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Female Sexual Interest/Arousal Disorder and Female Orgasmic Disorder

Author: Emily Rosen, MD

Editor: Julie DeCesare, MD

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Sexual function is a complex interaction among biological, medical, psychosocial, interpersonal, and sociocultural factors. Almost half of women (43%) experience sexual dysfunction and 12% of women report related personal distress with a peak in middle age (14.8% in women aged 45-64 years) compared with reports in younger women (10.8%) and older women (8.9%).

Female sexual dysfunction is categorized into sexual interest/arousal disorders, orgasmic disorder, and genitopelvic 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).

Estrogen has shown a small to moderate benefit in sexual function for perimenopausal and menopausal women. Flibanserin is an FDA-approved serotonin receptor agonist/antagonist for interest/arousal disorders in premenopausal women. Risks include somnolence and hypotension, and it is contraindicated in patients with a history of depression or alcohol use. Sildenafil is not recommended for treatment of interest/arousal disorders.

Androgen therapy is not FDA approved for female sexual dysfunction. Testosterone levels are difficult to measure in women, and there is no correlation between androgen levels and sexual desire. Although absolute testosterone levels decline with age, there is a relative increase in circulating free testosterone as sex hormone–binding globulin decreases in postmenopausal women. With the use of systemic estrogen therapy, sex hormone–binding globulin increases, causing a drop in free testosterone. Evidence supports the short-term efficacy and safety of transdermal testosterone in postmenopausal women with sexual dysfunction related to interest/arousal. Testosterone levels should be followed if treatment extends beyond 6 months. Potential risks include hirsutism, acne, and clitoral enlargement that may persist after medication discontinuation. Long-term effects regarding cardiovascular disease, breast cancer, and other cancer risks are unknown. Safety data on long-term use are lacking. There is insufficient evidence to support testosterone use in premenopausal women.

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

Female orgasmic disorder 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.

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.

Basson R. Testosterone therapy for reduced libido in women. Ther Adv Endocrinol Metab. 2010 Aug;1(4):155-64. doi: 10.1177/2042018810379588. PMID: 23148160; PMCID: PMC3474615.

Initial publication August 2023

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


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