Evaluation of Sexual Dysfunction
Female sexual dysfunction is defined as any sexual complaint or problem that results from disorders of desire, arousal, orgasm, or sexual pain and causes marked distress or interpersonal difficulty. The term “female sexual dysfunction” encompasses the clinical entities of hypoactive sexual desire disorder, arousal disorder, orgasmic disorder, dyspareunia, and vaginismus. Though this DSM-IV terminology is still commonly used, the updated DSM-V terminology includes: female sexual interest and arousal disorder, female orgasmic disorder, and genito-pelvic pain/penetration disorder. Hypoactive sexual desire disorder is the most common type of female sexual dysfunction, with estimated prevalence between 5.4-13.6%.
The etiology of female sexual dysfunction is multifactorial and may include biological, psychological, relationship, and sociocultural factors. Biological causes include chronic medical illnesses such as diabetes mellitus, hypertension, coronary artery disease, malignancies, and neurological disorders such as multiple sclerosis. Gynecologic conditions that may contribute to sexual dysfunction include vulvar dermatoses, vulvodynia, urinary incontinence, STIs, endometriosis, chronic pelvic pain, pelvic organ prolapse, and vulvovaginal atrophy.
Medications may also contribute to sexual dysfunction. The most common medications associated with sexual dysfunction are the selective serotonin reuptake inhibitors, with an incidence of associated sexual dysfunction of 30 to 70%. Most commonly, this manifests as hypoactive sexual desire. Other medications that are associated with sexual dysfunction include antihistamines, anticholinergics, antihypertensives, antipsychotics, and tricyclic antidepressants. Some hormonal medications, including aromatase inhibitors, selective estrogen receptor modulators, and GnRH agonists, may also be associated with sexual dysfunction. Data regarding the effect of combined hormonal contraceptives on sexual function is inconclusive.
Psychological factors impacting sexual function include depression, anxiety, psychotic disorders, and history of abuse. Relationship distress, partner sexual dysfunction, and certain cultural or religious views toward sexuality may all also contribute to sexual dysfunction.
Evaluation for sexual dysfunction should be a routine part of well woman care. Studies suggest that women do not frequently raise sexual dysfunction concerns but do want their health care provider to address these issues. A brief set of questions or a validated screening questionnaire, such as the Brief Sexual Symptom Checklist, Brief Profile of Female Sexual Dysfunction, or the PISQ+IR questionnaire in the setting of pelvic floor dysfunction, can serve as useful screening tools.
When sexual dysfunction is identified, an open discussion should ensue to obtain further information. Questioning should focus around determining the specific type of dysfunction (desire, arousal, orgasm, pain) as well as any previous treatments and the result of treatment. The patient’s complete past medical and social history should be elicited, with particular attention to chronic medical conditions, medications, and psychosocial factors such as relationship discord, life stage stressors, or history of physical, emotional, or sexual abuse. A physical examination should be performed with the patient’s permission and should include attention to any dermatologic abnormalities of the vulva and vagina, pelvic organ prolapse, vaginismus or pelvic floor muscle hypertonicity, and vulvovaginal atrophy. There are no specific laboratory or imaging tests that are routinely warranted in the evaluation of sexual dysfunction.
American College of Obstetricians and Gynecologists Committee on Practice Bulletins-Gynecology. ACOG Practice Bulletin No. 213: Female sexual dysfunction. Obstet Gynecol. 2019 Jul;134(1):e1-e18. doi: 10.1097/AOG.0000000000003324.
Kingsberg S, Rezaee R., Hypoactive sexual desire in women. Menopause. 2013 Dec;20(12):1284-300. doi: 10.1097/GME.0000000000000131.
Faubion S, Ruillo J. Sexual Dysfunction in Women: A Practical Approach. Am Fam Physician. 2015 Aug 15;92(4):281-8.
Initial Approval May 2019
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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.
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