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8/13/2023

Female Sexual Interest/Arousal Disorder and Female Orgasmic Disorder

Female Sexual Interest/Arousal Disorder (FSIAD), previously termed hypoactive sexual desire disorder and female sexual arousal disorder, is a condition where a woman has low or no interest in sex and/or difficulty becoming aroused, causing distress for at least six months. Symptoms include less sexual desire, fewer sexual thoughts, little interest in starting sex, and reduced pleasure during intimacy. This condition is categorized into sexual interest/arousal disorders, orgasmic disorder, and genito-pelvic pain/penetration disorders that cause personal distress and persist for at least 6 months.

Treatment of interest/arousal disorders focuses on identifying and treating contributing factors, as well as medical interventions. Contributing factors include stress; fatigue; depression; relationship discord; history of abuse; substance abuse; chronic medical conditions; surgeries; medications (antidepressants, psychotropic agents, antiestrogens, anticholinergic agents, cytotoxic agents); and hormonal factors such as hypothyroidism, hyperprolactinemia, and natural or surgical menopause.

Medical conditions should be optimized. Psychologic disorders and interpersonal concerns should be managed with a combination of individual, couples, and sex therapy, including sensate focus. Medications should be adjusted as needed (eg, supplementation with bupropion for women with antidepressant-induced sexual dysfunction may improve symptoms).

There are two medications FDA approved for interest/arousal disorders in premenopausal women. Flibanserin works as a serotonin receptor agonist/antagonist. Side effects include somnolence and hypotension, and it is contraindicated in patients with a history of depression or alcohol use. Bremelanotide is the second medication, and is a melanocortin receptor agonist which helps to improve sexual desire. Its most common side effects include flushing and nausea.

Hormone therapy is an option for interest/arousal disorders. Estrogen has shown a small to moderate benefits in sexual function for perimenopausal and menopausal women by  improving vaginal health and sexual comfort, but for some women, it may not be enough to restore sexual desire. Androgen therapy is not FDA approved for female sexual dysfunction, but evidence supports the short-term efficacy and safety of transdermal testosterone in postmenopausal women. Testosterone levels should be monitored for androgen excess if treatment extends beyond 6 months. Use of any testosterone preparation that results in supraphysiologic concentrations of testosterone, including pellets and injections, is not recommended. Potential risks include hirsutism, acne, and clitoral enlargement that may persist after medication discontinuation. The long-term effects on cardiovascular disease, breast cancer, and other cancer risks remain unknown, and safety data on extended use are lacking.

Mechanical treatments for arousal disorders are costly with limited data on benefit; however, given the low risk, they can be considered.

Female orgasmic disorder (FOD) is the delay in, infrequency of, or absence of orgasm causing personal distress. This can be a primary disorder (rarely due to a physical cause and can be associated with abuse) or secondary disorder (often linked to interest/arousal disorder or medical or psychosocial issues). Treatment includes education about arousal techniques, counseling, treatment of other associated sexual dysfunction, and medication changes. Mindfulness-based techniques and Cognitive-behavioral therapy (CBT) have shown growing support in managing psychosocial factors that contribute to FOD.

Further Reading:

American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology. Female Sexual Dysfunction: ACOG Practice Bulletin Clinical Management Guidelines for Obstetrician-Gynecologists, Number 213. Obstet Gynecol. 2019 Jul;134(1):e1-e18. doi: 10.1097/AOG.0000000000003324. PMID: 31241598.

Parish SJ, Simon JA, Davis SR, et al. International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women. J Sex Med. 2021 May;18(5):849-867. doi: 10.1016/j.jsxm.2020.10.009. Epub 2021 Apr 1. PMID: 33814355.

Davis SR, Baber R, Panay N, et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Sex Med. 2019 Sep;16(9):1331-1337. doi: 10.1016/j.jsxm.2019.07.012. PMID: 31488288.

 

Initial publication August 2023. Revised March 2025.

Final editing of initial publication performed by The Medical Pen, LLC.

 

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