MANAGEMENT OF FEMALE SEXUAL DYSFUNCTION

Wimpie Pangkahila
Post Graduate Program in Anti-Aging Medicine
Department of Andrology and Sexology
Medical Faculty Udayana University

Introduction
In females, sexual function consists of 4 components, i.e. sexual desire, sexual
arousal, and orgasm. Even though females can experience ejaculation, but it does not
relate with sexual function. However, in males as ejaculatory disorder could disturb
sexual function, it is included as a component of sexual function.
Another component that is rarely mentioned is sexual satisfaction. Mostly it is not
differentiated with orgasm, even though in fact they are not the same. Sexual
satisfaction is a combination of orgasm with emotional involvement. Orgasm may occur
without sexual satisfaction.

Classification of FSD
Female Sexual Dysfunction (FSD) is classified as follows:
1. Sexual desire disorders: Hypoactive sexual desire disorder, Sexual aversion disorder
2. Sexual arousal disorder
3. Orgasmic disorder
4. Sexual pain disorders: dyspareunia, vaginismus, non coital sexual pain disorder
The definition of each kind of FSD is as follows. Hypoactive sexual desire
disorder is the persistent or recurrent deficiency (or absence) of sexual fantasies/
thoughts, and/ or desire for or receptivity to sexual activity, which causes personal
distress. Sexual aversion disorder is the persistent or recurrent phobic aversion to and
avoidance of sexual contact with a sexual partner, which causes personal distress.
Sexual Arousal Disorder is the persistent or recurrent inability to attain or
maintain sufficient sexual excitement, causing personal distress, which may be
expressed as a lack of subjective excitement, or genital (lubrication/swelling) or other
somatic responses.
Orgasmic Disorder is the persistent or recurrent difficulty, delay in or absence of
attaining orgasm following sufficient sexual stimulation and arousal, which causes
personal distress.
Dyspareunia is the recurrent or persistent genital pain associated with sexual
intercourse. Vaginismus is the recurrent or persistent involuntary spasm of the
musculature of the outer third of the vagina that interferes with vaginal penetration,
which causes personal distress. Non coital sexual pain disorder is recurrent or persistent
genital pain induced by non coital sexual stimulation

Causes of FSD
Many factors may cause one or more FSD. Basically the etiologies of FSD are
divided into 2 groups, i.e. physical factors and psychogenic factors. However, whatever
the etiology, finally the patients will also suffer from psychogenic problems that make the
sexual dysfunction worse.
There are 4 groups of physical factors as the causes of FSD, i.e. hormonal,
vasculogenic, neurogenic, and iatrogenic factors. In addition to these physical factors,
there are two other important factors that may cause FSD, i.e. sexual function of the
male partner and the coital position. Sexual dysfunctions of the male partner that

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commonly cause FSD are erectile dysfunction and rapid ejaculation. The coital position
that is not sexually effective for women may cause FSD.
Hormonal factors may cause reduced or inhibited sexual desire which
secondarily disturb other sexual function. Some hormonal abnormalities associated with
FSD are dysfunction of hypothalamus-hypophyse-ovary axis, ovarectomy, menopause,
premature ovarian failure, and long term use of hormonal contraceptive agent.
Testosterone is responsible for sexual desire in women and men as well. Many
basic and clinical data demonstrate that decreased or deficient level of testosterone
results in sexual desire
Vasculogenic factors as the causes of FSD among others are hypertension,
hyperlipidemia, diabetes, traumatic injury of the arteries due to pelvic fracture, and
cardiovascular diseases. The diseases or disorders of arteries may restrict the blood
inflow into the genital organs. Women with uncontrolled diabetes may experience
decreased or inhibited vaginal lubrication and orgasmic dysfunction.
The neurogenic causes of FSD include any disease or injury affecting the central
nervous system, spinal cord, and peripheral nervous system. Damages of nerves may
result in sexual dysfunction, especially in sexual arousal disorder.
Iatrogenic factors include some operation procedures, drugs, and life style as
heavy smoking and alcoholism. Some drugs that may cause FSD are psychotropic
agents, anti-depressants, anti-hypertensives, hormonal drugs, anti- cholinergic agents,
and recreational drugs.
On the other side, the psychogenic factors can be divided into three groups, i.e.
predisposing, precipitating, and maintaining factors. In females, psychogenic factors
have stronger influence in sexual dysfunction compared to males. This might be caused
by sociocultural position of females in the society.

Management
The principle of management of FSD is as follows.
1. Diagnose the kind sexual dysfunction
2. Evaluation to find the etiology
3. Treatment toward the etiology
4. Treatment to recover the sexual function:
Sexual counseling and sex therapy
Medication
Sexual device

However, there are some problems in the management of FSD. In fact, it is not
always easy to diagnose the sexual dysfunction. Some obstacles occurred during
patient’s visit, as follows: patient is difficult or not able to express their sexual problem,
patient-physician do not have a same perception about the sexual complaint expressed
by the patient, physician does not have proper knowledge and skill.
Many women with sexual dysfunction need sexual counseling, not only
medication. Therefore counseling capability of the physician is needed. Women with
complaints of decreased sexual desire, decreased sexual arousal, and unexplained
fatigue are suggested to have testosterone test.
Testosterone therapy is needed in women with Sexual Desire Disorder caused
by decreased testosterone level. In menopause women, combination of estrogen and
testosterone treatment result in better all sexual function compared to estrogen only
treatment. The questions are what the preparation of testosterone is used for female and
what is the dosage. The testosterone preparation recommended for women is short
acting testosterone with low dose.

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 As in other Hormone Replacement Therapies, testosterone treatment in FSD
also needs evaluation and monitoring. Evaluation and monitoring should be performed
every 6 months including improvement of sexual function, physical examination including
breast examination and virilization of the skin, genitalia, and hair. Annually it needs tests
of lipid profile, complete blood count, mammography, and USG of endometrium.
Certain cases of sexual dysfunction need special device to recover their sexual
function. Women with vaginismus need a series of dilator to be used in sex therapy.
Eros CTD is a device to stimulate clitoris and brings to orgasm.

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