Female sexual dysfunction (FSD) is a complex and controversial disorder that includes components of desire and arousal and orgasmic and sex pain disorders (dyspareunia and vaginismus). Female sexual dysfunction can occur at all stages of life, and it may be ongoing or happen only once in a while. The incidence of sexual dysfunction in women was found to be 43% while it was 31% in men.

Female sexual dysfunction is multifactorial condition likely to be associated with numerous anatomical, physiological and psychological factors and likely to affect woman’s self- confidence, quality of life, mental status and relationships.

A sexual dysfunction is described when:

  • persists for a minimum of 6 months
  • causes clinically significant distress
  • is not better explained by a non-sexual mental disorder or as a consequence of severe relationship stress or other significant stressors
  • is not attributed to the effects of a substance or medication or another medical condition

Among women, sexual dysfunction can be divided into three categories: 

  1. Female sexual interest/arousal disorder
  2. Female orgasmic disorder (FOD)
  3. Genitopelvic pain/penetration disorder

Female sexual interest/arousal disorder

Low sexual desire is defined as the diminished libido, or lack of sex drive. Sexual arousal disorder is defined when women desire for sex might be intact, but women have difficulty or are unable to become aroused or maintain arousal during sexual activity. 

Sexual desire disorder is the most frequent complaint among women with sexual problems. Obstetricians and gynecologists should stress the fact that a creative and romantic dyadic (between two parties) relationship motivates couples to engage in sexual relations and correlates with sexual satisfaction. However, long-term relationships may reduce the spontaneous sexual desire and sexual thoughts in women.

The management of women with sexual desire/arousal dysfunction must take into account that this disorder may arise from organic and/or psychical factors (Pic. 1). 

Female orgasmic disorder (FOD)

The clitoris seems to be the most important anatomic structure to female orgasm, which can occur in women when the clitoris is effectively stimulated during masturbation, oral sex, anal intercourse, partner masturbation, or during vaginal intercourse. Orgasm disorder is defined as a persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. Up to 20–30% of women reported an inability to orgasm (anorgasmia) during sexual intercourse. 

Anorgasmia can occur after prolapse and urinary incontinence, and after surgical treatment due to alteration in sensitivity of the distal posterior and distal anterior parts of the vaginal wall. Moreover, predictors of orgasmic difficulty in women within the context of a partnered sexual experience include arousal issues, levels of distress, and latency to orgasm.

Genitopelvic pain/penetration disorder

Genitopelvic/penetration pain is described if pain occurs in the genital or pelvic area during vaginal intercourse or attempts at penetration. Sexual pain disorders may have a biological (e.g. vulvovaginal infections, dermatoses, hormonal, vascular, neurological, or iatrogenic), psychosexual and functional (pelvic floor hypertonicity) component. Context-related factors may contribute to this. A multisystemic, multidisciplinary approach is advised when treating female sexual pain, with attention to mucous membrane, pelvic floor experience of pain, sexual and relationship functioning, and psychosocial adjustment/sexual abuse.

Sexual functioning depends on changing hormonal phases, aging, lifestyle, psychosocial and physical factors. Sexual dysfunction is associated with diminished quality of life; therefore, recognizing special risk factors may provide earlier diagnosis and treatment of sexual dysfunction which increase quality of life.

Various validated instruments for the diagnosis of sexual dysfunction are available, and can help physicians identify it. However, most instruments are complex and designed to be applied by professionals with expertise in the area of sexuality, for specific situations, time or post treatment controls. 

Sexual problems are more common among infertile couples and are reported to be between 5 and 55 percent. Sexual dysfunctions can be the cause of infertility or the result of it.

Associated diseases

Cardiovascular disease, dyslipidemia (abnormal amount of lipids in the blood), or diabetes mellitus may be considered as early symptoms of the underlying disease, in which case the diagnosis serves as sentinel complementary actions. 

Complications

Sexual activity is important to the overall health and well-being of an individual. Sexual dysfunction leads to negative effects on interpersonal and social relationships, and on the well-being and the quality of life of women. Numerous clinical, psychological and social conditions may affect this important aspect of life, and patients may report full recovery only if normal sexual activities are restored. Female sexuality and sexual relations also depend heavily on the mores of each era and society.

Risk factors

Drugs, depression, surgery and trauma in the pelvic region are factors that are frequently associated with sexual difficulties in women. Sexual abuse may have physical and emotional implications for women, who are at high risk for depression, anxiety, worries, loneliness, low quality of life, as well as sexual problems. The interventions in these cases may require an interdisciplinary approach.

Relationship between sexual dysfunctions and infertility can be mutual. Infertility can be the result of sexual problems itself, also having a desirable sexual relationship may increase fertility. It seems like orgasm might help a woman conceive, but it does not seem to matter.

Frequent sexual intercourse is imperative for conceiving, particularly on fertile days. Fertile days are a window of fertility during the menstrual cycle includes the day of ovulation and the 5 days prior. If the couple has rare sexual intercourses due to some sexual dysfunction, then it is very likely that fertile days are missed and, thus, conception is not achieved. 

With regard in mind of many people, pregnancy is the score of sexual intercourse, when pregnancy does not occur, sexual intercourse is regarded as an ungainly relation in mind of people, and gradually the desire and tendency to have sexual intercourse is decreased. If intercourse is painful, women are less likely to want to try for a baby. 

Teaching to understand of one's body and of sexual functioning, emphasize the importance and normalcy of sexuality is critical to avoiding the guilt and fear that sometimes result in sexual dysfunction.

The first prevention technique is to understand any side effects caused by the medications currently taking. Also, avoid alcohol and drug abuse that can lessen sexual desire or impair your sexual response is recommended.

Female sexual interest/arousal disorder

  • absent/reduced interest in sexual activity
  • absent/reduced sexual/erotic thoughts or fantasies
  • no/reduced initiation of sexual activity
  • unreceptive to a partner's attempts to initiate
  • absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (75 - 100%) sexual encounters (in identified situational contexts or, if generalised, in all contexts)
  • absent/reduced sexual interest/arousal in response to any internal or external sexual/ erotic cues (e.g. written, verbal, visual)
  • absent/reduced genital or non-genital sensations during sexual activity in almost all or all (75 - 100%) sexual encounters (in identified situational contexts or, if generalised, in all contexts)

Female orgasmic disorder

Female orgasmic disorder is defined as the presence of either of the following symptoms and experienced on almost all or all (75 - 100%) occasions of sexual activity: 

  • marked delay in, marked infrequency of, or absence of orgasm
  • markedly reduced intensity of orgasmic sensations

Genitopelvic pain/penetration disorder

This disorder is defined as 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 of or anxiety regarding 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

Treatment should focus on providing specific information regarding desire and variations with age, relationship duration, lifestyle changes or the female sexual response cycle, including motivations for sexual intimacy. Techniques that encourage focusing on awareness of genital response, including cognitive therapy, behavioral and mindfulness exercises, have been shown to improve arousal.

Treatment of female sexual dysfunction depends on the form of disease.

Pharmacotherapy

Female sexual interest/arousal disorder

Pharmacotherapy use is limited. Decreased androgen (male sex hormones) levels do not correlate well with decreased desire. However, testosterone (300 ug daily) administered transdermally has been shown to benefit sexual desire in oestrogen-repleted, naturally and surgically postmenopausal women. Topical and systemic oestrogen (female sexual hormone) improves vaginal lubrication for vaginal atrophy. In postmenopausal women, tibolone, that mimicks the activity of the female sex hormones, has been associated with significant increases in sexual desire and arousal compared with placebo. 

Female orgasmic disorder

The use of testosterone as well as tibolone may improve orgasm domains. Hormone treatments for postmenopausal women may be indicated, with more research recommended in women with FOD as a primary complaint. 

Genitopelvic pain/penetration disorder

Pain management includes pharmacotherapy (systemic and/or topical) with tricyclic anti-depressants and topical lidocaine. 

Surgical therapy

Genitopelvic pain/penetration disorder

Vestibulectomy is a surgical procedure that is used to treat painful intercourse. The procedure is recommended as a last resort when distinct mucosal (mucus lubricates and protects the vaginal tissue) involvement occurs.

The surgery takes place below the urinary meatus, down to the border of the perineal area and includes the fourchette. Incisions are made on each side adjacent and parallel to the labia minora. The structures removed are the hymen, mucous membrane, Bartholin glands ducts and minor vestibular glands. In some surgeries, the amount of tissue removed is not so extensive. Vaginal mucosa tissue remains attached and then is pulled downward to cover the area where tissue was removed. This surgery is also used to treat lichen sclerosus. The complete surgery removes the entire lateral hymenal tissues to the lateral vestibular walls at Hart’s line, and involves removal of the entire posterior fourchette from the posterior hymenal remnants down to the perineum" which barring complications, enables the entire procedure to be over within an hour. 

Other therapies

Female orgasmic disorder

Treatment recommendations include a combination of cognitive and behavioural techniques, directed masturbation training, and anxiety reduction techniques, with mindfulness and yoga practice as possible adjuncts. 

Education regarding coital positioning with maximum glans clitoral stimulation during vaginal intercourse has been shown to be beneficial. At this level, women with anorgasmia can receive education that involves knowledge on genital anatomy, acceptance through touch and sexual fantasies, masturbation techniques, as well as acceptance of a clitoral vibrator.

Genitopelvic pain/penetration disorder

Preventive hygiene measures are encouraged (e.g. avoiding soaps/douches, nylon underwear and, if an irritant, vulvar contact with semen). Sitz baths may help to reduce inflammation and symptoms. While pain is present, avoidance of penetration during sexual activity may be advised to break the cycle of avoidance and catastrophism. Counselling regarding restarting of the sexual relationship is recommended.

If phobic avoidance of penetration is present, treatments targeting fear-avoidance issues, progressive desensitisation by vaginal dilatation using fingers or vaginal trainers, education on sexuality, and Kegel's and relaxation exercises may help to decrease penetration fear and anxiety. If considered necessary, treatment for sexual trauma should occur prior to treatment for sexual dysfunction.

If conservative medical treatments fail to achieve a full term pregnancy, the physician may suggest the patient undergo in vitro fertilization (IVF). IVF and assisted reproductive techniques (ART) generally start with stimulating the ovaries to increase egg production. Most fertility medications are agents that stimulate the development of follicles in the ovary. Examples are gonadotropins and gonadotropin releasing hormone. After stimulation, the physician surgically extracts one or more eggs from the ovary, and unites them with sperm in a laboratory setting, with the intent of producing one or more embryos. Fertilization takes place outside the body, and the fertilized egg is reinserted into the woman's reproductive tract, in a procedure called embryo transfer.

The fertilized eggs (embryos) are cultivated under very stringent conditions and examined every day by the embryologist to evaluate their progress. The embryos are usually cultured for 3 to 5 days, before the best one(s) are selected to be put (transferred) in to the womb. 

Among women with older reproductive age, with history of repetitive abortions or genetic disorders, genetic analysis is highly recommended. The preimplantation genetic screening (PGS)/preimplantation genetic diagnosis (PGD) allows studying the DNA of eggs or embryos to select those that carry certain damaging characteristics. It is useful when there are previous chromosomal or genetic disorders in the family, within the context of in vitro fertilization programs.

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Sources

Assisted reproductive technology ―sourced from Fertilitypedia licensed under CC BY-SA 4.0
Sexual dysfunction in infertile women ―by Zare et al. licensed under CC BY 3.0
Female sexual dysfunction ―by Boa licensed under CC BY-NC 4
A Model for the Management of Female Sexual Dysfunctions ―by Silva Lara et al. licensed under CC BY 4.0
Female sexual arousal disorder ―sourced from Wikipedia licensed under CC BY-SA 3.0
Depression and Female Sexual Dysfunction ―by Chaudhury and Mujawar licensed under CC BY 3.0
Vestibulectomy ―sourced from Wikipedia licensed under CC BY-SA 3.0
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