UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Sexual dysfunction in women: Management

Author
Jan L Shifren, MD
Section Editor
Robert L Barbieri, MD
Deputy Editor
Sandy J Falk, MD, FACOG

INTRODUCTION

Sexual problems are highly prevalent in women. In the United States, approximately 40 percent of women have sexual concerns and 12 percent report distressing sexual problems [1]. Female sexual dysfunction takes different forms, including lack of sexual desire, impaired arousal, inability to achieve orgasm, pain with sexual activity, or a combination of these issues. Treatment must be tailored to the sexual dysfunction diagnosis or diagnoses and to underlying physical and psychological factors.

The management of female sexual dysfunction will be reviewed here. The epidemiology, risk factors, and evaluation of female sexual dysfunction and evaluation and treatment of sexual pain disorders are discussed separately. The epidemiology, pathogenesis, clinical manifestations, course, assessment, diagnosis, and treatment of female orgasmic disorder are also described separately. (See "Sexual dysfunction in women: Epidemiology, risk factors, and evaluation" and "Approach to the woman with sexual pain" and "Differential diagnosis of sexual pain in women" and "Female orgasmic disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Treatment of female orgasmic disorder".)

APPROACH TO MANAGEMENT

Female sexual dysfunction is multifactorial, often with several different etiologies contributing to the problem. Nonetheless, careful evaluation and use of available therapies can improve sexual function for many women.

Complete the evaluation and diagnosis — Evaluate the patient for all sexual issues and associated physical or psychological factors before starting treatment. Most women with sexual complaints have issues that impact more than one phase of the normal sexual response cycle (desire, arousal, orgasm) or may complain of a general decrease in sexual satisfaction. As an example, if a woman complains of decreased libido, a full evaluation may also reveal issues with arousal or pain. We restrict use of pharmacologic therapy to women who meet diagnostic criteria for a sexual disorder and for whom non-pharmacologic interventions have proven ineffective. A sexual disorder is defined as a sexual problem that is persistent or recurrent and causes marked distress or interpersonal difficulty. It must not be better accounted for by a general medical or psychiatric condition (ie, anxiety and depression) or due exclusively to the direct physiologic effects of a substance or medication (See "Sexual dysfunction in women: Epidemiology, risk factors, and evaluation", section on 'Diagnostic evaluation'.)

In addition, sexual complaints usually arise in the context of other physical, psychological, and relationship issues.

                                         

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Thu May 19 00:00:00 GMT 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Shifren JL, Monz BU, Russo PA, et al. Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol 2008; 112:970.
  2. Sarwer DB, Durlak JA. A field trial of the effectiveness of behavioral treatment for sexual dysfunctions. J Sex Marital Ther 1997; 23:87.
  3. Pace G, Silvestri V, Gualá L, Vicentini C. Body mass index, urinary incontinence, and female sexual dysfunction: how they affect female postmenopausal health. Menopause 2009; 16:1188.
  4. Billups KL, Berman L, Berman J, et al. A new non-pharmacological vacuum therapy for female sexual dysfunction. J Sex Marital Ther 2001; 27:435.
  5. North American Menopause Society. The role of testosterone therapy in postmenopausal women: position statement of The North American Menopause Society. Menopause 2005; 12:496.
  6. Somboonporn W, Davis S, Seif MW, Bell R. Testosterone for peri- and postmenopausal women. Cochrane Database Syst Rev 2005; :CD004509.
  7. Modelska K, Cummings S. Female sexual dysfunction in postmenopausal women: systematic review of placebo-controlled trials. Am J Obstet Gynecol 2003; 188:286.
  8. Buster JE, Kingsberg SA, Aguirre O, et al. Testosterone patch for low sexual desire in surgically menopausal women: a randomized trial. Obstet Gynecol 2005; 105:944.
  9. Davis SR, van der Mooren MJ, van Lunsen RH, et al. Efficacy and safety of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomized, placebo-controlled trial. Menopause 2006; 13:387.
  10. Shifren JL, Davis SR, Moreau M, et al. Testosterone patch for the treatment of hypoactive sexual desire disorder in naturally menopausal women: results from the INTIMATE NM1 Study. Menopause 2006; 13:770.
  11. Braunstein GD, Sundwall DA, Katz M, et al. Safety and efficacy of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomized, placebo-controlled trial. Arch Intern Med 2005; 165:1582.
  12. Davis SR, Moreau M, Kroll R, et al. Testosterone for low libido in postmenopausal women not taking estrogen. N Engl J Med 2008; 359:2005.
  13. Blümel JE, Del Pino M, Aprikian D, et al. Effect of androgens combined with hormone therapy on quality of life in post-menopausal women with sexual dysfunction. Gynecol Endocrinol 2008; 24:691.
  14. Simon J, Braunstein G, Nachtigall L, et al. Testosterone patch increases sexual activity and desire in surgically menopausal women with hypoactive sexual desire disorder. J Clin Endocrinol Metab 2005; 90:5226.
  15. El-Hage G, Eden JA, Manga RZ. A double-blind, randomized, placebo-controlled trial of the effect of testosterone cream on the sexual motivation of menopausal hysterectomized women with hypoactive sexual desire disorder. Climacteric 2007; 10:335.
  16. http://www.biosantepharma.com/LibiGel.php (Accessed on March 13, 2012).
  17. Sexual dysfunctions. In: Diagnostic and Statistical Manual of Mental Disorders, 5th ed., American Psychiatric Association, Arlington, Virginia 2013.
  18. Basson, R. Int Journal Impotence Research 2008; 20;466.
  19. Morales AJ, Nolan JJ, Nelson JC, Yen SS. Effects of replacement dose of dehydroepiandrosterone in men and women of advancing age. J Clin Endocrinol Metab 1994; 78:1360.
  20. Barnhart KT, Freeman E, Grisso JA, et al. The effect of dehydroepiandrosterone supplementation to symptomatic perimenopausal women on serum endocrine profiles, lipid parameters, and health-related quality of life. J Clin Endocrinol Metab 1999; 84:3896.
  21. Davis SR, Panjari M, Stanczyk FZ. Clinical review: DHEA replacement for postmenopausal women. J Clin Endocrinol Metab 2011; 96:1642.
  22. Labrie F, Archer D, Bouchard C, et al. Effect of intravaginal dehydroepiandrosterone (Prasterone) on libido and sexual dysfunction in postmenopausal women. Menopause 2009; 16:923.
  23. Davis S, Papalia MA, Norman RJ, et al. Safety and efficacy of a testosterone metered-dose transdermal spray for treating decreased sexual satisfaction in premenopausal women: a randomized trial. Ann Intern Med 2008; 148:569.
  24. Goldstat R, Briganti E, Tran J, et al. Transdermal testosterone therapy improves well-being, mood, and sexual function in premenopausal women. Menopause 2003; 10:390.
  25. Chudakov, B. J Sex Med. 2007 Jan;4(1):204.
  26. http://www.redorbit.com/news/health/108270/fda_says_more_study_of_intrinsa_necessary/index.html. (Accessed June 8, 2009).
  27. Hameed A, Brothwood T, Bouloux P. Delivery of testosterone replacement therapy. Curr Opin Investig Drugs 2003; 4:1213.
  28. Parasrampuria J, Schwartz K, Petesch R. Quality control of dehydroepiandrosterone dietary supplement products. JAMA 1998; 280:1565.
  29. http://www.fda.gov/bbs/topics/NEWS/2009/NEW02011.html (Accessed May 12, 2009).
  30. Braunstein GD. Safety of testosterone treatment in postmenopausal women. Fertil Steril 2007; 88:1.
  31. Lukanova A, Lundin E, Micheli A, et al. Circulating levels of sex steroid hormones and risk of endometrial cancer in postmenopausal women. Int J Cancer 2004; 108:425.
  32. Allen NE, Key TJ, Dossus L, et al. Endogenous sex hormones and endometrial cancer risk in women in the European Prospective Investigation into Cancer and Nutrition (EPIC). Endocr Relat Cancer 2008; 15:485.
  33. Jongen VH, Thijssen JH, Hollema H, et al. Is aromatase cytochrome P450 involved in the pathogenesis of endometrioid endometrial cancer? Int J Gynecol Cancer 2005; 15:529.
  34. Tan O, Bradshaw K, Carr BR. Management of vulvovaginal atrophy-related sexual dysfunction in postmenopausal women: an up-to-date review. Menopause 2012; 19:109.
  35. Nijland EA, Weijmar Schultz WC, Nathorst-Boös J, et al. Tibolone and transdermal E2/NETA for the treatment of female sexual dysfunction in naturally menopausal women: results of a randomized active-controlled trial. J Sex Med 2008; 5:646.
  36. Cayan F, Dilek U, Pata O, Dilek S. Comparison of the effects of hormone therapy regimens, oral and vaginal estradiol, estradiol + drospirenone and tibolone, on sexual function in healthy postmenopausal women. J Sex Med 2008; 5:132.
  37. Osmanağaoğlu MA, Atasaral T, Baltaci D, Bozkaya H. Effect of different preparations of hormone therapy on sexual dysfunction in naturally postmenopausal women. Climacteric 2006; 9:464.
  38. Wu MH, Pan HA, Wang ST, et al. Quality of life and sexuality changes in postmenopausal women receiving tibolone therapy. Climacteric 2001; 4:314.
  39. Basson R, McInnes R, Smith MD, et al. Efficacy and safety of sildenafil citrate in women with sexual dysfunction associated with female sexual arousal disorder. J Womens Health Gend Based Med 2002; 11:367.
  40. Caruso S, Intelisano G, Lupo L, Agnello C. Premenopausal women affected by sexual arousal disorder treated with sildenafil: a double-blind, cross-over, placebo-controlled study. BJOG 2001; 108:623.
  41. Caruso S, Intelisano G, Farina M, et al. The function of sildenafil on female sexual pathways: a double-blind, cross-over, placebo-controlled study. Eur J Obstet Gynecol Reprod Biol 2003; 110:201.
  42. Basson R, Brotto LA. Sexual psychophysiology and effects of sildenafil citrate in oestrogenised women with acquired genital arousal disorder and impaired orgasm: a randomised controlled trial. BJOG 2003; 110:1014.
  43. Berman JR, Berman LA, Toler SM, et al. Safety and efficacy of sildenafil citrate for the treatment of female sexual arousal disorder: a double-blind, placebo controlled study. J Urol 2003; 170:2333.
  44. Nurnberg HG, Hensley PL, Heiman JR, et al. Sildenafil treatment of women with antidepressant-associated sexual dysfunction: a randomized controlled trial. JAMA 2008; 300:395.
  45. Caruso S, Rugolo S, Agnello C, et al. Sildenafil improves sexual functioning in premenopausal women with type 1 diabetes who are affected by sexual arousal disorder: a double-blind, crossover, placebo-controlled pilot study. Fertil Steril 2006; 85:1496.
  46. Dasgupta R, Wiseman OJ, Kanabar G, et al. Efficacy of sildenafil in the treatment of female sexual dysfunction due to multiple sclerosis. J Urol 2004; 171:1189.
  47. Sipski ML, Rosen RC, Alexander CJ, Hamer RM. Sildenafil effects on sexual and cardiovascular responses in women with spinal cord injury. Urology 2000; 55:812.
  48. Singh A, Kandimala G, Dewey RB Jr, O'Suilleabhain P. Risk factors for pathologic gambling and other compulsions among Parkinson's disease patients taking dopamine agonists. J Clin Neurosci 2007; 14:1178.
  49. Caruso S, Agnello C, Intelisano G, et al. Placebo-controlled study on efficacy and safety of daily apomorphine SL intake in premenopausal women affected by hypoactive sexual desire disorder and sexual arousal disorder. Urology 2004; 63:955.
  50. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm458734.htm (Accessed on August 24, 2015).
  51. Joffe HV, Chang C, Sewell C, et al. FDA Approval of Flibanserin--Treating Hypoactive Sexual Desire Disorder. N Engl J Med 2016; 374:101.
  52. Borsini F, Evans K, Jason K, et al. Pharmacology of flibanserin. CNS Drug Rev 2002; 8:117.
  53. Simon JA, Kingsberg SA, Shumel B, et al. Efficacy and safety of flibanserin in postmenopausal women with hypoactive sexual desire disorder: results of the SNOWDROP trial. Menopause 2014; 21:633.
  54. Jaspers L, Feys F, Bramer WM, et al. Efficacy and Safety of Flibanserin for the Treatment of Hypoactive Sexual Desire Disorder in Women: A Systematic Review and Meta-analysis. JAMA Intern Med 2016; 176:453.
  55. Derogatis LR, Komer L, Katz M, et al. Treatment of hypoactive sexual desire disorder in premenopausal women: efficacy of flibanserin in the VIOLET Study. J Sex Med 2012; 9:1074.
  56. Thorp J, Simon J, Dattani D, et al. Treatment of hypoactive sexual desire disorder in premenopausal women: efficacy of flibanserin in the DAISY study. J Sex Med 2012; 9:793.
  57. Gellad WF, Flynn KE, Alexander GC. Evaluation of Flibanserin: Science and Advocacy at the FDA. JAMA 2015; 314:869.
  58. Katz M, DeRogatis LR, Ackerman R, et al. Efficacy of flibanserin in women with hypoactive sexual desire disorder: results from the BEGONIA trial. J Sex Med 2013; 10:1807.
  59. Segraves RT, Clayton A, Croft H, et al. Bupropion sustained release for the treatment of hypoactive sexual desire disorder in premenopausal women. J Clin Psychopharmacol 2004; 24:339.
  60. Safarinejad MR, Hosseini SY, Asgari MA, et al. A randomized, double-blind, placebo-controlled study of the efficacy and safety of bupropion for treating hypoactive sexual desire disorder in ovulating women. BJU Int 2010; 106:832.
  61. Ju YH, Doerge DR, Helferich WG. A dietary supplement for female sexual dysfunction, Avlimil, stimulates the growth of estrogen-dependent breast tumors (MCF-7) implanted in ovariectomized athymic nude mice. Food Chem Toxicol 2008; 46:310.
  62. Ferguson DM, Steidle CP, Singh GS, et al. Randomized, placebo-controlled, double blind, crossover design trial of the efficacy and safety of Zestra for Women in women with and without female sexual arousal disorder. J Sex Marital Ther 2003; 29 Suppl 1:33.