Sexual dysfunction in women

Case history #1

A 54-year-old teacher, 3 years post menopause, reports gradual reduction of sexual desire and interest for the past 4 years. She states her marriage of 15 years is sound with few conflicts. However, she feels her husband's career as a lawyer is his priority in life. When sexually active with her husband, she is very rarely aroused from physical stimulation, genital or nongenital. Neither is she aroused from literature nor movies. She has not self-stimulated since her teens. Her last orgasms were some 2 years ago. Past history includes postpartum depression. For the past 6 months she has taken citalopram, having been diagnosed with persistent depressive disorder rather than major depressive disorder. For 3 years she has received transdermal estradiol and oral progesterone daily. Physical exam is within normal limits and laboratory studies reveal a diagnosis of type 2 diabetes mellitus.

Case history #2

A 28-year-old woman complains of low desire and minimal arousal in terms of mental sexual excitement. However, she reports that vaginal lubrication is adequate. These symptoms have persisted throughout her present and only sexual relationship of 2 years. There is no past significant medical or psychiatric history or sexual abuse. For the past 10 years she has been taking ethinyl estradiol and desogestrel, initially for acne and currently also for birth control. She, unlike her husband, is sure she does not want children. Her upbringing was conservative with minimal sexual information. She speaks of being very work-focused and despite good achievement in her career is self-critical and expresses a poor self-image. Their sexual activity is intercourse-focused with minimal guiding from her to her husband as to how to please her. She has never self-stimulated. Routine laboratory studies, including TFTs, and physical exam are within normal limits.

Other presentations

The vignettes illustrate the common occurrence of both desire/interest and arousal difficulties.

Women with orgasmic disorder may also express a distressing reduction in their sexual desire/interest.

Sexual complaints not covered in the present topic include vaginal tightening and/or pain. In the case of vaginal tightening, the presenting complaint may be an unconsummated relationship with fear of vaginal penetration, with muscle tensing and an expressed fear of pain. In the case of vaginal pain (dyspareunia) with or without tightening, there may or may not be abnormalities on examination. When abnormalities are present, the most common findings are the allodynia of provoked vestibulodynia and the vulvar vaginal atrophy of localized estrogen deficiency. These physical findings may coincide, explaining an apparent failure of systemic estrogen treatment, necessitating adjuvant topical locally acting estrogen. In all of these situations, there may be associated sexual desire/interest and arousal disorders.