Version May 2024
INTRODUCTION — Sexual problems are reported by approximately 40 percent of females worldwide, and approximately 12 percent (one in every eight females) have a sexual problem associated with personal or interpersonal distress [1-5].
Female sexual dysfunction refers to a sexual problem associated with personal distress. It takes different forms, including lack of sexual desire, impaired arousal, inability to achieve orgasm, or pain with sexual activity [6]. Sexual dysfunction may be a problem since the start of sexual activity or may be acquired later in life after a period of normal sexual functioning.
The epidemiology, risk factors, and evaluation of female sexual dysfunction will be reviewed here. Management of female sexual dysfunction and evaluation and treatment of dyspareunia are discussed separately. The epidemiology, pathogenesis, clinical manifestations, course, assessment, diagnosis, and treatment of female orgasmic disorder are also discussed separately. (See "Overview of sexual dysfunction in females: Management" and "Female sexual pain: Evaluation" and "Female sexual pain: Differential diagnosis" and "Female orgasmic disorder: Epidemiology, clinical features, assessment, and diagnosis" and "Treatment of female orgasmic disorder".)
FEMALE SEXUAL RESPONSE CYCLE — An understanding of sexual response is helpful in the evaluation and treatment of sexual dysfunction.
The traditional description of the sexual response cycle was divided into four phases [7]: desire (libido), arousal (excitement), orgasm, and resolution. This framework cannot be applied consistently to a patient's sexual response. For many patients, the phases may vary in sequence, overlap, repeat, or be absent during some or all sexual encounters. Also, subjective satisfaction with the sexual experience may not require achieving all response phases, including orgasm.
As an example, for many patients in long-term relationships, desire may not be present prior to sexual activity but may increase with arousal in response to pleasurable activity [7]. While it is helpful to know which aspect of sexual function a problem impacts, many patients have concerns that relate to multiple aspects of sexual response.
Sexual response must also be understood within an interpersonal context. While desire may be an initiating factor for sexual activity, patients are also often motivated by other reasons, including a wish for emotional closeness or to strengthen a relationship with a partner [7].
Sexual pain disorders in females represent a separate category of sexual dysfunction, often with specific causes and therapies [8]. These include genitourinary syndrome of menopause (including vulvovaginal atrophy), pelvic floor hypertonus (previously known as vaginismus), and other forms of dyspareunia, which are discussed in detail separately. Sexual pain often contributes to problems of desire and arousal. (See "Female sexual pain: Evaluation" and "Female sexual pain: Differential diagnosis".)
ENDOCRINOLOGY
Role of estrogens — Declining levels of estrogens in peri- and postmenopausal patients have been associated with changes in sexual function, most commonly from the effects of hypoestrogenism on vulvovaginal tissues and the pelvic floor. Vasomotor symptoms may also cause discomfort or sleep disturbance that impact sexual function.
Genitourinary syndrome of menopause (GSM) refers to urogenital signs and bothersome symptoms associated with postmenopausal estrogen deficiency and involves changes to the labia, vagina, urethra, and bladder [9]. GSM may include symptoms of genital dryness, burning, and irritation; sexual symptoms of diminished lubrication; decreased vasocongestion during sexual arousal [10]; and pain. Urinary symptoms include urgency, dysuria, and recurrent urinary tract infections and may also interfere with sexual activity. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis".)
Vulvovaginal atrophy (VVA) is one component of GSM and often results in sexual pain [11]. Low serum estrogen levels result in a thinning of the vulvovaginal mucosa associated with dryness, discomfort, and tissue fragility, which may result in small lacerations with sexual activity and postcoital bleeding.
Symptomatic VVA has a significant adverse effect on sexual function in perimenopausal patients. Representative studies include:
●In a longitudinal cohort study, over 400 perimenopausal patients were monitored with hormone levels and a sexuality questionnaire annually for up to eight years [12]. Declining levels of estradiol (E2) were associated with vaginal dryness and dyspareunia, while no aspect of sexual functioning correlated with any of the androgens measured (total testosterone, free testosterone index, and dehydroepiandrosterone sulfate [DHEA-S]).
●In the Vaginal Health: Insights, Views & Attitudes (VIVA) survey of menopausal patients, 48 percent reported vaginal discomfort, most often vaginal dryness (85 percent) and dyspareunia (52 percent) with a negative impact on quality of life [13].
●In the Clarifying Vaginal Atrophy's Impact on Sex and Relationships (CLOSER) survey, menopausal patients with vaginal discomfort experienced loss of libido and avoided intimacy, which was confirmed by male partners [14].
In addition to GSM, the role of other menopausal symptoms is discussed below. (See 'Age and menopause' below.)
Females who are hypoestrogenic from other causes, including hypothalamic amenorrhea or postpartum, also may experience painful sex due to VVA.
Role of androgens — Androgens likely play a role in female sexual function; however, the magnitude of this role is uncertain [15]. In most studies, androgen levels do not correlate with female sexual function. However, supraphysiologic doses of androgen therapy have been found to increase libido and sexual frequency.
The major androgens in females, as in males, are DHEA-S, dehydroepiandrosterone (DHEA), androstenedione, testosterone, and dihydrotestosterone. Nearly all (98 percent) circulating testosterone is protein bound (mainly to sex-hormone binding globulin [SHBG] or albumin). The unbound, or free, fraction is biologically active, although binding to albumin is weak so even the albumin-bound portion may also be bioavailable [16]. Thus, factors that increase SHBG concentrations (eg, pregnancy, oral contraceptives, or oral estrogen therapy) will decrease free testosterone. Transdermal estrogen therapy (in physiologic doses) does not affect SHBG levels and has minimal impact on free testosterone concentration [17]. Given this effect, transdermal rather than oral estrogen therapy would be advised in a menopausal patient with sexual concerns initiating estrogen therapy. In an ancillary study of the Kronos Early Estrogen Prevention Study (KEEPS) of recently menopausal patients [18], treatment with transdermal E2 improved overall sexual function score compared with placebo, while treatment with oral E2 did not. SHBG levels were unchanged with transdermal E2 and increased with oral estrogen treatment, so the varying effect of estrogen formulation on sexual function in this study may reflect the impact of varying free testosterone levels. (See "Overview of androgen deficiency and therapy in females", section on 'Androgen production'.)
Ovarian and adrenal androgen production decrease throughout a patient's life, so a patient in their 50s has approximately half the circulating testosterone they had in their 20s. Unlike estrogen, which declines significantly with natural menopause, ovarian testosterone production remains relatively constant. New-onset sexual dysfunction with natural menopause, therefore, should not be attributed to changes in testosterone levels. With surgical menopause (ie, bilateral oophorectomy), testosterone levels decrease by approximately 50 percent. However, the majority of studies on the effect of bilateral oophorectomy on sexual function do not identify a significant change in sexual function postoperatively [19-21].
In studies that evaluated hormone levels and sexual function in females, the correlation between androgen levels and sexual function is unclear. In a meta-analysis of 34 observational studies including over 3200 females (mean age 36.5 years) evaluating the association between endogenous androgens and sexual desire, patients without sexual dysfunction compared with patients with sexual dysfunction had higher endogenous levels of total testosterone (standardized mean difference [SMD] 0.55, 95% CI 0.28-0.82), free testosterone (SMD 0.55, 95% CI 0.17-0.92), and DHEA-S (SMD 0.55, 95% CI 0.31-0.79) [22]. By contrast, in other studies this correlation is either weak or nonexistent [12,23-28]. As an example, in a study of over 2900 females ages 42 to 52 years, no association was found between sexual function and levels of testosterone, DHEA-S, and SHBG [24].
Furthermore, patients with high androgen levels due to polycystic ovarian syndrome (PCOS) do not exhibit beneficial sexual effects. In fact, sexual function in patients with PCOS appears to be similar or worse compared with patients without PCOS [29,30]. A negative influence on sexuality in PCOS may be due to changes in self-image from PCOS-related hirsutism, obesity, and acne [31,32].
Adrenal insufficiency may be a special case, as some data suggest that young females with this condition may show improvement in sexual function with the addition of DHEA to their replacement regimen, although the effects on sexual function were inconsistent [33-35]. Systemic DHEA therapy does not appear to improve sexual function in patients without adrenal insufficiency [36].
Some studies have found positive effects on female sexual function with exogenous androgens given at physiologic levels. Several randomized trials evaluated physiologic transdermal (patch) testosterone treatment in a total of more than 1500 surgically and naturally menopausal patients with low sexual desire associated with distress and no other etiologic factors [37-39]. Satisfying sexual activity, desire, arousal, and response increased significantly in patients receiving testosterone compared with those receiving placebo. Although these studies do not prove that low testosterone causes sexual dysfunction, they suggest a role for testosterone in female sexuality. However, these findings were not confirmed in two randomized trials reported by the manufacturer of a topical testosterone gel, which showed no significant increase in sexual desire or the number of sexually satisfying events compared with placebo, despite achieving testosterone blood levels similar to those seen in clinical trials of the testosterone patch [40].
Studies of androgen therapy in which females were treated with supraphysiologic doses have shown some positive effects on sexual function, but this does not address the question of the role of androgens in normal female sexuality [41,42]. As an example, a randomized trial of intramuscular testosterone administration in postmenopausal patients demonstrated that significant improvement in sexual function occurs only with supraphysiologic dosing. Patients were assigned to receive weekly intramuscular injections of placebo or testosterone (3, 6.25, 12.5, or 25 mg) for 24 weeks [43]. Compared with placebo, significant increases in libido and sexual frequency were seen only in patients assigned to the highest testosterone group, in which circulating testosterone levels approached the lower limit of normal for men.
CLINICAL APPROACH — Sexual function issues should be addressed as part of every comprehensive health visit. Unfortunately, most sexual problems in females remain unrecognized and untreated. Asking a patient whether she has a sexual concern is easily incorporated into a clinician's questions about gynecologic health, along with asking whether she is sexually active, practices safe sex, uses contraception (if indicated), and has any current or past experience of sexual abuse.
Many clinicians avoid asking about sexual concerns because they do not feel they have the time or knowledge to address these issues. A useful strategy is to defer full evaluation and treatment until a follow-up visit or refer the patient to a clinician experienced in sexual health, unless a sexual concern is raised that requires immediate attention (eg, patient is unsafe or at high risk of a sexually transmitted infection). The patient is often grateful to be asked about sexual concerns. Patients should be informed that you appreciate their sharing their concerns, that many females experience sexual problems, and effective treatments are available. While awaiting the follow-up visit to fully address the sexual problem, encourage your patient to read about sexual problems in females. (See "Overview of sexual dysfunction in females: Management", section on 'Resources for clinicians and patients'.)
At the follow-up visit, a detailed history of the sexual problem is essential (table 1). By identifying the onset of the problem and contributing factors, the appropriate intervention is often clear. If a patient experienced low desire upon reaching menopause (eg, concurrent with the onset of vaginal dryness, dyspareunia, hot flashes, and sleep disruption), treatment of her menopausal symptoms is likely to improve her low libido. If problems with arousal and orgasmic response started after the onset of depression or initiation of a selective serotonin reuptake inhibitor, sexual function should improve with treatment of the mood disorder and/or use of an antidepressant less likely to affect sexual function, such as bupropion. Addressing sources of discomfort during sexual activity, including arthritis or endometriosis, or treating urinary or fecal incontinence often improves sexual interest and satisfaction. Likewise, identifying that the onset of low libido was associated with the birth of a baby, a cancer diagnosis, or infidelity in the relationship informs etiology and approach to treatment.
Sexual health concerns are usually multifactorial. Relationship and family issues often play a role as does work or other sources of stress. Poor body image (eg, associated with weight gain or cancer surgery) may adversely affect sexual interest and response. Patients should be informed that they are not alone, many females have sexual problems, and just sharing a concern and wanting improvement is a good first step.
EPIDEMIOLOGY — Sexual concerns are reported by approximately 40 percent of females worldwide [1-5]. This was demonstrated in a study conducted in 29 countries among almost 14,000 females ages 40 to 80 years responding to a questionnaire in person or on the telephone [4]. The most commonly reported problems were low sexual desire (26 to 43 percent) and inability to reach orgasm (18 to 41 percent). For all categories of sexual problems, prevalence was highest in Southeast Asia (Indonesia, Malaysia, Philippines, Singapore, and Thailand) and lowest in Northern Europe (Austria, Belgium, Germany, Sweden, and the United Kingdom). In a survey of over 25,000 females in China, 29.7 percent reported sexual problems [5].
Most studies have not assessed whether sexual issues are associated with personal distress, a key requirement for diagnosis of female sexual dysfunction (see 'Diagnostic criteria' below). In addition, some studies still exclude females who are not in sexual relationships, so that females for whom sexual dysfunction is a barrier to forming sexual relationships or those experiencing a problem with unpartnered sexual activity are not assessed [44].
The largest United States study of female sexual dysfunction, Prevalence of Female Sexual Problems Associated with Distress and Determinants of Treatment Seeking (PRESIDE), did measure personal distress and included females who were not currently in a sexual relationship; over 30,000 females responded to validated questionnaires regarding low desire, low arousal, orgasm difficulties, and sexually related distress [1]. The prevalence of any of these three sexual problems (with or without distress) was 43 percent; 22 percent reported sexually related personal distress, and 12 percent reported distress related to a sexual problem, meeting criteria for sexual dysfunction.
Low desire was the most common sexual problem reported (39 percent of females) and was associated with distress in 10 to 14 percent [1]. Low arousal (26 percent) and orgasm difficulties (21 percent) were slightly less prevalent and were both associated with distress in 5 percent of females [1].
Data regarding sexual pain disorders are often not reported by studies of female sexual dysfunction; thus, there are fewer data about the prevalence of these conditions. In studies of over 1000 females, reported rates of pain during sex ranged from 14 to 16 percent [2,45]. In postmenopausal patients, genitourinary syndrome of menopause with bothersome vaginal dryness results in uncomfortable sexual activity in approximately 40 percent of patients [46,47].
RISK FACTORS — The etiology of sexual dysfunction is often multifactorial and may include psychological problems such as depression or anxiety, conflict within the relationship, fatigue, stress, lack of privacy, issues relating to prior physical or sexual abuse, medications, or physical problems that make sexual activity uncomfortable, such as endometriosis or genitourinary syndrome of menopause (GSM). In general, the reasons for sexual dysfunction are similar in females who have sex with females as in those who have sex with males. Large, population-based studies assessing sexual dysfunction in transgender or nonbinary individuals are not available.
The presence of any serious medical condition is likely to impair sexual function due not only to the condition itself but also to the associated impact on physical and psychological well-being. In a study of sexuality in females ages 57 to 85 years, physical health was more strongly associated with sexual problems than age alone [48]. In the PRESIDE study, poor self-assessed health was a significant correlate of distressing sexual problems.
Relationship factors — In addition to overall physical and mental health, the relationship with a partner is a principal determinant of sexual satisfaction:
●In a national probability sample of almost 1000 females ages 20 to 65 years, the best predictors of sexual distress were markers of general emotional well-being and relationship with a partner [26].
●In the Women's International Study of Health and Sexuality (WISHeS), a questionnaire study of over 2000 females, low sexual desire with distress was associated with emotional and psychological distress, lower sexual and partner satisfaction, and decrements in general health status, including aspects of mental and physical health [49].
●In a longitudinal study of over 400 females studied across the menopausal transition, sexual response was predicted by prior level of sexual function, change in partner status, and feelings for partner, demonstrating that relationship factors were more important than hormonal determinants of sexual function for midlife females [50]. Similarly, when examining correlates of sexual function among multiethnic middle-aged females in the Study of Women's Health Across the Nation (SWAN), variables having the greatest association included relationship factors [51].
Relationship duration has a major effect on sexual satisfaction. In a study of over 1800 males and females between the ages of 19 to 32 years in stable relationships, sexual activity and satisfaction declined as the duration of partnership increased [52]. Interestingly, sexual desire over time declined only for females, while desire for tenderness declined in men and rose in females.
A partner's sexual problems, most commonly erectile dysfunction, will also influence a patient's sexual experience. For many patients, simply not having a spouse or intimate partner may be a limitation [48].
A history of sexual or physical abuse is a major risk factor for sexual problems. In a community-based epidemiologic study of over 3000 females ages 30 to 79 years, the odds of female sexual dysfunction were doubled by childhood and adult abuse [53].
The effect of pornography on sexual dysfunction in females is unclear [54,55].
Fatigue and stress — Fatigue and stress are not often studied as risk factors for female sexual dysfunction, but based on clinical experience, they have a major impact on libido for females. Fatigue may be due to family or work pressures or a medical problem, including cardiovascular disease, anemia, chronic obstructive pulmonary disease, or depression. For example, after the birth of a child, in addition to physical changes, fatigue and meeting the demands of an infant significantly decrease sexual interest for many patients. (See "Overview of the postpartum period: Disorders and complications", section on 'Sexual dysfunction'.)
At midlife, beyond the endocrinologic changes, patients are often challenged by the needs of older adult parents and adolescent children, career demands, and a partner's midlife changes. The typical improvement in sexual interest and response on vacation reflects the negative impact of fatigue and stress on female sexuality.
Age and menopause — The effect of age on sexual function in females is complex as it is difficult to differentiate the effect of age itself from the effect of menopause and life changes inherent to growing older [1,2,26].
In the PRESIDE study, presence of distressing sexual problems was age related; although all sexual problems increased with advancing age, the prevalence of sexual problems associated with distress was highest in females ages 45 to 64 years (15 percent), lowest in females 65 years or older (9 percent), and intermediate in females ages 18 to 44 years (11 percent) [1]. Rates of low desire associated with distress followed an age-related pattern similar to that for any sexual problem.
By contrast, in the National Health and Social Life Survey study in which 1749 females were interviewed, prevalence of sexual problems tended to decrease with increasing age, except for reports of trouble with lubrication. Of note, only females ages 18 to 59 years who had a sexual partner within the past year were included in this study [2]. In a national probability study of over 1500 females ages 57 to 85 years, sexual activity declined with age, although 40 percent of females ages 65 to 74 years and 17 percent of those over 75 years reported sexual activity. Approximately one-half of females studied reported a sexual problem, although sexually related personal distress was not assessed [48].
Menopausal status correlates closely with age, and the likelihood of the onset of sexual disorders with menopause appears to depend on the specific type of sexual dysfunction. Vaginal dryness and dyspareunia are consistently increased after menopause, related primarily to the lack of estrogen on vaginal tissue [56]. Postmenopausal patients are also more likely to report low desire or arousal [1,13,14,49,57]. (See 'Role of estrogens' above.)
In addition, greater impairment of sexual function may be associated with surgical versus natural menopause. In natural menopause, estrogen levels are low, but ovarian androgen production is maintained at premenopausal levels (see 'Role of androgens' above). In the PRESIDE study, surgical, but not natural, menopause was associated with orgasm problems and the decrease in arousal was greater in females after surgical menopause [1]. Similarly, in one retrospective study of patients following hysterectomy, patients who had bilateral oophorectomy reported significantly decreased sexual satisfaction postoperatively, despite estrogen treatment, compared with patients who had their ovaries preserved [58]. On the other hand, this result was not observed in a subsequent prospective study that found sexuality was unaltered postoperatively in patients following hysterectomy with bilateral oophorectomy [19]. Furthermore, a cross-sectional study of over 1000 females found no difference in sexual ideation in patients age 57 years or older who had undergone oophorectomy [59].
Hormonal changes alone may not account directly for changes in sexual function. Menopausal symptoms may have an independent adverse effect on sexuality [1,60]. As an example, in a study of 341 peri- and postmenopausal patients, common menopausal symptoms, including night sweats, sleep disturbances, and mood changes, were associated with diminished libido [60].
Other life changes that occur at the time of menopause may also supersede the effect of hormonal changes [12,57]. This was illustrated in a study of 200 females ages 51 to 61 years that found menopause had a smaller impact on sexual functioning than overall health, mental health, or having a new partner [57]. Sexual dysfunction in older females is generally multifactorial. In a study involving individual interviews and focus groups, causes of low libido in females over age 60 years included postmenopausal vaginal symptoms, erectile dysfunction in male partners, body image concerns, fatigue and bodily pain, and life stressors [61]. In a community-based study of 2000 Australian females aged 40 to 65 years, factors associated with low libido included being partnered, vaginal dryness, pain with intercourse, depressive symptoms, and use of psychotropic medication [62].
The effects of menopause and age on sexual function are also discussed separately. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis" and "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment" and "Sexual dysfunction in older adults" and "Clinical manifestations and diagnosis of menopause", section on 'Genitourinary syndrome of menopause'.)
Psychiatric disorders and medications — Several psychiatric symptoms and disorders have been associated with sexual dysfunction:
●Depression – Depression is present in 17 to 26 percent of females who report low sexual desire [63,64] and was a significant correlate of distressing sexual problems in the PRESIDE study [1].
●Anxiety – Anxiety was a significant correlate of distressing sexual problems in the PRESIDE study [1] and anxiety disorders are risk factors for sexual dysfunction [65].
●Psychosis – Psychotic disorders are risk factors for sexual dysfunction [65].
Several classes of psychotropic medications are associated with sexual dysfunction:
●Selective serotonin receptor inhibitors (SSRIs) can cause low desire and difficulty with orgasm in females. (See "Sexual dysfunction caused by selective serotonin reuptake inhibitors (SSRIs): Management".)
●Antipsychotic medications are associated with sexual dysfunction in both males and females [66-68]. These medications inhibit dopamine, which may serve as a central neuromodulator of sexual function. It is also possible that a resultant increase in prolactin, causing gonadal suppression, affects sexual function.
●Second-generation antipsychotic medications (eg, aripiprazole) generally raise prolactin levels to a lesser degree than first-generation antipsychotics (eg, chlorpromazine or haloperidol) and thus may have less of an impact on sexual function. This is discussed in detail elsewhere. (See "First-generation antipsychotic medications: Pharmacology, administration, and comparative side effects" and "Second-generation antipsychotic medications: Pharmacology, administration, and side effects".)
●Benzodiazepines are associated with sexual dysfunction, specifically loss of libido [69-71].
Gynecologic issues
Pregnancy and childbirth — Sexual function appears to be diminished during pregnancy and is often impacted during the postpartum period [72].
Given the extraordinary fatigue and stress associated with the arrival of an infant, and the strain on couples of an enlarging family, the etiology of sexual dysfunction in the postpartum period is multifactorial and extends beyond anatomic and hormonal changes. Within three months postpartum, 80 to 93 percent of patients have resumed sexual intercourse [73]. Sexual problems, including low desire and dyspareunia, are common during the postpartum period. As an example, in a study of over 400 primiparous females, 83 percent reported sexual problems at three months postpartum and 64 percent at six months [74]. (See "Overview of the postpartum period: Disorders and complications", section on 'Sexual dysfunction'.)
Mode of birth does not appear to impact sexual function [75]. Data are inconsistent regarding the risk of dyspareunia at six or more months following episiotomy, severe vaginal or perineal laceration, or operative vaginal birth [73,74,76]. As an example, a study of 1094 patients age 40 years or older found no significant difference in patients with a history of vaginal birth alone compared with cesarean birth in rates of low desire or low sexual satisfaction [77]. Patients with a history of operative vaginal birth were 1.4-fold more likely to report low desire. Greater parity was not associated with increased risk of reporting low sexual desire or low sexual satisfaction.
In the PRESIDE study, parous patients were not more likely to have sexual dysfunction than those who were nulliparous [1].
Although having children is a risk factor for sexual problems so, too, is infertility [78,79]. Sexual problems are commonly associated with the diagnosis and treatment of infertility, and females are more frequently affected than males [80]. Most infertile couples will be advised about timing and frequency of intercourse, with the goal of optimizing pregnancy rather than pleasure. After months or years of unsuccessful attempts at conception, sex may become associated with frustration and failure.
Pelvic organ prolapse and incontinence — Pelvic organ prolapse and urinary incontinence are also associated with female sexual problems [81,82].
Sexual dysfunction is reported by 26 to 47 percent of females with urinary incontinence [83]. Among females with urinary incontinence, 11 to 45 percent experience urinary incontinence during sexual intercourse, typically during penetration or orgasm [81,84]. Urinary incontinence was a significant correlate of distressing sexual problems in the PRESIDE study [1]. In females with both prolapse and urinary incontinence, the rate of sexual dysfunction appears to be higher than with either condition alone [85].
While some patients report improved sexual function after surgical repair of pelvic floor disorders, others report no change or the development of dyspareunia [86,87].
The impact of pelvic floor issues on sexual function is discussed in detail separately. (See "Sexual function in females with pelvic floor and lower urinary tract disorders".)
Endometriosis — Deep dyspareunia is a cardinal symptom of endometriosis, which may adversely affect sexual function. (See "Endometriosis: Clinical features, evaluation, and diagnosis".)
Uterine fibroids — Patients with uterine fibroids may experience deep dyspareunia. Heavy and irregular bleeding caused by fibroids and resulting anemia and fatigue also may impair sexual function. (See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on 'Pelvic pressure or pain'.)
Genitourinary syndrome of menopause — GSM may adversely affect sexual function. (See 'Role of estrogens' above.)
Other medical conditions
Endocrine disorders
●Diabetes – The effect of diabetes on female sexuality is uncertain. While one study found reduced genital sensation in females with diabetes [88], studies comparing sexual dysfunction in females with and without diabetes have yielded inconsistent results [89,90].
●Hyperthyroidism – Females with overt hyperthyroidism may be at an increased risk of sexual dysfunction. In one meta-analysis including three case-control studies, overt hyperthyroidism (89 patients) was associated with a twofold higher risk of sexual dysfunction (diminished sexual arousal, lubrication, orgasm, and satisfaction) compared with the general population (relative risk 2.51, 95% CI 1.47-4.28) [91]. The analysis did not address the effect of subclinical hyperthyroidism on sexual dysfunction.
●Hyperprolactinemia – Patients with hyperprolactinemia may also experience increased rates of sexual dysfunction. In a prospective study of 25 females with hyperprolactinemia compared with age-matched controls, hyperprolactinemia was associated with lower scores for sexual desire, arousal, lubrication, orgasm, and satisfaction [92]. Further study is needed to replicate these results and evaluate whether this is an independent effect of elevated prolactin levels or due to associated changes in hypothalamic or other pituitary hormones, principally hypoestrogenism [23]. (See "Clinical manifestations and evaluation of hyperprolactinemia", section on 'Menstrual cycle dysfunction'.)
Hypertension — Hypertension may be a risk factor for sexual dysfunction [93,94]. It remains unclear whether this is related to the hypertension itself or is an adverse effect of antihypertensive medications.
Several studies have reported that hypertensive females have higher rates of sexual dysfunction, including sexual pain, than normotensive females (42 versus 19 percent in one study) [94,95]. These studies also found no significant difference in sexual problems in females with treated compared with untreated hypertension. In addition, prospective data from a study of over 2700 postmenopausal patients found no association between sexual problems and antihypertensives [96]. In the PRESIDE study, having hypertension or taking medication to lower high blood pressure or high cholesterol was not significantly associated with any distressing sexual problems.
However, some data suggest that beta blockers have a detrimental effect on female sexual function. Effects of beta blockers on male sexual function are well known. Two small studies have reported that the risk of sexual dysfunction was greater in hypertensive females treated with beta blockers compared with those treated with other agents (69 versus 43 percent in one study) [94,97]. (See "Sexual activity in patients with cardiovascular disease".)
Neurologic disease — Females with multiple sclerosis and Parkinson disease report sexual dysfunction, the degree of which correlates with severity of disease [66]. Sensory dysfunction in the genital region is found in 62 percent of females with advanced multiple sclerosis [98]. (See "Manifestations of multiple sclerosis in adults", section on 'Sensory symptoms'.)
Sexual dysfunction has been reported in females who have epilepsy, particularly in association with the antiseizure medications lamotrigine, gabapentin, and topiramate [99-102].
Sexual issues related to neurologic symptoms or disorders are discussed separately. (See "Primary headache associated with sexual activity" and "Manifestations of multiple sclerosis in adults", section on 'Sexual dysfunction'.)
Other conditions — Obesity and a poor body image may negatively impact female sexual function [103]. Following bariatric surgery, females have significant improvements in sexual function, as assessed by the Female Sexual Function Index [104,105].
Females with interstitial cystitis/bladder pain syndrome often also have dyspareunia. This condition also may be associated with low libido or difficulty with arousal. (See "Interstitial cystitis/bladder pain syndrome: Clinical features and diagnosis", section on 'Epidemiology'.)
Females with medical conditions associated with chronic pain, including rheumatoid arthritis and fibromyalgia, are at risk for sexual problems, likely related to physical disability and psychiatric comorbidities [106,107].
Chronic kidney disease and dialysis have been associated with sexual dysfunction in both males and females [108]. In females, this may be related to associated anovulation, as well as to the burden of having a serious, chronic medical illness. Few studies exist concerning the treatment of decreased libido and sexual function in uremic females [109-112]. In one of the largest studies involving females from 27 dialysis units in Europe and South America (659 patients), sexual dysfunction was reported by 84 percent, but the only significantly associated factor related to renal disease was diuretic therapy, which was likely a marker for comorbid conditions [110,113]. (See "Sexual and reproductive health after kidney transplantation".)
Patients with cancer may experience sexual dysfunction during or after treatment [114]. At particular risk are those who undergo pelvic or breast surgery or radiation or who have chemotherapy-induced premature ovarian failure [115-117]. In addition, adjuvant endocrine therapy may result in sexual side effects. Aromatase inhibitor (AI) use results in profound hypoestrogenemia and is associated with a high incidence of sexual problems. In one study, patients treated with AIs were significantly more likely to report low sexual interest, insufficient lubrication, and dissatisfaction with their sex life compared with controls and tamoxifen-treated patients [118,119]. Fatigue associated with treatment, reactive depression and anxiety, distress related to infertility, and changes in body image following surgery on the breasts or pelvic organs also contribute to sexual dysfunction in patients with cancer. (See "Overview of sexual dysfunction in female cancer survivors".)
Other — Medications and other pharmacologically active substances may affect sexual function. Antihypertensives are discussed above. (See 'Hypertension' above.)
Hormonal contraceptives — There are conflicting data about the effect of hormonal contraceptives on female sexuality. The effect of oral contraceptives (OCs) has been a major focus of investigation, since concerns have been raised that these medications may be associated with decreased libido.
The largest study to address this issue was a prospective cohort study that found a decrease in interest in sex among patients using some birth control methods, but not others [120]. The results did not support any consistent pattern regarding estrogen-progestin versus progestin-only contraceptives or route of administration. The study included prospective cohort data from 1938 patients ages 14 to 45 years. Compared with patients who used the copper intrauterine device (IUD), decreased interest in sex was reported by patients using depot medroxyprogesterone, the progestin implant, and the estrogen-progestin vaginal ring. No effect on interest in sex was found in patients using the progestin IUD, estrogen-progestin OCs, or estrogen-progestin patch.
Other study results are mixed, with some showing decreased libido with OCs, and others showing increased libido and frequency of sexual encounters with use of hormonal contraceptives [121-127]. Other well-designed studies of nonoral delivery of estrogen-progestin contraceptives (patch, vaginal ring) [128,129] and of progestin-only contraceptive methods [123,125,130-132] have not found an association with sexual dysfunction. In addition, the different progestin components of OCs do not appear to influence sexual effects.
Relationship and other factors may confound the findings regarding the impact of hormonal contraceptives on female sexual function. Patients on hormonal contraceptives are more likely to be in a sexual relationship, and sexual activity may be facilitated by confidence in the ability to be sexually active without becoming pregnant. Conversely, libido may decrease with increased duration of a relationship and childcare responsibilities, which may contribute to the decreased libido observed in patients on hormonal contraceptives. (See 'Relationship factors' above.)
In terms of physiology, interest in the effect of OCs on sexual function derives from the potential role of androgens in female sexuality. OCs reduce ovarian testosterone production via suppression of pituitary luteinizing hormone secretion. In addition, the estrogen component of OCs increases sex hormone-binding globulin levels, decreasing free testosterone concentrations [121,133]. However, it remains unproven that any effect of OCs on sexual function is caused by the decrease in androgen activity. In fact, in OC users who report decreased libido, treatment with exogenous androgens does not improve desire [134]. (See 'Role of androgens' above.)
Also, while there is a dose-response relationship between the estrogen dose in OCs (eg, 35 versus 25 mcg) and suppression of androgens, higher doses of estrogen do not appear to increase the likelihood of sexual side effects [135].
Substance use — Nicotine may inhibit sexual arousal in females [136].
Alcohol and opioid use disorders may result in a hypogonadotropic state and impaired sexual function in both females and males [102,137].
In addition to endocrine changes, substance use disorders often are associated with poor mental and physical health, disrupted relationships, lowered social status, and financial instability, all of which will negatively impact sexual function.
DIAGNOSIS — Female sexual dysfunction is diagnosed by identifying diagnostic criteria through the medical and sexual history [138]. A pelvic examination is required for diagnosis of sexual pain disorders and strongly recommended for the evaluation of any sexual problem.
Diagnostic criteria — The American Psychiatric Association (APA) guidelines for sexual disorders require that a sexual problem be recurrent or persistent and cause personal distress or interpersonal difficulty to establish the diagnosis [6]. In addition, the problem must be present for at least six months and not be accounted for by a different diagnosis (eg, depression).
Sexual dysfunctions are defined in relation to one or more phases of the sexual response cycle, though in clinical practice, it is uncommon to see a disorder that is limited to a single phase [6]. In the diagnostic criteria published in 2013, several categories were combined and definitions were changed. The major categories are:
●Female sexual interest/arousal disorder (this includes the former categories hypoactive sexual desire disorder and female sexual arousal disorder) – Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three of the following:
•Absent/reduced interest in sexual activity.
•Absent/reduced sexual/erotic thoughts or fantasies.
•No/reduced initiation of sexual activity, and typically unreceptive to a partner’s attempts to initiate.
•Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approximately 75 to 100 percent) sexual encounters (in identified situational contexts or, if generalized, in all contexts).
•Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (eg, written, verbal, visual).
•Absent/reduced genital or nongenital sensations during sexual activity in almost all or all (approximately 75 to 100 percent) sexual encounters (in identified situational contexts or, if generalized, in all contexts).
●Female orgasmic disorder – Presence of either of the following symptoms and experienced on almost all or all (approximately 75 to 100 percent) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts):
•Marked delay, infrequency, or absence of orgasm.
•Markedly reduced intensity of orgasmic sensations.
(See "Female orgasmic disorder: Epidemiology, clinical features, assessment, and diagnosis" and "Treatment of female orgasmic disorder".)
●Genitopelvic pain/penetration disorder (this includes the former categories dyspareunia and vaginismus) – Persistent or recurrent difficulties with one (or more) of the following:
•Vaginal penetration during intercourse.
•Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts.
•Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration.
•Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.
●Substance/medication-induced sexual dysfunction – A clinically significant disturbance in sexual function is predominant in the clinical picture. There is evidence from the history, physical examination, or laboratory findings of both of the following:
•A significant disturbance in sexual function that developed during or soon after substance intoxication or withdrawal or after exposure to a medication.
•The involved substance/medication is capable of producing the symptoms.
•The disturbance is not better explained by a sexual dysfunction that is not substance/medication-induced. Such evidence of an independent sexual dysfunction could include the following: the symptoms precede the onset of the substance/medication use, the symptoms persist for a substantial period of time (eg, approximately one month) after the cessation of acute withdrawal or severe intoxication, or there is other evidence suggesting the existence of an independent nonsubstance/medication-induced sexual dysfunction (eg, a history of recurrent nonsubstance/medication-related episodes).
•The disturbance does not occur exclusively during the course of a delirium.
●Other specified sexual dysfunction – This category applies to presentations in which symptoms characteristic of a sexual dysfunction that cause clinically significant distress in the individual predominate but do not meet the full criteria for any of the disorders in the sexual dysfunctions diagnostic class (eg, "sexual aversion").
●Unspecified sexual dysfunction – This category applies to presentations in which symptoms characteristic of a sexual dysfunction that cause clinically significant distress in the individual predominate but do not meet the full criteria for any of the disorders in the sexual dysfunctions diagnostic class and there is insufficient information to make a more specific diagnosis.
Emerging concepts of normal female sexual function have focused on the differences between female and male sexuality. Specifically, spontaneous desire is unusual in females, except in new relationships, and thus, its absence is not necessarily a disorder. This further highlights that sexual symptoms should be elicited in the medical history but that making a diagnosis depends upon ascertaining that a symptom is associated with personal distress or interpersonal difficulty.
Desire in females may be responsive, commonly triggered by situational and emotional factors, exposure to erotic images, or physical proximity [139]. In addition, self-reports by females often do not distinguish between desire and arousal [139]. Arousal may relate to either thoughts and feelings or physiologic arousal, including genital vasocongestion and lubrication. Most studies identify little correlation between a patient's concerns of limited genital arousal and objective measures of vulvovaginal blood flow and engorgement.
DIAGNOSTIC EVALUATION — The evaluation of female sexual dysfunction includes a medical and sexual history. A pelvic examination is required for diagnosis only for the sexual pain disorders, but an examination is important in all patients with sexual problems to identify possible etiologic factors and associated conditions. Laboratory testing and imaging are required only to evaluate for associated conditions, as indicated by the history or physical examination.
Medical history — A complete medical history is necessary to identify comorbidities; medications; or psychological, relationship, lifestyle, or substance-related issues that may affect sexuality [44]. (See 'Risk factors' above.)
An assessment of sexual problems should be a part of every comprehensive health visit. Patients and health care providers may hesitate to bring up sexual concerns due to time constraints or embarrassment. The importance of asking about sexual function was demonstrated in a questionnaire study of over 1000 females seen for a primary care visit; 98 percent reported one or more sexual concerns, but only 18 percent of clinicians asked about sexual health [140]. Patients who discussed their sexual concerns with their clinician found the discussion helpful. Of approximately 3000 females identified in the PRESIDE study with a distressing sexual problem, only 6 percent of patients who sought medical advice scheduled a visit specifically for a sexual problem, and approximately 80 percent of the time, the patient, rather than the clinician, initiated the conversation [141].
A gynecologic history should include symptoms and conditions that may affect sexual activity or signal the need for further evaluation, including:
●Menopausal status (natural, surgical, or following chemotherapy or pelvic radiation)
●Pregnancy and childbirth history
●History of vulvovaginal or pelvic injury, cancer, or surgery
●Vulvovaginal or pelvic pain
●Vulvovaginal pruritus, dryness, or discharge
●Abnormal genital tract bleeding
●Urinary or fecal incontinence
●Urogenital prolapse
●Fibroids
●Endometriosis
●Infertility
The following questions help to assess whether the patient needs assistance to engage in safe sexual or relationship practices:
●Are you currently sexually active?
●Do you need contraception or preconceptional counseling?
●Are you practicing safe sex?
●Would you like to be screened for sexually transmitted infections?
●Do you feel safe in your relationship?
●Are you currently experiencing or have you ever experienced sexual abuse or assault?
(See "Contraception: Counseling and selection" and "The preconception office visit" and "Screening for sexually transmitted infections" and "Prevention of sexually transmitted infections" and "Intimate partner violence: Epidemiology and health consequences" and "Intimate partner violence: Diagnosis and screening".)
Sexual history
Eliciting sexual dysfunction symptoms — In addition to questions regarding basic gynecologic health, contraception, and safe sex practices, all patients should be asked an open-ended question, such as "Do you have any sexual concerns?"
Menopausal patients should be asked specifically about vaginal dryness and dyspareunia. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis".)
If the response is affirmative, there is typically inadequate time in the current encounter to complete a thorough sexual history and discuss treatment options. The approach we use is to inform the patient that sexual problems are common in patients, are important, and should be thoroughly evaluated. A follow-up visit is then scheduled to complete the sexual history and address the patient's sexual concerns.
How to take a sexual history — At the follow-up visit, a comprehensive sexual history is taken.
Useful questions are listed in the table (table 1). In addition, there are many questionnaires used to assess sexual dysfunction. For office assessment for hypoactive sexual desire disorder, the Decreased Sexual Desire Screener is useful [142].
Questions about sexual activity should be open-ended and nonjudgmental. Assumptions should not be made about the sex or number of a patient's sexual partners or about sexual practices. The history may begin with a general question, such as "Are you sexually active now or have you been in the past?" Patients may define "sexual activity" differently, so specific follow-up questions may be asked if the information is relevant to medical care.
Sexual dysfunction may be a lifelong problem or acquired later in life after a period of normal sexual functioning. In addition, it may be generalized or situational, and the patient should be asked if it occurs only in certain settings or with a specific partner. The patient should be asked about any factors (eg, relationship issues, illness) that were associated with the onset of the sexual issue.
Discussion of a patient's sexual concerns should include whether the issues are persistent or recurrent and whether they cause the patient personal distress or interpersonal difficulty.
As relationship factors are principal determinants of sexual satisfaction for patients, patients with partners should be asked about the quality of their relationships, including shared interests, communication, and time spent together enjoying activities unrelated to work or family responsibilities, often referred to as "date nights." A patient should also be asked whether her partner has sexual issues (eg, lack of desire or erectile dysfunction).
In studies of sexual function in older females, a common reason for sexual inactivity was not having a partner or a male partner's sexual problem [48]. As erectile dysfunction in men increases with aging, and females typically live longer than males, the "partner gap" becomes a major cause of sexual dissatisfaction for older females.
Distressing sexual problems also may exist outside of a partnered relationship, including low desire or anorgasmia. Patients without a sexual partner should also be asked about sexual concerns (eg, a patient may be distressed by anorgasmia with masturbation). For some patients, sexual concerns deter them from seeking a romantic relationship.
Patients should be asked about intimate partner violence or a history of sexual trauma. (See "Intimate partner violence: Diagnosis and screening".)
Physical examination — For diagnosis of sexual dysfunction, a pelvic examination is required only for the sexual pain disorders. However, we perform a pelvic examination in all patients with sexual concerns to confirm normal pelvic anatomy and to assess for genital or pelvic tenderness, lesions, pelvic organ prolapse, pelvic floor hypertonus, or vulvovaginal atrophy. A pelvic examination may be necessary to evaluate concerns raised by the medical history (eg, vaginal discharge or abnormal bleeding). (See "Female sexual pain: Evaluation", section on 'Physical examination' and "Sexual function in females with pelvic floor and lower urinary tract disorders", section on 'Our approach'.)
Laboratory evaluation — Laboratory testing should be performed only if indicated by history and/or examination.
Androgen levels should not be used to determine the cause of a sexual problem, as serum androgen concentrations do not appear to be an independent predictor of sexual function in females [12,23,24,140]. In addition, available laboratory assays for the low serum androgen levels seen in females are often unreliable [143,144]. This approach is supported by an Endocrine Society clinical practice guideline, which recommends against making a diagnosis of androgen deficiency because of the lack of both a well-defined clinical syndrome and age-based normative data for serum testosterone and free testosterone concentrations [145]. (See 'Role of androgens' above.)
Similarly, testing estradiol or other hormones (eg, follicle-stimulating hormone [FSH]) has no utility in evaluating sexual dysfunction. Menopause is best diagnosed clinically, with FSH testing reserved for patients with possible menopausal symptoms occurring at a young age. (See "Clinical manifestations and diagnosis of menopause", section on 'Diagnosis'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Female sexual dysfunction".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Sex problems in females (The Basics)" and "Patient education: Sex as you get older (The Basics)")
●Beyond the Basics topics (see "Patient education: Sexual problems in females (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Sexual problems are reported by approximately 40 percent of females worldwide, and approximately 12 percent (one in every eight females) have a sexual dysfunction associated with personal or interpersonal distress. (See 'Epidemiology' above.)
●Female sexual dysfunction includes lack of sexual desire, impaired arousal, inability to achieve orgasm, or pain with sexual activity associated with distress. For many patients, the phases may vary in sequence, overlap, or be present during some or all sexual encounters. Also, subjective satisfaction with the sexual experience may not require achieving all response phases, including orgasm. (See 'Female sexual response cycle' above.)
●To meet the diagnostic criteria for sexual dysfunction, a sexual problem must be recurrent or persistent and cause personal distress or interpersonal difficulty. (See 'Diagnosis' above.)
●A pelvic examination is required only for the diagnosis of sexual pain disorders; however, an examination is important in all patients with sexual problems to identify possible etiologic factors and associated conditions. (See 'Diagnostic evaluation' above.)
●Sexual function is strongly affected by relationship and sociocultural factors, medical conditions, and psychological issues. (See 'Risk factors' above.)
•A history of physical or sexual abuse is strongly associated with female sexual dysfunction. (See 'Relationship factors' above.)
•Depression and anxiety are strongly associated with female sexual dysfunction as are other medical conditions, including urinary or fecal incontinence, chronic pain conditions, cardiovascular and pulmonary disease, substance use disorders, renal failure, and cancer. (See 'Psychiatric disorders and medications' above and 'Other medical conditions' above.)
•Medications, specifically certain antidepressants (selective serotonin reuptake inhibitors), are associated with female sexual dysfunction. Other agents, including beta blockers, antipsychotics, and aromatase inhibitors may contribute to sexual problems. (See 'Other' above.)
●How estrogens and androgens affect sexuality is unclear. (See 'Endocrinology' above.)
•The effects of age and menopause on female sexual dysfunction vary considerably among patients. In general, sexual problems increase with aging, but distressing sexual problems peak in midlife. (See 'Age and menopause' above.)
•The lack of estrogen associated with menopause may cause vulvovaginal changes, hot flashes, and night sweats; resulting dyspareunia and fatigue contribute to sexual problems at midlife. (See 'Role of estrogens' above.)
•Hormonal contraception, including estrogen-progestin contraceptives, is unlikely to adversely affect female sexual function. (See 'Hormonal contraceptives' above.)
•Serum androgens and other reproductive hormone levels are not useful in evaluating female sexual dysfunction. (See 'Role of androgens' above and 'Laboratory evaluation' above.)
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