Female sexual problems doctors should be aware of

The following article is the first in a two-part series on sexual dysfunction. This article focuses on sexual dysfunction in women, while the second will cover sexual dysfunction in men.

It’s not all bliss in the bedroom. According to the Cleveland Clinic, about 43% of women and 31% of men say they experience some degree of sexual dysfunction—and along with it, stigma.

Is female pleasure sidelined?

Despite the fact that sexual dysfunction is more common in women, male sexual dysfunction has received the lion’s share of attention in society, including more research and treatment options. In 1998, the FDA approved sildenafil (Viagra) for erectile dysfunction, and since then—thanks to an endless marketing blitz from pharmaceutical companies and new medicines—the topic of male sexual dysfunction has moved into the mainstream.  

The same can’t be said for women, however. Treatment options for sexual dysfunction in women have been much slower to arrive on the market, although some progress has been made. In 2013, the FDA approved ospemifene (Osphena) for moderate to severe painful intercourse in women. In 2015, the FDA green-lighted flibanserin (Addyi) for low sexual desire in premenopausal women. Most recently, the FDA approved bremelanotide (Vyleesi ) in 2019, also for premenopausal women with low sexual desire. 

Moreover, social stigma around female sexuality remains strong in Western culture, and as a result, women often avoid or are embarrassed to discuss their sexual health with their health care professionals (HCPs), according to the authors of an article in the Journal of Women’s Health.

“Based on cultural norms and biases, conversations about sex are sometimes thought of as taboo in American society and in many other cultures worldwide. This is especially true for women, and particularly when sex is for pleasure rather than reproductive purposes,” the authors wrote.

In addition, women in midlife are often unaware or have misconceptions about conditions that may adversely impact their sexual life, such as genitourinary syndrome of menopause and hypoactive sexual desire disorder. “Lack of training, tools, time, and limited treatment options impede HCPs from providing women with necessary sexual health support,” they added.

Any physician treating sexual dysfunction navigates a complex condition that’s emotionally charged and multi-layered. Let’s have a look at female sexual dysfunction.

Female sexual dysfunction

Sexual dysfunction in women typically presents as loss of desire, sexual pain, decreased arousal, and/or inability to reach orgasm—and these frequently overlap, according to the Journal of Women’s Health article. While sexual dysfunction can occur at any age, women in the menopausal transition and beyond tend to experience sexual health-related conditions or concerns more often. 

Sexual dysfunction in women is less recognized than its counterpart in males, but the subject is attracting more research, according to the authors of a review published in the Canadian Urological Association Journal (CUAJ).

“Fortunately,” wrote the authors, “over the past decade there has been an increase in the clinical and academic interest in female sexual function. The times appear to be changing.” 

Today, there are published guidelines and position papers that reinforce the practical aspects of female sexual dysfunction evaluation and management, an increase in research on the impact of cancer and its treatment on female sexual function, along with the new FDA-approved therapies for low desire and sexual pain, they added.

Here’s a closer look at the four common categories of female sexual dysfunction. 

Low sexual desire

Loss of sexual desire in women can be distressing and is the most common of the sexual disorders in women, according to the Mayo Clinic.

Various etiologies for low sexual desire exist, including medical conditions (eg, cancer, kidney failure, multiple sclerosis; heart disease, or bladder problems; hormonal changes due to menopause or childbirth/breastfeeding; medications (eg, certain antidepressants, antipsychotics, opioids); hormonal contraception; and psychosocial factors like untreated anxiety and depression, or a history of sexual abuse.

Treatment often entails a multidisciplinary approach, and can include sex education and counseling; medications like the above-mentioned FDA-approved flibanserin and bremelanotide for premenopausal women; hormone therapy such as estrogen, testosterone (or ospemifene, if sexual pain is related to low desire); a vaginal insert called prasterone (Intrarosa); and lifestyle remedies, such as exercise, stress reduction, taking time for sexual intimacy, and more.

Sexual pain

Sexual pain refers to pain associated with sexual stimulation or vaginal contact. Sexual pain is common among women of all ages and includes vulvar pain (eg, vulvodynia); deep pain with penetration (dyspareunia); or tightening of the pelvic musculature.

Many conditions can cause sexual pain, including insufficient lubrication, vulvar skin lesions such as lichen sclerosus and lichen planus, pelvic floor muscle abnormalities leading to deeper pelvic pain, and endocrine abnormalities such as low testosterone or changes induced by oral contraception. 

Depending on the cause, treatment can include vulvar physiotherapy, switching forms of contraception, and topical anesthetics. The above-mentioned treatment ospemifene is indicated for moderate to severe painful intercourse in women, and prasterone (Intrarosa) vaginal capsules are also designed to relieve dyspareunia. 

Emerging research is also investigating local hormone treatment with intravaginal testosterone and estradiol-releasing vaginal rings, according to the CUAJ article. Vaginal laser therapy is also being explored, the authors wrote, and resection of vestibular tissues with posterior vaginal advancement flap (ie, vestibulectomy) can also be considered for refractory and severe cases of vulvodynia.

Low arousal

Low arousal—difficulty or inability to become or stay physically aroused or excited during sexual activity—can present as a decrease in vaginal lubrication or genital warmth due to decreased blood flow. A full medical and sexual history and physical examination should be conducted. 

Low arousal states can be due to hypertension, hyperlipidemia, or diabetes, and should be treated. Also, low arousal may be related to hormonal changes following menopause. A decrease in estrogen leads to decreased blood flow to the pelvic region, which can result in less genital sensation, as well as needing more time to build arousal and reach orgasm, according to the Mayo Clinic.

In some, but not all, women with low arousal, PDE5 inhibitors (eg, sildenafil) have shown some efficacy, according to the CUAJ article. Cognitive behavioral therapy may also be helpful.

Orgasmic dysfunction

Some women complain of delayed, less intense, or absent orgasm, which can be lifelong or acquired. In women, orgasmic dysfunction often co-occurs with sexual pain or poor arousal. The clinician should identify any psychosocial contributors. Orgasmic dysfunction can also be induced by phimosis, or covering, of the clitoris, with or without an underlying pathology, such as lichen sclerosus.

Treatment for orgasmic dysfunction is challenging and can involve mindfulness training, yoga, directed masturbation, use of sex toys, and sex therapy. Because SSRIs can delay or vanquish orgasms, their doses can be reduced. Other physicians have experimented with testosterone supplementation, dopamine agonists, yohimbine hydrochloride, and PDE5 inhibitors when treating this condition, according to the CUAJ article.

Bottom line

Female sexual dysfunction is distressing for many women and warrants medical attention. Unfortunately, sexual dysfunction, in general, is often minimized due to cultural stigma. Clinicians should attain a robust history and physical examination and look for possible contributors and stressors. Treatment of sexual dysfunction can be complex and often requires a multidisciplinary approach. Physicians should thus have a low threshold for appropriate referral to the proper specialists.