Female sexual dysfunction—from diagnosis to treatment

Key points 

Female sexual dysfunction (FSD) is a common condition that affects 30% to 65 % of American women. Prevalence may increase with age, especially after menopause, and may be associated with certain diseases and medications.

Sexual dysfunction is prevalent in both sexes but more common in women than men. In a study by Laumann et al, it was found to be present in 43% of women and 31% of men (1).

Female sexual response and classification of FSD 

Masters and Johnson were the first to describe the sexual response cycle in 1966, listing the following phases: excitement, plateau, orgasm, and resolution (2). In 1979, Kaplan modified the phases to: desire, arousal, orgasm, and resolution (3). These phases are the basis for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) definitions of female sexual dysfunction, along with the classification system of the American Foundation of Urologic Disease (AFUD) (4).

The AFUD consensus classifications incorporate medical risk factors and causes of female sexual dysfunction into three different categories, depending on whether it is primary (realistic sexual expectations have never been met under any circumstances), secondary (all phases have functioned in the past, but one or more no longer do so), or situational (the response cycle functions under some circumstances, but not others)Fig 1..

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Figure 1.

It should be noted that sexual dysfunction is sometimes a result of the different sexual needs of each partner in a relationship. Each condition is subtyped as lifelong vs acquired; generalized vs situational; organic vs psychogenic; or mixed. Many women have more than one condition and the origin of any disorder may also be multifactorial.

Causes of FSD 

Medical therapies for female sexual dysfunction 

Treatment of the woman with sexual dysfunction often involves a combination of psychological and medical treatment. Approved therapies for men are more advanced than those for women, but recently more progress has been made. However, with the exception of hormone therapy (HT), most treatments are still in experimental phases.

1.Medications

Multiple medications have been tried for the treatment of female sexual dysfunction, some as a result of research in the male sexual dysfunction area. However most do not have FDA indications for female sexual dysfunction. A list of possible treatments can be seen in Table 1, Table 2, Table 3.

Table 1. Hormonal Treatments

	Hormonal therapies	Administration	Indications	Side effects	Comments
	Estrogen replacement therapy	a) Oral: Premarin, Estrace, etc 0.05–2.5 mg/day b) Transdermal/patch: Vivelle, Estraderm, etc.−0.025–0.1 mg twice a week c) Vaginal cream: Premarin-0.625/g 1–2 g pv 1–3 ×/weekEstrace-0.1mg/g-1g pv 1–3 ×/week d) Vaginal pill: estradiol-0.025-1 tab pv 2×/week e) Vaginal ring: Femring-0.05-0.1/d- ring pv q 3 mo	Hot flashes Vaginal dryness	-Thromboembolic events -Possible increased risk or cardiovascular disease -Possible increased risk of breast cancer -Allergic reactions -Increases risk of endometrial cancer if unopposed with progesterone therapy	-Prevents osteoporosis -Improves genital sensation -Decreases pain and burning during intercourse
	Androgen replacement therapy	a) Oral methytestosterone: 10–25 mg/daye.g. Android, Oreton Methyl, Testred b) Transdermal testosterone: 2.5–5 mg/daye.g. Testoderm, Androderm c) Topical testosterone: propionate cream 2% d) Testosterone gel: AndroGel 1% up to 3×/week	Not FDA approved for treatment of FSD Used for decreased desire, vaginal dryness, and diminished genital sensation	-Acne -Weight gain -Excess facial and body hair -Voice changes -Emotional changes -Lipid changes -Possible liver damage	-Must check labs before and every 2–3 months during treatments: testosterone, lipids, liver enzymes
	Estrogen/androgen combination	Estratest: 1.25/2.5 per day	Vasomotor symptomsPost-menopausal treatment	See above risks for estrogen and testosterone therapy	Add progestins day 10–14 of cycle

Table 2. Herbal Treatments

	Herbal product	Administration	Indications	Side effects	Comments
	L-Arginine	Oral-6 g- administered 45 minutes before intercourse	Not FDA approved for FSD	-Thickening and coarsening of the skin -Muscle weakness -Diarrhea -Nausea	-Nonessential amino acid which is a precursor to nitric oxide- may increase blood flow to clitoral and vaginal tissues and may improve sensitivity and responsiveness to sexual stimulation
	ArginMax	Oral-6 capsules/day for at least 2–4 weeks	Not FDA approved for FSD	-Heartburn -Nausea	-Increased libido and sexual stamina
	Xzite	Oral-1 pill daily	Not FDA approved for FSD	-Nausea	-Combination of herbs that increases arousal

Table 3. Other Therapies

	Name	Administration	Indications	Side effects	Mechanism of Action
	Sildenafil citrate/Viagra	Oral-50–100 mg ½ hr to 4 hr before intercourse	Not FDA approved for FSD	-Headache -Uterine contractions -Dizziness -Possible MI or stroke -Sudden death -Hypotension	Selective type 5 (cGMP-specific) phosphodiesterase inhibitor that decreases the catabolism of cGMP, the second messenger in the nitric oxide-mediated relaxation of clitoral and vaginal smooth muscle
	Wellbutrin HCL	75–100 mg p.o. TID	Not FDA approved for FSD	-HeadacheDry mouth -Insomnia -Rare seizures	-Antidepressant -Weak blocker of serotonin and norepinephrine uptake
	Zestra	Topical-0.5ml-1ml with gentle massage to the external female genitalia- 5 minutes prior to intercourse	Not FDA approved for FSD	-Local burning or stinging	-Increases genital sensory nerve conduction as well as genital blood flow
	Prostaglandin E1	Topical-100–400 μg once or twice/dayE.g. Alprostadil/Muse	Not FDA approved for FSD	-Pain -Hypotension -Possible syncope	-Relaxes arterial smooth muscle producing vasodilatation
	Phentolamine	Vasomax-40 mg/day	Not FDA approved for FSD	-Tachycardia -Weakness -Possible MI/stroke/hypotension	-Nonspecific adrenergic blocker -Relaxes vascular smooth muscle
	Apomorphine	Nasal-used before intercourse	Not FDA approved for FSD	-Nausea -Headache -Dizziness	-Short-acting dopamine agonist
	α-melanocyte stimulating hormone/PT-141	Used 30 minutes before intercourse	Not FDA approved for FSD	-Local burning or stinging	-Stimulates sexual arousal

2.Medical Devices

a.Vacuum Therapy. The Eros-Clitoral Therapy Device is the first treatment approved by the Food and Drug Administration for arousal and orgasmic disorders in women. It applies a gentle vacuum to the clitoris, increasing blood flow to the clitoris and surrounding tissue.

b.Electronic Stimulation. Slightest Touch, a battery-operated device available without prescription, applies electrode pads to the top of the foot, above the ankles, and above the buttocks, to stimulate nerve pathways to the genital area.

c.External Clitoral Stimulation. Vielle is a widely available device designed to be worn on the fingers and used with a special lubricant. It may improve orgasm.

d.Sacral Nerve Stimulation. The InterStim sacral nerve stimulating system is a surgically implanted device that was initially designed to treat urge urinary incontinence and found to benefit sexual arousal and the ability to achieve orgasm in women. Multicenter studies are ongoing.

Conclusion 

Female sexual dysfunction is a real problem that affects a significant proportion of our population. Increased awareness of this problem in the medical community will lead to further research in female sexual dysfunction, as well as improved treatment options.