Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

sexual interest/arousal disorder

1st line – psychological therapy

Back
ONGOING
|
sexual interest/arousal disorder
1st line – 

psychological therapy

Use of each of the psychological treatments (psychoeducation, cognitive behavioral therapy [CBT], sex therapy, psychotherapy, mindfulness, and mindfulness-based cognitive therapy [MBCT]) can be helpful for women with sexual interest/arousal disorder.

Psychoeducation is given to all women treated for sexual concerns.

Psychoeducation that incorporates mindfulness has also been found helpful for women with sexual interest/arousal disorder.[125][126]

MBCT, in addition to other mindfulness practices, identifies maladaptive and exaggerated thoughts, but rather than changed, as in CBT, they are simply viewed as "mental events," "what the brain does," and not necessarily true. Encouragement is given to just let them exist for now without following or believing them. Benefit for women with sexual interest/arousal disorder as compared to detailed assessment and wait list has been shown.[126][127][144]

Consider – estrogen or dehydroepiandrosterone

Back
ONGOING
|
sexual interest/arousal disorder
Consider – 

estrogen or dehydroepiandrosterone

Treatment recommended for SOME patients in selected patient group

Vaginal estrogen: indicated if loss of genital arousal is due to vulvovaginal atrophy. Any vaginal formulation is appropriate (e.g., estradiol vaginal tablet, vaginal ring, or vaginal cream).[146] However, it should be noted that high-dose estradiol cream (containing estradiol 100 micrograms/g or 0.01%) should be limited to a single treatment period of up to 4 weeks due to the risk of adverse effects usually associated with systemic (oral or transdermal) hormone replacement therapy, and other vaginal estrogen formulations may be preferred.[147] There is no approval for use of vaginal estrogen in women with previous estrogen-dependent breast cancer; each woman must be assessed individually.[30] The American College of Obstetrics and Gynecologists advise that in these patients it should be reserved for those who are unresponsive to nonhormonal remedies.[148]

Systemic estrogen: only indicated if loss of genital congestion is identified to be due to vulvovaginal atrophy and systemic estrogen is preferred because of other menopausal health considerations. Meta-analysis suggests estrogens alone or in combination with progestogens can allow a small to moderate improvement in sexual function, but mostly in pain, but not in unselected postmenopausal women.[149]

Vaginal dehydroepiandrosterone (DHEA): preliminary evidence suggests vaginal DHEA benefits both atrophy (dryness and dyspareunia) and sexual response (orgasm intensity and desire/motivation).[46] It is approved by the Food and Drug Administration for dyspareunia related to menopause. Randomized controlled trials also confirm enhanced genital sexual sensitivity as reflected by ease and intensity of orgasm, and increased desire in postmenopausal women.[150]

Dose depends on type of estrogen and formulation; consult specialist for guidance on dose.

female orgasmic disorder (FOD)

1st line – psychological therapy

Back
ONGOING
|
female orgasmic disorder (FOD)
1st line – 

psychological therapy

Psychological methods are the mainstay of therapy in lifelong FOD.

Cognitive behavioral therapy (CBT) and behavioral techniques have been found across studies to be highly effective for women with lifelong FOD.[35] For all women with FOD, education on anatomy and physiology may be given, along with normalising the absence of coital orgasms, while simultaneously attending to affect and irrational thoughts.

First-line behavioral treatments are guided/directed self-stimulation and coital alignment technique (CAT).

Guided/directed self-stimulation: of the various behavioral techniques, directed self-stimulation is used most frequently and has the most empiric support for lifelong FOD. It involves education and information followed by body awareness exercises designed to enhance women's awareness of their genitals and to challenge any negative or distorted thoughts that might emerge. The exercises progressively increase in intensity, including using a hand-held mirror to enhance sensory experience, until the woman learns to reach orgasm on her own. She is then guided on how to transfer this new knowledge to a partner. Success rates for directed self-stimulation are high (80% to 90%), but the success rate for secondary FOD is lower (10% to 75%).[171][172]

CAT: CAT is a behavioral technique in which the male partner lies on top of and slightly more forward on his partner so that there is direct clitoral pressure during intercourse. One study that directly compared CAT with directed self-stimulation for women with secondary FOD found that CAT produced a significantly better response (37% of women in CAT group gained >50% improvement versus 18% in the directed self-stimulation group).[173]

Mindfulness: this involves learning to be present in the moment, and not react to potentially negative feelings or thoughts, but simply observe them and return to the sexual sensations. Although scientific study of the benefits is only just beginning, clinical experience supports the use of this meditative skill for FOD.

Mindfulness-based cognitive therapy: In addition to mindfulness practices, maladaptive and exaggerated thoughts are identified, but rather than changed, as in CBT, they are simply viewed as "mental events," "what the brain does," and not necessarily true. Encouragement is given to just let them exist for now without following or believing them. Benefit for women with sexual interest/arousal disorder as compared to detailed assessment and wait list has been shown.[126]

Psychological techniques used in lifelong FOD can also be effective in acquired cases. Interpersonal issues such as trust may need addressing. Personal psychological issues related to the woman's past may have surfaced (e.g., onset of problem coincident with giving birth) to lead to new onset orgasmic disorder.

Consider – vibrostimulation

Back
ONGOING
|
female orgasmic disorder (FOD)
Consider – 

vibrostimulation

Treatment recommended for SOME patients in selected patient group

Can increase the stimulus by providing more prolonged direct stimulation to clitoral tissue, including the clitoral bulbs deep to the superficial perineal muscles and around the urethra in the anterior vaginal wall (the so-called G spot). This can be recommended in addition to skills to stay focused such as mindfulness training, but outcomes have not been published.

When there is associated neurologic disease leading to acquired FOD, different and stronger means of sexual stimuli are encouraged (e.g., vibrostimulation, the use of fantasy, and stimulation of other parts of the body when there is loss of genital sensation). Treatment strategies vary depending on type of neurologic condition and sexual symptoms.[73] Women with spinal cord injury can have orgasms from vibrostimulation to the cervix.[73][74]

substance/medication-induced sexual dysfunction

1st line – psychological therapy

Back
ONGOING
|
substance/medication-induced sexual dysfunction
1st line – 

psychological therapy

Up to 70% of women prescribed antidepressants, if asked directly, will admit to medication-associated dysfunction.[174] A major limitation in this research is that both antidepressants and depression are associated with sexual dysfunction, so it is difficult to determine precise etiology.

General psychological techniques are applicable to women with antidepressant-induced FOD. Psychoeducation on the mechanisms by which iatrogenic FOD can affect a woman's sense of self, mood, and relationship is given. Mindfulness techniques that teach women to attune to genital arousal, and psychological techniques that encourage women to challenge irrational thoughts about themselves as being "dysfunctional," have shown to be helpful clinically.

Mindfulness-based cognitive therapy, in addition to mindfulness practices, identifies maladaptive and exaggerated thoughts, but rather than changed, as in cognitive behavioral therapy, they are simply viewed as "mental events," "what the brain does," and not necessarily true. Encouragement is given to just let them exist for now without following or believing them. Benefit for women with sexual interest/arousal disorder as compared to detailed assessment and wait list has been shown.[126]

Consider – review antidepressant therapy

Back
ONGOING
|
substance/medication-induced sexual dysfunction
Consider – 

review antidepressant therapy

Treatment recommended for SOME patients in selected patient group

For sexual dysfunction associated with antidepressant use, consider lowering the antidepressant dose; switching to an alternative antidepressant that is associated with a lower risk of sexual dysfunction (e.g., vilazodone, vortioxetine, bupropion); using an add-on treatment (e.g., bupropion, buspirone); or replacing medication with another mode of therapy if safe to do so.[153][154]

back arrow

Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer