease of the nervous system (e.g., multiple sclerosis, neuropathies, stroke) can result in neurogenic FSD with resultant impaired lubrication and orgasm. Any condition that affects blood flow, such as cardiovascular disease, hyperlipidemia, atherosclerosis, renal disease, and smoking, can affect sexual functioning. Vascular insufficiency with subsequent diminished genital blood flow may directly contribute to genital arousal disorder because of impairment of vaginal and clitoral engorgement. Decreased pelvic blood flow can lead to smooth muscle fibrosis of the clitoris and vagina, which may in turn cause symptoms of vaginal dryness and dyspareunia. Pelvic surgeries may injure autonomic pelvic nerves or interrupt blood flow, both of which may result in FSD. Dysfunction of the hypothalamic-pituitary axis from natural menopause, surgical or medical castration, premature ovarian failure, or exogenous hormones can result in hormonally based FSD. The most common symptoms associated with estrogen deficiency are vaginal dryness, coital pain, and decreased desire. Diminished testosterone levels in women have been implicated as a cause of decreased arousal, libido, and orgasm. The muscles of the pelvic floor contribute to sexual arousal and are responsible for the involuntary rhythmic contractions during orgasm. Increased tone of the levator ani muscle may cause dyspareunia and vaginismus, whereas hypotonia is associated with decreased vaginal sensation, coital anorgasmia, and urinary incontinence during sexual intercourse or orgasm. Anatomic causes such as uterine prolapse, pelvic tumors, and endometriosis are commonly associated with deep dyspareunia. In addition, chronic illnesses, certain medications, substance abuse, and psychogenic issues, with or without organic disease, may contribute to the development of FSD. Self-esteem, body image, sociocultural factors, relationship issues, depression, and other mood disorders may significantly affect sexual response. Furthermore, many of the medications used to treat depression, especially the selective serotonin reuptake inhibitors (SSRIs), are associated with sexual side effects. Most often, the cause of FSD is mixed, involving a combination of neurogenic, vascular, psychological, and hormonal causes. For example, women with diabetes may experience sexual dysfunction owing to disease-related neurovascular changes, medication side effects, and the psychological effects of coping with a chronic illness. In women, those who report excellent health compared with good, fair, or poor health are less likely to have sexual dysfunction. Sexual dysfunction is common in women with hypertension who use hypertensive drugs and seems to be associated with lubrication and orgasm dysfunction.5
Sexual Dysfunction (Female)
Definition and Epidemiology
Pathophysiology
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