Practice Essentials
Female sexual problems are common, although estimated prevalence varies greatly depending on who is asked and how the question is framed. Female sexual dysfunction (FSD) was recently redefined, and now includes Female Sexual Interest/Arousal Disorder (FSIAD) and Female Orgasmic Disorder and Genitopelvic Pain/Penetration Disorder. To be considered dysfunctional, these symptoms must cause distress and must occur at least 75% of the time over a 6-month period. This definition has been in place since the development of the Diagnostic and Statistical Manual, Fifth Edition (DSM-5) in 2013, and so incidence and prevalence data based on the new definitions are developing. [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11]
Pathophysiology
Possible causes of FSD are diverse and overlapping, and the initial etiology is sometimes an enormous challenge to discern. Etiologies include organic elements such as hormonal, neurological and vascular issues, as well as psychosocial factors such as relationship issues, social stressors, mood, history of physical or sexual abuse, and psychiatric history. In terms of physiology, neurotransmitters play an important role. Appropriate female sexual function requires a delicate balance of dopamine for desire, and epinephrine, norepinephrine, and serotonin for arousal and orgasm. Disorders and medications that disrupt these elements may lead to FSD. Hormonal deficits may be another factor in pathophysiology. The decrease in estrogen associated with menopause may induce decreased sexual desire and atrophy of genital tissue that leads to painful intercourse. [11]
Epidemiology
Past estimates of the incidence of FSD range from approximately 10% if distress is used as a criterion, to 75% of menopausal women, if symptoms alone are used as the criterion. The peak age group for female sexual dysfunction (FSD) consists of women aged 51-59 years, around the time of menopause; however, FSD can occur in women of all ages. [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11]
Prognosis
Prognosis is greatly dependent on the underlying etiology, the ability for the patient and partner to recognize the underlying problem, and the compliance of the couple with treatment. Although therapies exist for all types of sexual dysfunction, the prognosis is different depending on the severity of the dysfunction and the underlying etiologies. Prognosis may also vary based on whether the dysfunction is primary or secondary, and whether it is situational or generalized. [7, 12, 13, 14, 11]
Patient Education
It is important for patients to understand that sexual function is a part of women’s health, that normal sexual function is different from one person to the next, and that misinformation and lack of education are common barriers to discussing the topic. Many patients lack the language or the knowledge needed to openly and comfortably engage in working through this problem. Patients may have difficulty using the correct anatomic terms and knowledge of anatomic structure and function may be limited, including lack of awareness of the clitoris and female orgasm. It is the healthcare provider’s role to educate the patient about these issues, and to provide the patient with the tools necessary to establish a healthy discourse, negotiate safe and reasonable goals, and then identify potential solutions to her problems. [11]
When orgasm and arousal difficulties are associated with insufficient or ineffective genital stimulation, education related to ensuring stimulation may be helpful. [9] Some women may be unaware of the importance of clitoral stimulation in inducing arousal, and education regarding clitoral anatomy can be useful.
