Female Sexual Dysfunction

Abstract

Female sexual function and dysfunction historically have not well been studied and are poorly understood. This chapter will summarize current concepts. Theories of normal female sexual function will be reviewed with a focus on the circular model proposed by Basson, as compared to the Masters and Johnson linear model which is more applicable to the male. Female sexual dysfunction is common, and the definition requires that a sexual problem cause personal distress to the affected woman. Female sexual dysfunction (FSD) can be divided into four categories: problems with desire, arousal, orgasm, and pain, with symptoms often falling into more than one category. Assessment of a woman with sexual problems requires a complete history and physical with focus on the stage(s) of the sexual dysfunction(s) as well as possible contributors including medical, surgical, and psychiatric issues and medications. Screening for FSD can be accomplished with three simple questions easily obtained from an intake questionnaire which are as effective as a lengthy interview: Are you sexually active, Are there any problems, and Do you have pain with sexual activity? Validated sexual function questionnaires may be useful to obtain more reliable and quantifiable in-depth information. Treatment is then tailored to the individual woman with a focus on treatable causes, most commonly pain disorders due to vaginal atrophy or scarring. Education on average sexual practices including the frequency of sexual encounters and the relatively common practice of partnered vibrator use, as well as a brief discussion of the differences between male and female sexual responses, can be reassuring for current sexual practices or helpful to overcome religious or cultural traditions. Sex and psychotherapy referral may be warranted based on the woman’s current life stressors/social situation/relationships, accompanying psychiatric illness, and history of sexual abuse as well as type of sexual dysfunction(s). Medications may also play a role depending on symptoms and category of FSD, with vaginal estrogen helpful for dyspareunia related to vaginal atrophy and transdermal testosterone useful for problems with desire, arousal, and orgasm. However, phosphodiesterase inhibitor medications (PDE5i) that work well for male arousal dysfunction have not been uniformly efficacious in the treatment of FSD as there is a poor correlation in females between objective arousal with increases in genital blood flow and feelings of subjective arousal. Other medications may lead to improvement in desire, arousal, and orgasm and act via either a central effect through changes in neurotransmitters including serotonin, dopamine, and norepinephrine that play a role in sexual response, or have a genital effect on sexual function, or a combination. Vibrator use either before or during sexual activity can improve arousal and orgasm as well as increase genital blood flow. Finally, vaginal and vulvar laser and radiofrequency may improve sexual function through neovascularization, neoelastogenesis, and neocollagenesis, although evidence for these procedures in the treatment of FSD is limited including long-term benefits and risks.