Female Sexual Function and Dysfunction

Abstract

Sexual function is an important part of most women’s lives. Female sexual dysfunction (FSD), defined as a sexual problem that causes clinically significant distress, is common, but under-identified and undertreated. Clinicians should ask about sexual concerns in routine visits. Assessment of FSD should include a comprehensive history and physical examination utilizing a biopsychosocial approach. Providers should explore psychological, emotional, interpersonal, and sociocultural contributing factors. Medications should be reviewed as possible contributors. Antidepressants are a common cause of FSD. Treatment of FSD should focus on the underlying diagnosis. Given its complexity, FSD is best treated utilizing a multidisciplinary approach, including a medical provider, pelvic floor physical therapist, and sex therapist. General recommendations for all patients with FSD include increasing exposure to sexual stimuli such as erotic literature, scheduling sex, decreasing stressors, and improving overall general health through adequate sleep, exercise, and a healthy diet.

Review Questions

• 1. Female sexual response has been described by various models. The model which includes both physical and emotional satisfaction as important outcomes of sexual activity is called the:

  • A. Masters-Johnson model

  • B. Basson model

  • C. Masters-Johnson-Kaplan model

  • D. Robinson model

  The correct answer is B. Several models of female sexual response have been proposed and provide a framework for evaluating and diagnosing female sexual dysfunction (FSD). The most commonly discussed models are the Masters and Johnson model and the Basson model. The Masters and Johnson model was developed in the 1960s and applies to both women and men. This model is linear and illustrates sexual response progressing from excitement to plateau, orgasm, and then resolution. The Basson model includes both physical and emotional satisfaction as important outcomes of sexual activity. These two factors may lead to higher emotional intimacy and subsequently greater receptivity and interest in sexual stimuli, creating a circular feedback loop. Furthermore, the Basson model highlights that sexual activity is not always prompted by desire, and instead feelings of emotional intimacy with one’s partner may lead her to be more receptive to sexual stimulation. Sexual arousal and desire often co-occur and may be the result of sexual stimuli and not the impetus that leads to sexual stimuli.

• 2. Female sexual problems are prevalent, with rates as high as 43%. The most common female sexual problem reported is with:

  • A. Lubrication

  • B. Orgasm

  • C. Desire

  • D. Arousal

  The correct answer is C. The most commonly reported female sexual problem is low sexual desire. Although 43% of US women report sexual problems, 12% of women have sexual problems causing significant distress. Reporting of sexual problems consistently increases with older age, but reporting of sexual problems causing distress peaks at midlife.

• 3. Female sexual dysfunction is defined as a sexual problem accompanied by:

  • A. Vaginal dryness

  • B. Clinically significant distress

  • C. Decreased frequency of intercourse

  • D. Pain

  The correct answer is B. It is only when women express clinically significant distress that a sexual health problem becomes a dysfunction. Importantly, distress to the partner does not qualify for the diagnosis. Although vaginal dryness, pain, and decreased intercourse frequency are common sexual problems, they would only be considered a dysfunction if the woman was distressed by the symptom.

• 4. The only FDA-approved medication that specifically addresses low libido and hypoactive sexual desire disorder (HSDD) in premenopausal women is:

  • A. Testosterone

  • B. Sildenafil

  • C. Flibanserin

  • D. Bupropion

  The correct answer is C. Flibanserin is the only FDA-approved treatment for HSDD in premenopausal women. Testosterone is frequently used off-label to treat HSDD, especially in postmenopausal women. Sildenafil can improve antidepressant-induced FSD. Bupropion is an antidepressant with lower risk for sexual side effects and can be used as augmentation therapy to improve antidepressant-induced FSD.

• 5. A 54-year-old female presents with decreased libido and no other sexual function problems after starting citalopram 2 months ago. She has tried lowering the dose of citalopram and took a drug holiday without significant improvement. She noticed worsening depression on the drug holiday. Which next treatment recommendation is best to help with her probable antidepressant-induced FSD?

  • A. Augmentation therapy with bupropion.

  • B. Lower the dose of the antidepressant further.

  • C. Add sildenafil.

  • D. All of the above.

  The correct answer is A. Sildenafil, a phosphodiesterase type 5 inhibitor FDA-approved for male erectile dysfunction, has been shown in one small randomized, double-blind, placebo-controlled study to improve orgasm functioning in women with antidepressant-induced FSD effects. The patient in the case has libido issues but is not reporting orgasm issues, so sildenafil would not be as helpful in her case. Since she has already tried lowering her antidepressant with a flare of her depression, this is not a good option. Augmentation therapy with higher doses of bupropion (150 mg twice daily) has been shown to improve antidepressant-induced FSD.