History and exam
Key diagnostic factors
common
sexual symptoms leading to distress
Required for diagnosis.
absent/reduced interest in sexual activity (SIAD)
absent/reduced sexual/erotic thoughts or fantasies (SIAD)
Integral to the diagnosis of sexual interest/arousal disorder.[1]
absent/reduced sexual excitement/pleasure during sexual activity (SIAD)
no subjective arousal from erotic or sexual cues (SIAD)
Integral to the diagnosis of sexual interest/arousal disorder.[1]
absent/reduced awareness of genital or non-genital sensations during sexual activity (SIAD)
Integral to the diagnosis of sexual interest/arousal disorder.[1]
no/reduced initiation of sexual activity (SIAD)
orgasm absent or of minimal intensity (FOD)
Integral to the diagnosis of female orgasmic disorder.[1]
marked delay in orgasm (FOD)
Integral to the diagnosis of female orgasmic disorder.[1]
marked infrequency of orgasm (FOD)
Integral to the diagnosis of female orgasmic disorder.[1]
spontaneous, intrusive, unpleasant genital congestion and feeling of impending orgasm (PGAD/GPD)
Integral to the diagnosis of persistent genital arousal disorder.[116]
Other diagnostic factors
common
current stressors
Current stressors are strongly linked to sexual dysfunction (by increasing a woman's baseline level of anxiety or by acting as distractions in the immediate sexual scenario).[2][59]
Acute stressors can elicit negative sexual esteem while being sexual, which interferes with the capacity to experience sexual satisfaction and orgasm.[112]
negative emotions during sex
Because negative emotions arising during sex are usually associated with underlying negative thoughts and behaviours, a woman may implicitly be engaging in behaviour that reduces her ability to become aroused and experience desire (e.g., being attuned to parts of the experience she does not like, posturing her body in a manner not conducive to reaching arousal, allowing her mind to wander on non-sexual cues).[117][118]
vulvovaginal atrophy
Due to low oestrogen states.
uncommon
galactorrhoea
Highly suggestive of high prolactin, which is correlated with desire and arousal disorders.[77]
Risk factors
strong
depression
Depression is a major risk factor. Prevalence rates are as high as 50% to 80% for sexual dysfunction.[53][54]
Even after controlling for current depressive symptoms and psychotropic medicine, women with a past history of major depression are likely to have more arousal and desire problems than controls.[55][56]
Depression (and negative thoughts, especially about the future of the woman's relationship) emerge as a risk factor for every sexual dysfunction in women aged 40 to 80 years.[23]
antidepressant use
Highly serotonergic antidepressants may lessen desire and arousal and delay orgasm in up to 70% of women (if specifically asked), and sexual adverse effects represent a major reason for medicine non-compliance.[28][57]
Depression-associated sexual dysfunction is ameliorated in the vast majority of women provided that the depression remits, even when medicines with known sexually negative adverse effects are used.[53][54]
Factors predisposing to medicine-associated dysfunction include age, being without college or higher education, being without full-time work, having less sexual enjoyment prior to depression, taking concomitant medicines of all types, or having a comorbid illness that might affect sexual function.[58]
comorbid anxiety disorder
Women with anxiety disorders have higher prevalence of sexual concerns, including arousal disorders.[59]
Anxiety-induced cognitive distraction shifts attention from sexual on to non-sexual cues and is thought to be a major factor in the aetiology of sexual dysfunction.[60]
Anxiety associated with partner-presence is a major factor for female orgasmic disorder.
psychological aspects of cancer
Both the diagnosis and treatment of cancer have been shown to significantly impact women's sexual function.[61]
The most important predictors of dysfunction include changes in how a woman views herself sexually. These can be induced by a scar, breast removal, hair loss and other consequences of cancer treatment, poorer quality of relationship, and myths held by either partner about sexual problems that may exist between women with cancer and their partners.[62][63][64]
breast cancer
Sexual adverse effects, including symptoms of vaginal dryness and loss of libido are commonly reported by patients surviving breast cancer, and management needs to be both psychosexual and medical.[65][66][67]
Chemotherapy plays a major role in causing loss of desire, subjective arousal, vaginal dryness, and dyspareunia.[62][64][68]
Preliminary research suggests that the experience of chemotherapy, rather than hormonal factors, modulates its effects on sexual function.[69]
Tamoxifen does not consistently alter sexual function but aromatase inhibitors, by producing a state close to total absence of oestrogen activity, can be associated with severe symptoms of vulvar vaginal atrophy-associated dyspareunia and therefore loss of sexual motivation/interest.
gynaecological and other pelvic cancer
The extent and type of surgery can influence sexual outcome: radical vulvectomy and pelvic exenteration are the most extreme examples, whereas minimally invasive surgical procedures and sentinel lymph node mapping may allow fewer comprehensive lymphectomies and other complications.[70][71] Radiation can have profound effects on genital tissues acutely and in the longer term, plus there is risk of permanent infertility from damage to the dividing granulosa cells lining the follicles of maturing oocytes.[72] Cancer treatments commonly invoke sexual pain by different mechanisms.[63]
neurological disease
Sexual dysfunction is common.[30][73]
Spinal cord and peripheral nerve involvement (autonomic and somatic) interrupt sexual response.[73]
Involvement of the central nervous system usually impairs desire and arousal but occasionally may cause problematic high desire: for example, with lesions involving temporal lobe and amygdala, or in Parkinson's disease treated with dopaminergic agents.[30][74]
endometriosis
Sexual dysfunction is common among women with endometriosis. One study reported a prevalence of 73%.[75] Sexual function can be affected by physical symptoms of endometriosis (e.g., dyspareunia, chronic pelvic pain), physical and mental comorbidities, and psychosocial factors (e.g., personality traits, expectations, relationship stress, fertility concerns).[76]
hyperprolactinaemia
Women typically have reduced arousal and orgasm, and increased dyspareunia, without demonstrable changes in other hormones.[77]
radical hysterectomy (non-nerve-sparing)
Prevalence of dysfunction is unknown but the autonomic nerves, particularly those in the uterosacral and cardinal ligaments, may be disrupted unless nerve-sparing techniques are used. There is preliminary evidence of benefit from these techniques.[30][78][79]
Of note, studies have not supported a difference in sexual outcome in women who underwent vaginal, sub-total, or total hysterectomy. Overall sexual satisfaction improves in the majority of women.[80]
personality factors and attitudes
A woman's view of herself as a sexual person (i.e., her sexual self-image) strongly influences sexual function.[82]
Personal factors diminishing function include distractions, stress, concerns about STIs or unplanned pregnancies, lack of privacy, and having past negative sexual experiences or past non-sexual experiences whereby letting go of control and being vulnerable caused major distress.[26]
Suppression of anger either towards the current partner or towards parental or other figures in the past may result in suppression of emotions generally, including sexual emotions.
Studies have shown that women complaining of low desire and low arousal have vulnerable self-esteem, high levels of anxiety, guilt, and more negative body image, as well as higher personality traits of introversion, perfectionism, self-doubt, and somatisation.[4][82][83]
Negative or distorted beliefs about one's sexual function, the impact of ageing on sexual function, or low hopes about the future of the relationship have all been strongly predictive of women's low desire and female orgasmic disorder.[23]
relationship difficulties
A woman's feelings for her partner, or a recent change of partner, have been identified as major determinants of a woman's desire, responsivity, satisfaction, and freedom from distress about sex.[3][5][6][20][25][84] A relationship may affect non-heterosexual women differently, with research suggesting it affects function but not desire or interest.[85] Avoiding interpersonal closeness may predict orgasm difficulty.[27]
partner sexual dysfunction
premature ovarian failure
Women with primary ovarian failure have lowered sexual arousal and increased genital pain compared with control women. Of note, they also have more complaints of anxiety, depression, and psychological distress.[92]
Some 16% to 20% of women under 49 years old report low desire subsequent to recommended surgical menopause (resulting in unwanted fertility for some women).[15][16] However, women choosing elective bilateral oophorectomy with required hysterectomy for benign disease in mid-life do not develop sexual dysfunction in the next 3 years.[34][93]
renal failure
Anovulation, high prolactin, anaemia, and comorbid depression may all contribute to impaired sexual function.
Subjective arousal may improve after renal transplantation even though the vaginal congestive response does not.[101]
weak
reduced androgen activity
The role of testosterone in sexual function in women is not well understood.[88][89] Sexual dysfunction does not correlate with serum levels of testosterone.[7][8] Total androgenic activity (ovarian as reflected in the serum testosterone levels, plus testosterone produced in peripheral cells from adrenal substrates, including dehydroepiandrosterone [DHEA], DHEA sulfate [DHEAS], and androstenedione) does not appear to differ between women with or without sexual interest/arousal disorder.[9]
One 2019 systematic review found a consistent benefit from testosterone treatment for naturally and surgically menopausal women, regardless of oestrogen status. However, the clinical meaningfulness of the statistically significant benefit identified is much debated, and the lack of long-term safety data remains unaddressed.[90]
Intracellular production of androgens decreases with age due to the adrenal substrates reducing by around two-thirds. A number of studies report low DHEA levels in women with hypoactive sexual desire disorder.[52] However, limited research (focused neither on women with the disorder nor on women with low serum DHEA) of supplementing systemic DHEA has not shown benefit.[91]
oestrogen deficiency
Low oestrogen states are associated with the post-menopausal and post-partum state, gonadotrophin-releasing hormone agonist treatment, chemotherapy-induced ovarian failure, idiopathic ovarian failure, and sometimes with low-oestrogen combined contraceptives or depomedroxyprogesterone. Severe oestrogen depletion is associated with aromatase inhibitors.
Oestrogen levels have been correlated only with the sexual symptom of dryness dyspareunia.[5] However, clinical experience suggests that low oestrogen can also be associated with lost sexual sensitivity of genital tissues, which can lead to both female orgasmic disorder and loss of motivation to be sexual.
post-partum
Obstetric trauma and breastfeeding may contribute to post-partum sexual dysfunction.[89] Uncertainty about when to resume intercourse, reduced sexual desire, changes in body image, and concerns about physical healing following a vaginal delivery have all been suggested to predict post-partum sexual functioning in women.[94]
Delivery mode does not affect sexual function after 3 months post-partum.[95]
ageing
Most surveys do not report increased prevalence of disorder with age; the most common reason women give up on sex is lack of a functional partner. However, most studies only include those who are 'sexually active', and therefore omit women whose sexual dysfunction potentially precludes sexual activity.
One study reported an increased prevalence of reduced desire as a function of both menopausal status and age, increasing from 22% in the pre-menopausal group to 32% in the post-menopausal group.[96] As in many other studies, low desire was strongly associated with difficulties of arousal and orgasm.[96] One large longitudinal study of women over the 10-year menopausal transition showed a decline in desire and responsivity as a function of both age and menopause.[6] A larger study of 14,000 women from 17 countries found reduced lubrication as the only age-related factor for women, but only women engaging in intercourse in the last year were included.[23] Duration of relationship may be more important than age: using multivariate analysis, after adjusting for other factors, length of relationship, but not age, predicted low desire.[97]
For female orgasmic disorder, there is a decrease in prevalence with age.[98]
diabetes
Depression independently predicts sexual dysfunction in women with diabetes.[56][99][100]
Sexual dysfunction does not correlate with age, duration of disease, body mass index, glycaemic control, hormonal therapy, complications of disease, or menopausal status.
Reduced lubrication is the one dysfunction consistently seen more commonly in women with diabetes than in controls.[56]
cardiovascular disease
One study showed that atherosclerosis of the hypogastric pudendal arteries was associated with impaired sexual function, which became more severe after vascular intervention despite improved overall health.[102]
Compared with age-matched controls, both treated and non-treated pre-menopausal women with mild hypertension have reported decreased lubrication and poor orgasms.[103]
polycystic ovarian syndrome (PCOS)
There is no evidence that higher androgen levels associated with PCOS give protection from complaints of low desire and arousal. There is little research, but women with PCOS may have lower orgasmic function compared with controls.[104]
medication or substance use
Drugs that can negatively affect sexual function include antihypertensives (beta-blockers, thiazide diuretics), lithium, antipsychotics, benzodiazepines, anticonvulsants, gonadotrophin-releasing hormone agonists, aromatase inhibitors, anti-androgens (e.g., spironolactone), opioid analgesics, cocaine, and alcohol.[31] Studies on the role of oral contraceptives in sexual dysfunction have yielded contradictory results.[32][33]
hypothalamic-pituitary disease
The associated lack of testosterone might be relevant: one randomised controlled trial reported improvement in desire in women with hypopituitarism given testosterone along with oestrogen.[105]
infertility
lower urinary tract symptoms (LUTS)
LUTS with and without prolapse are correlated with sexual dysfunction.
Definitive surgery may or may not correct the dysfunction and may create new dysfunction.[108][109]
Anterior suspension for stress incontinence can decrease sensation, given that vaginal innervation is concentrated on the anterior and distal aspects of the vaginal wall.
Tension-free vaginal tapes can decrease genital sensation and vaginal lubrication.[109]
socio-economic status
In a study of women aged 18 to 59 years, more education was associated with fewer sexual concerns; however, in a study of women aged 40 to 80 years, more education was associated with a greater likelihood of genital arousal problems.[23][98]
Financial problems have been associated with female orgasmic disorder.
sexual abuse and developmental trauma
Sexual abuse is a significant problem globally. Survivors may be at increased risk for a number of sexual difficulties, including distrubances in desire, arousal, and orgasm.[110] Most studies have confirmed childhood sexual abuse to be a risk factor for adult sexual dysfunction.[111] However, in selected in university samples, childhood sexual abuse was is not associated with adult sexual dysfunction.[112]
Studies have associated prolonged stress due to childhood trauma with adult hypothalamic pituitary dysregulation with blunting of hormonal response to stress. While preventing harm from prolonged high cortisol levels during childhood, such blunting may be maladaptive in later life, increasing vulnerability to mental and physical health disorders.[113] Data from one study confirms similar dysregulation in 137 women diagnosed with hypoactive sexual desire disorder compared to 138 sexually healthy women.[52]
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