Men and women initiate or agree to sexual activity for many reasons, including sharing sexual excitement and physical pleasure and experiencing affection, love, romance, or intimacy. However, women are more likely to report emotional motivations such as
Women access sexual desire (responsive desire) once sexual stimulation triggers excitement and pleasure (subjective arousal) and genital congestion (physical genital arousal). Desire for sexual satisfaction, which may or may not include one or multiple orgasms, builds as sexual activity and intimacy continue, and a physically and emotionally rewarding experience fulfills and reinforces the woman’s original motivations.
A woman’s sexual response cycle is strongly influenced by her mental health and by the quality of her relationship with her partner. Initial desire typically lessens with age but increases with a new partner at any age.
Sexual response includes the following:
Physiology of the female sexual response is incompletely understood but involves hormonal and central nervous system (CNS) factors.
Estrogens influence sexual response. It is suspected but not proved that androgens are involved and act via androgen receptors and estrogen receptors (after intracellular conversion of testosterone to estradiol). Estrogen helps maintain genital tissue sensitivity, vaginal pH, normal microflora, elasticity, lubrication, urinary continence, and pelvic muscle tone.
After menopause, ovarian estrogen production ceases, while ovarian androgen production varies. However, adrenal production of prohormones (eg, dehydroepiandrosterone sulfate [DHEAS]) that are converted to both androgens and estrogens in peripheral cells decreases starting in a woman’s 30s. Ovarian production of prohormones also declines after menopause. Overall, levels of androgen tend to stop decreasing at about age 60. Whether the decrease in sex hormone production plays any role in diminishing sexual desire, interest, or subjective arousal is unclear.
The brain produces sex hormones (neurosteroids) from cholesterol, and production may increase after menopause. Whether this documented increase is universal, whether it facilitates arousal as peripheral production decreases, and whether it is affected by exogenous hormone administration are all unknown.
Motivation is the wish to engage in sexual activity. There are many reasons for wanting sexual activity, including sexual interest or desire. Sexual interest or desire may be triggered by thoughts, words, sights, smells, or touch. Motivation may be obvious at the outset or may build once the woman is aroused.
Brain areas involved in cognition, emotion, motivation, and organization of genital congestion are activated. Neurotransmitters acting on specific receptors are involved. Based on known actions of drugs and on animal studies, some neurotransmitters appear to be prosexual; they include dopamine, norepinephrine, and melanocortin. Serotonin is usually sexually inhibitory, as are prolactin and gamma-aminobutyric acid (GABA).
This reflexive autonomic response occurs within seconds of a sexual stimulus and causes genital engorgement and lubrication. The brain's appraisal of the stimulus as biologically sexual, not necessarily as erotic or subjectively arousing, triggers this response. Smooth muscle cells around blood spaces in the vulva, clitoris, and vaginal arterioles dilate, increasing blood flow (engorgement) and transudation of interstitial fluid across the vaginal epithelium (lubrication). Women are not always aware of congestion; genital tingling and throbbing are more typically reported by younger women. As women age, basal genital blood flow decreases, but genital congestion in response to sexual stimuli (eg, erotic videos) may not.
Peak excitement occurs; it is accompanied by contractions of pelvic muscles every 0.8 seconds and is followed by slow release of genital congestion. Thoracolumbar sympathetic outflow tracts appear to be involved, but orgasm is possible even after complete spinal cord transection (when a vibrator is used to stimulate the cervix). Prolactin, antidiuretic hormone (ADH), and oxytocin are released at orgasm and may contribute to the sense of well-being, relaxation, or fatigue that follows (resolution). However, many women experience a sense of well-being and relaxation without experiencing any definite orgasm.
Female sexual dysfunction can be characterized by at least one of the following:
Female sexual dysfunction is diagnosed when any of these symptoms result in personal distress.
The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition [DSM-5]) includes the following types of female sexual dysfunction, classified based on symptoms:
Persistent genital arousal disorder is a separate, rare disorder not included in the DSM-5. It involves persistent excessive genital arousal that occurs when sexual desire is absent, there is no known cause, and arousal does not resolve with orgasm.
Female orgasmic disorder involves orgasm that is absent, markedly diminished in intensity, or markedly delayed in response to stimulation despite high levels of subjective arousal. Symptoms must occur during almost all sexual activities and must have been present for ≥ 6 months. Acquired orgasmic disorders are frequently related to a new disorder, including psychologic or behavioral disorders, or to anatomic changes (eg, due to cancer or surgery). Typically, women with orgasmic disorder have normal levels of sexual desire.
Genitopelvic pain/penetration disorder can be lifelong or acquired. It is characterized by the presence of ≥ 1 of the following symptoms for ≥ 6 months:
Deep pelvic pain and tension during penetration or superficial burning vulvovaginal pain caused by slight touch
Fear or anxiety before, during, or after penetration, which often leads to decreased sexual desire or avoidance of sexual activity
Reflexive tightening of the vaginal muscles when vaginal entry is attempted, making penetration difficult or impossible
Female sexual interest/arousal disorder is absence of or a decrease in ≥ 3 of the following for ≥ 6 months:
Interest in sexual activity
Initiation of sexual activity and responsiveness to a partner's initiation
Excitement or pleasure during almost all sexual activity
Sexual or erotic fantasies or thoughts
Genital or nongenital sensations during sexual activity
Interest or arousal in response to internal or external sexual or erotic stimuli (eg, written, verbal, visual)
In substance/medication-induced sexual dysfunction, sexual dysfunction is related to initiation, change in dose, or discontinuation of a substance or drug.
Other specified and unspecified sexual dysfunction includes sexual dysfunction that does not meet criteria for the other categories.
A sexual dysfunction disorder is typically diagnosed when symptoms have been present for ≥ 6 months and cause significant distress. Some women may not be distressed or bothered by decreased or absent sexual desire, interest, arousal, or orgasm.
Almost all women with sexual dysfunction have features of more than one disorder. For example, genitopelvic pain/penetration disorder often leads to sexual interest/arousal disorder; impaired arousal may make sex less enjoyable or even painful, decreasing the likelihood of orgasm and subsequent sexual motivation. However, pain during intercourse due to impaired lubrication may occur as an isolated symptom in women with a high level of sexual desire, interest, and subjective arousal.
Female sexual disorders may be secondarily categorized as lifelong or acquired; situation-specific or generalized; and mild, moderate, or severe based on the degree of distress it causes the woman.
Although research is limited, these disorders probably apply equally to women in heterosexual and homosexual relationships.
The traditional separation of psychologic and physical etiologies is artificial; psychologic distress causes changes in hormonal and neurologic physiology, and physical changes may generate psychologic reactions that compound the dysfunction. There are often several causes of symptoms within and between categories of dysfunction, and the cause is often unclear.
Mood disorders are closely correlated with low interest and arousal. In up to 80% of women with major depression and sexual dysfunction, sexual dysfunction becomes less severe when antidepressants effectively treat the depression. However, sexual dysfunction persists or worsens when antidepressants are ineffective. Women with an anxiety disorder are also more likely to have sexual dysfunction involving sexual interest, arousal, orgasm and genitopelvic pain disorders. Various fears—of letting go, of being vulnerable, of being rejected, or of losing control—and low self-esteem can contribute.
Previous experiences can affect a woman’s psychosexual development, as in the following:
Past negative sexual or other experiences may lead to low self-esteem, shame, or guilt.
Emotional, physical, or sexual abuse during childhood or adolescence can teach children to control and hide emotions—a useful defense mechanism—but such inhibition can make expressing sexual feelings difficult later.
Early traumatic loss of a parent or another loved one may inhibit intimacy with a sex partner for fear of similar loss.
Concerns about a negative outcome (eg, unwanted pregnancy, sexually transmitted diseases [STDs], inability to have an orgasm, sexual dysfunction in a partner) can also impair sexual response.
Contextual causes (those specific to a woman’s current situation) include the following:
Intrapersonal context: Low sexual self-image (eg, due to infertility, premature menopause, or surgical removal of a breast, the uterus, or another body part associated with sex)
Relationship context: Lack of trust, negative feelings, or reduced attraction toward a sex partner (eg, due to the partner’s behavior or to a growing awareness of a change in sexual orientation)
Sexual context: For example, surroundings that are not sufficiently erotic, private, or safe
Cultural context: For example, cultural restrictions on sexual activity
Distractions and emotional stress (eg, from family, work, or finances) can interfere with arousal.
Various genital lesions, systemic and hormonal factors, and drugs may lead or contribute to dysfunction (see table Some Physical Factors Contributing to Female Sexual Dysfunction).
Some Physical Factors Contributing to Female Sexual Dysfunction
Genitourinary syndrome of menopause
Vulvar dermatoses (eg, lichen sclerosus)
Postsurgical introital narrowing
Recurrent tearing of the posterior fourchette
Other physical factors
Bilateral oophorectomy in premenopausal women
Nerve damage (eg, due to diabetes, multiple sclerosis, peripheral neuropathy, or spinal cord dysfunction)
Beta-blockers and other antihypertensive drugs
Gonadotropin-releasing hormone agonists
Genitourinary syndrome of menopause describes symptoms and signs due to estrogen and androgen deficiency, such as
Genitourinary syndrome of menopause affects about half of menopausal women. Low estrogen levels can cause similar symptoms, as occur postpartum or during treatments with certain drugs such as aromatase inhibitors.
Selective serotonin reuptake inhibitors (SSRIs) are a particularly common drug cause of sexual dysfunction. SSRIs may contribute to several types of sexual dysfunction.
Alcohol dependence can cause sexual dysfunction.
Most sexual dysfunction disorders are diagnosed based on clinical criteria described by the DSM-5. These disorders include genitopelvic pain/penetration disorder, female orgasmic disorder, female sexual interest/arousal disorder, and substance/medication–induced sexual dysfunction. For diagnosis of all of these disorders, there must be no more likely alternative explanation for symptoms; for all except substance/medication–induced sexual dysfunction, symptoms must have been present for ≥ 6 months. If sexual dysfunction does not meet criteria for any of these disorders, dysfunction is categorized as other specified or unspecified sexual dysfunction according to DSM-5.
Diagnosis of sexual dysfunction and its causes is based on history and physical examination. Clinicians should routinely ask about sexual dysfunction to help decrease any related stigma. Validated questionnaires, such as the Female Sexual Function Index (FSFI), can help facilitate this practice.
Ideally, history is taken from both partners, interviewed separately and together; it begins by asking the woman to describe the problem in her own words and should include specific elements (see table Components of the Sexual History for Assessment of Female Sexual Dysfunction). Clinicians should also obtain a detailed sexual history. Problematic areas (eg, past negative sexual experiences, negative sexual self-image) identified at the first visit can be investigated more fully at a follow-up visit.
Components of the Sexual History for Assessment of Female Sexual Dysfunction
Physical examination, including the pelvic examination, is done to identify any gynecologic abnormalities that may be causing sexual dysfunction; this examination can often pinpoint the location of pain. The technique may differ slightly from that used in a routine gynecologic examination. Explaining what will occur during the examination helps the woman relax and should be continued throughout the examination. The examiner may ask the woman whether she wants to sit up and view her genitals in a mirror during the examination; doing so may impart a sense of control.
During the examination, the clinician should look for signs of low estrogen, particularly thinning of labia minora, loss of the labial fat pad, pale vaginal mucosa, and loss of vaginal folds. A moist cotton swab can be used to identify pain points on the vulva and vulvar vestibule.
Wet-preparation examination of vaginal discharge and Gram stain with culture or DNA probe to detect Neisseria gonorrhoeae and chlamydiae are indicated when history or examination suggests vulvitis, vaginitis, or pelvic inflammatory disease.
Unless an undiagnosed disorder is suspected, the initial evaluation of female sexual dysfunction typically does not require laboratory evaluation. Low estrogen is detected clinically during the examination. Sexual function does not correlate with testosterone levels, regardless of how they are measured. However, if hyperprolactinemia is clinically suspected, the prolactin level is measured. If a thyroid disorder is clinically suspected, appropriate testing is done; it includes thyroid-stimulating hormone if hypothyroidism is suspected, thyroxine (T4) if hyperthyroidism is suspected, and sometimes other thyroid function tests.
Treatment of sexual dysfunction in women varies by disorder and cause; often more than one treatment is required because disorders overlap. Even if criteria for a particular DSM-5 disorder are not completely met, treatment may help.
Sympathetic understanding and careful evaluation may themselves be therapeutic. Teaching women about sexual anatomy and physiology, including what is involved in the female sexual response may also help.
Treatment may require a multidisciplinary team, including sex counselors, pain specialists, psychotherapists, and/or physical therapists.
Contributing factors are corrected if possible, as for the following:
Treating mood disorders
If women are taking an SSRI, switching to an antidepressant that has fewer sexual adverse effects (eg, bupropion, moclobemide, mirtazapine, duloxetine) or possibly adding bupropion to an SSRI
For substance/medication–induced sexual dysfunction, stopping the abused substance or changing a prescription drug
Cognitive-behavioral therapy targets the negative and often catastrophic self-view resulting from illness (including gynecologic disorders) or from infertility.
Mindfulness, an eastern practice with roots in Buddhist meditation, may help. It focuses on nonjudgmental awareness of the present moment. Its practice helps free women from distractions that interfere with attention to sexual sensations. Mindfulness lessens sexual dysfunction in healthy women and in women who have pelvic cancer or provoked vestibulodynia. Women can be referred to community or Internet resources to learn how to practice mindfulness. Mindfulness-based cognitive therapy (MBCT) combines an adapted form of cognitive-behavioral therapy with mindfulness. As in cognitive-behavioral therapy, women are encouraged to identify maladaptive thoughts, but then to simply observe their presence, realizing that they are just mental events and may not reflect reality. This approach can make such thoughts less distracting. MBCT is used to prevent recurrent depression and can be adapted to treat sexual arousal disorder and sexual interest/arousal disorder as well as the chronic pain of provoked vestibulodynia.
Some women (eg, women with a history of sexual abuse) require more extensive psychotherapy.
Estrogen therapy can be used to treat sexual dysfunction in women with genitourinary syndrome of menopause. The atrophic changes in the vulva and vagina can be treated with low-dose vaginal estrogen (tablets, gels, creams, rings). Low-dose systemic estrogen or estrogen plus progesterone (in women with a uterus) can be used if women have concomitant vasomotor menopausal symptoms (eg, hot flushes). Ospemifene (a selective estrogen receptor modulator) may be useful in treating genitourinary syndrome of menopause.
Androgen therapy can be considered for postmenopausal women with sexual interest/arousal disorder. Transdermal testosterone (300 mcg once a day) is used. Testosterone levels should be measured at baseline and after 3 to 6 weeks. Short-term treatment is recommended, and testosterone should be stopped if there is no response after 6 months of use. Monitoring for adverse effects such as acne, hirsutism, and virilization is indicated. Clinicians should clearly explain that evidence about testosterone therapy is limited, and they should provide detailed information about its harmful effects and benefits. Testosterone therapy should be considered only if other interventions have been unsuccessful and if the woman is generally healthy and has no contraindications. Long-term use of testosterone has not been studied as treatment for sexual interest/arousal disorder, and systemic dehydroepiandrosterone (DHEA) has been shown to be ineffective. Intravaginal prasterone (a DHEA preparation) can be used for postmenopausal women with dyspareunia and genitopelvic pain/penetration disorder).
Current evidence for using androgens to enhance women's sexual response is weak. Some evidence suggests that testosterone supplementation may modestly benefit women who have low sexual interest but are able to have satisfactory sexual experiences. Total androgen activity (measured as metabolites) is similar in women with or without sexual interest.
Flibanserin, a serotonin-receptor agonist/antagonist, can be used to treat premenopausal women without depression; however, in a systematic review, the quality of evidence for effectiveness and safety was graded low and the beneficial effect was minimal (1). Flibanserin has black box warnings stating that ingesting flibanserin and alcohol close together, taking flibanserin with a moderate or strong CYP3A4 inhibitor, or having a hepatic impairment increases the risk of hypotension and syncope.
Some evidence suggests that women with sexual interest/arousal disorder due to use of SSRIs may benefit from adding bupropion (a norepinephrine-dopamine reuptake inhibitor). Some evidence suggests that if women stopped having orgasms when they started taking SSRIs, sildenafil (a phosphodiesterase type 5 inhibitor) may help them have orgasms again. However, study results have been contradictory; this drug is not recommended for this purpose in routine practice.
Pelvic floor physical therapy is a mainstay of treatment of women with genitopelvic pain/penetration disorder. Its aim is to teach women to relax the pelvic floor and decrease reflex tightening. Pelvic floor physical therapy includes pelvic floor muscle training, soft-tissue mobilization and myofascial release, trigger-point pressure, electrical stimulation, biofeedback, and therapeutic ultrasonography.
Prescription and nonprescription devices are available for self-dilation in women with tight pelvic muscles, which contribute to dyspareunia in genitopelvic pain/penetration disorder.
Depending on the type of dysfunction, sexual skills training (eg, instruction in masturbation) and exercises to facilitate communication with a partner about sexual needs and preferences can be implemented.
Various lubricants and moisturizers can reduce vaginal dryness, which causes dyspareunia. These treatments include food-based oils (eg, coconut oil), silicone-based products, and water-based products. Food-based oils should not be used with condoms, but silicone- and water-based lubricants can be used. If lubricants are needed, clinicians and the woman should discuss which kind of lubricant she should use.
Except in small pilot studies, there is scant evidence that devices such as vibrators or clitoral suction devices are effective in women with sexual interest/arousal or orgasmic disorder; however, some of these products are available over the counter and may be tried.
1. Jaspers L, Feys F, Bramer VM, et al: Efficacy and safety of flibanserin for the treatment of hypoactive sexual desire disorder in women: A systematic review and meta-analysis. JAMA Intern Med 176 (4):453–462, 2016. doi: 10.1001/jamainternmed.2015.8565
Female sexual dysfunction includes female sexual interest/arousal disorder, female orgasmic disorder, genitopelvic pain/penetration disorder, substance/medication–induced sexual dysfunction, and other specified and unspecified disorders.
Psychologic and physical factors usually contribute to female sexual dysfunction; they may interact with each other, worsening dysfunction.
Psychologic factors include mood disorders, effects of past experiences, concerns about a negative outcome, the woman's specific circumstances (eg, low sexual self-image), and distractions.
Physical factors include genital conditions, systemic and hormonal factors, and drugs (particularly SSRIs).
Interview both partners, separately and together if possible.
Incorporate psychologic therapies (eg, cognitive-behavioral therapy, mindfulness, a combination of the two [MBCT]) into treatment for most types of female sexual dysfunction.
When indicated, use drugs (eg, an estrogen) to treat some types of female sexual dysfunction.
Recommend pelvic floor physical therapy, a mainstay of treatment for genitopelvic pain/penetration disorder, and discuss which kinds of lubricants women should use if lubricants are needed.