Overview of sexual dysfunction in females: Management

Official reprint from UpToDate® www.uptodate.com

©2024 UpToDate®

Overview of sexual dysfunction in females:

Management
Author: Jan L Shifren, MD
Section Editor: Robert L Barbieri, MD
Deputy Editor: Alana Chakrabarti, MD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Dec 2023. | This topic last updated: Feb 01, 2023.

INTRODUCTION

Sexual problems are highly prevalent in females. In the United States, approximately 40
percent of females 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, psychological, and relationship 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 sexual pain and of female
orgasmic disorder are also described separately. (See "Overview of sexual dysfunction in
females: Epidemiology, risk factors, and evaluation" and "Female sexual pain: Evaluation"
and "Female sexual pain: Differential diagnosis" and "Female orgasmic disorder:
Epidemiology, clinical features, assessment, and diagnosis" and "Treatment of female
orgasmic disorder".)

In this topic, when discussing study results, we will use the terms "woman/en" or
"patient(s)" as they are used in the studies presented. However, we encourage the reader
to consider the specific counseling and treatment needs of transgender and gender-
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expansive individuals.

CLINICAL APPROACH

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 patients.

Complete the evaluation and diagnosis — Evaluate the patient for the range of sexual
issues and physical, psychological, and relationship factors associated with their concerns
before starting treatment. Most patients with sexual concerns have clinical issues that
impact more than one aspect of sexual function. The problem may involve more than one
phase of the normal sexual response cycle (desire, arousal, orgasm), sexual pain, or a
general decrease in sexual satisfaction. As an example, if a patient complains of decreased
libido, a full evaluation may also reveal issues with arousal or pain. (See "Overview of
sexual dysfunction in females: Epidemiology, risk factors, and evaluation", section on
'Diagnostic evaluation'.)

Sexual dysfunction is defined as a sexual problem that is persistent or recurrent and

causes marked personal distress or interpersonal difficulty. It must not be better
accounted for by a medical or psychiatric condition (ie, anxiety and depression) or due
exclusively to the direct physiologic effects of a substance or medication. Intervention is
warranted when a patient presents with a distressing sexual concern, even if it does not
strictly meet DSM-5 criteria.

Assess patient goals — Assess a patient's goals prior to starting treatment, and use their
goals to evaluate progress. Improvement may also be tracked using a validated sexual
function questionnaire, such as the Female Sexual Distress Scale [2]. This also gives the
clinician the opportunity to set realistic patient expectations. While some patients may
desire modest improvements in their sexual life, others may expect that treatment will
allow them to achieve an ideal based on past experience or cultural or media images of
sexuality.

Counsel the patient — Patients may be hesitant to discuss sexual concerns and feel
anxious or embarrassed. Reassure the patient that they are not alone, sexual problems are
common in patients, and effective treatment interventions are available. Inform them that
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just sharing a concern and wanting improvement is a good first step.

Discuss that sexual problems are usually multifactorial. Review the management plan with
the patient and engage in shared decision-making. Let the patient know that most sexual
issues do not have an easy or immediate treatment and that there may be a period of trial
and error with management approaches before their sexual function improves.

Discuss with the patient that the principal factors associated with a satisfying sex life are
physical and psychological well-being and the quality of the relationship with one's partner.
Therefore, measures a patient takes to improve their health and relationship will likely
have a positive impact on their sex life. Lifestyle changes that increase physical and
emotional well-being, reduce fatigue and stress, and strengthen the partnership often
result in positive effects on sexual function.

Address partner issues — For patients with sexual partners, the partner must be
considered in the treatment plan. This may include treatment of the partner's sexual
dysfunction, if present. The clinician should also discuss with the patient involving the
partner in setting common goals and expectations, improving communication, and
addressing relationship issues.

If relationship conflict is identified, couples counseling may be helpful. Sex therapy with a
certified therapist is also an effective intervention for many patients and couples by
providing education about sexuality, improving communication, and prescribing specific
exercises and interventions to help couples focus on greater intimacy and pleasure. Often,
a patient is satisfied with their current level of interest and response but distressed by
discord stemming from discrepant levels of interest within a relationship. Let them know
that that this is not their sexual problem but rather a relationship problem that is often
effectively managed by couples counseling and sex therapy.

For patients without a sexual partner, the clinician should address the patient's goals and
concerns. For some patients, sexual function issues deter them from seeking out
relationships. Other patients may be dissatisfied with their sexual function during
masturbation or other partner-independent activities.

Treat associated conditions — Assess the medical history and current conditions and
medications to ensure associated conditions are treated before or during sexual
dysfunction therapy. Many physical and psychological conditions are associated with
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sexual dysfunction. Sometimes a sexual problem can be ameliorated by diagnosing and

treating an underlying problem or by adjusting therapy to minimize sexual side effects. As
an example, patients with depression who are experiencing low libido or anorgasmia on a
selective serotonin reuptake inhibitor can sometimes eliminate these side effects by
switching to a different antidepressant. Treating arthritis pain, urinary incontinence, or
anemia may improve sexual interest and response. In addition, identification and
treatment of a substance use disorder, as well as the underlying factors that precipitated it,
often results in greater sexual function and overall quality of life. (See "Overview of sexual
dysfunction in females: Epidemiology, risk factors, and evaluation", section on 'Risk factors'
and "Sexual dysfunction caused by selective serotonin reuptake inhibitors (SSRIs):
Management".)

Use a multidisciplinary and multimodal approach — Sexual disorders can be complex,

and their treatment can be time intensive and require special expertise. With the patient's
consent, communication and management decisions should be shared between the
treating clinician and the patient's other health care providers (eg, cardiologist,
psychiatrist, oncologist). Also, referrals to clinicians who specialize in sexual function,
psychotherapists, sex therapists, and pelvic physical therapists are often needed to
address specific aspects of treatment.

Treatment approaches may include lifestyle changes, counseling, physical therapy, or

medication. We restrict use of pharmacologic therapy to patients who meet diagnostic
criteria for a sexual disorder and for whom nonpharmacologic interventions have proven
ineffective.

EVIDENCE REGARDING MANAGEMENT

There are limited data to guide interventions for female sexual function issues. The
barriers to clear and consistent guidance regarding these issues include:

● Inconsistent measures to assess efficacy – Studies have used varying measures to

evaluate the efficacy of sexual function interventions. One measure that can be
quantified and compared among studies is an event log, which is the frequency of
sexually satisfying events. However, an event log does not typically assess qualitative
changes in sexual function, such as sexual interest or level of distress.

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Most studies of sexual dysfunction treatment use validated questionnaire scores as

an outcome measure. There are multiple questionnaires, which use different
questions and scales. This makes it difficult to compare data between studies and
treatments.

● Diagnoses and therapies are multifaceted – Female sexual dysfunction typically

affects more than one aspect of sexuality (eg, desire, arousal), and most therapies
also impact several aspects. Thus, it is not generally possible to identify an isolated
sexual issue and select a therapy that specifically targets that concern.

The management approaches discussed below are based on the best available data and
our clinical experience.

MANAGEMENT OVERALL AND BY SEXUAL FUNCTION ISSUE

Patients often have issues in more than one sexual domain (ie, desire, interest/arousal,
orgasm, pain). Thus, clinicians should identify all current issues and prioritize and
coordinate treatments.

Improvement of one sexual problem may result in improvement in another. For example,
successful management of sexual pain often improves sexual interest/arousal and orgasm.
Thus, in a patient with postmenopausal dyspareunia and low libido, the optimal approach
is to treat the genitourinary syndrome of menopause (GSM; vulvovaginal atrophy) first and
then reassess the status of sexual desire concerns.

Nonpharmacologic options should be the initial treatment for most patients. All currently
available pharmacologic therapies for female sexual dysfunction (except approved
treatments for vulvovaginal atrophy) are of limited efficacy and associated with side effects
and potential risks. As the principal predictors of sexual satisfaction are physical and
psychological health and the quality of the relationship with the partner, the focus of
therapy should be on interventions that optimize health, well-being, and the partner
relationship.

The majority of research reviewed in this section was performed in cisgender females with
limited published research on treatment of sexual dysfunction in transgender and non-
binary individuals. Thus, the management approaches here do not specifically address

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transgender individuals, though many of the approaches are likely to be applicable. The
management approach also does not specifically address those in multiple partner
relationships. Health care for transgender individuals is discussed separately. (See "Primary
care of transgender individuals", section on 'Sexual function'.)

Interventions that address multiple issues — Some interventions are low risk and may
improve sexual function overall. Barriers to accessing counselors and sex therapists with
appropriate expertise include limited insurance coverage of these services, cost, and lack
of experts in all geographic regions.

Counseling — Psychological and relationship issues often underlie, exacerbate, or are

amplified by sexual dysfunction in one or both partners. As an example, a major cause of
decreased sexual desire and response is a relationship with limited communication or
underlying conflict. Patients should be screened for a history of physical, sexual, or
emotional abuse and intimate partner violence. (See "Intimate partner violence: Diagnosis
and screening".)

Couples therapy and sex therapy — Patients with sexual dysfunction and their
partners will often benefit from referral to a sex and/or couples therapist.

Couples counselors are psychologists, social workers, or other mental health professionals
who see both members of the couple. This type of counseling is effective when there is
relationship conflict or limited communication.

Sex therapists are highly trained counselors with special expertise in human sexuality. They
often are psychologists or social workers with additional training and experience in sexual
function and dysfunction. Certified sex therapists may be located through the website of
the American Association of Sexuality Educators, Counselors, and Therapists. Their
services are often covered by insurers.

Many clinicians are uncertain of whether to refer a patient to a couples counselor or sex
therapist or both; some of this is due to being uncertain about the services sex therapists
provide [3]. In our practice, we refer to a sex therapist if the concerns are specifically
related to sex. We refer to a couples counselor if the concerns are about improving
communication and reducing conflict.

Sex therapy typically includes: educating patients and partners about the normal sexual

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response cycle, addressing cultural or religious concerns regarding sexuality, helping

negotiate a mutually acceptable frequency of sexual activity when disparate levels of
sexual interest are present and causing discord, and assigning specific exercises to aid
many patients and couples with sexual dysfunction. They may direct patients to a wide
range of helpful resources, including book lists, visual aids, and devices.

Examples of a sex therapy exercise include instruction in the appropriate use of vaginal
dilators, which is highly effective in treating most cases of provoked pelvic floor
hypertonus (vaginismus) and dyspareunia. Another approach is sensate focus exercises to
help couples increase mutual sexual pleasure, minimizing the importance of intercourse
with orgasm as the principal goal of sexual encounters.

In one study, 65 percent of 365 couples undergoing sex therapy for a range of sexual
dysfunctions described their treatment as successful [4].

Given the efficacy and high degree of safety of sex therapy, we consider consultation with
a sex therapist generally to be a prerequisite to a trial of pharmacologic therapy for most
patients with sexual dysfunction.

Psychotherapy and psychopharmacology — Psychiatric disorders, especially

depression and anxiety, are associated with an increased likelihood of sexual dysfunction,
although the majority of patients with sexual dysfunction do not have a psychiatric
diagnosis. Treatment of the underlying psychiatric problem, with appropriate medications
and/or psychotherapy, can lead to an improved sexual life. Prior physical, emotional, or
sexual abuse or substance use disorders also affect sexual function and may be addressed
effectively in this setting. (See "Overview of sexual dysfunction in females: Epidemiology,
risk factors, and evaluation", section on 'Psychiatric disorders and medications'.)

Pharmacologic treatment of psychiatric illness, particularly with selective serotonin

reuptake inhibitors (SSRI), may reduce libido and impair orgasmic response. If medically
appropriate, switching to bupropion, or adding this agent to SSRI treatment, often
improves SSRI-related sexual dysfunction. Bupropion is also an option for the treatment of
sexual dysfunction in patients without depression. (See "Sexual dysfunction caused by
selective serotonin reuptake inhibitors (SSRIs): Management" and 'Bupropion' below.)

Anxiolytic and antipsychotic medications also may adversely affect sexual function. For
some patients, the expertise of a psychopharmacologist may be required if sexual
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problems are exacerbated by these medications or additional psychiatric medications may

be part of the treatment plan.

Lifestyle changes — Fatigue and stress contribute significantly to low libido and sexual
problems. Treating an underlying sleep problem, adjusting work hours, and engaging
assistance with childcare and household responsibilities often improve sexual function.
Reducing stress through exercise, yoga, and other relaxation techniques may result in
improved sexual interest and satisfaction [5]. Lack of privacy can contribute to sexual
problems, and couples may benefit from simply placing a lock on their bedroom door.

Encouraging couples to establish a regular "date night" and to spend time together away
from family and work responsibilities can contribute to improved sexual interest and
response.

Research on sexual function consistently demonstrates increased libido and pleasure in

new relationships. Although patients in existing relationships certainly should not be
advised to improve their sex lives by seeking out new partners, they should be encouraged
to bring novelty to their current relationships. Reading books about sexuality (both
educational material and erotica), visiting a store with items designed to increase sexual
pleasure, and expanding the typical sexual repertoire often increase libido and response.

Improving body image — A patient's view of their own body affects their sexual interest
and satisfaction [6]. Negative body image may be impacted by many factors. Patients who
are overweight and in whom body image issues are contributing to sexual dysfunction
should be assisted with weight loss. Several studies confirm improved sexual function in
patients with obesity following weight loss surgery [7]. In addition, many patients note
improvements in their sex lives when they initiate a regular exercise program.

Treating pelvic floor dysfunction — Pelvic floor dysfunction, including urinary or fecal
incontinence, pelvic organ prolapse, or chronic pelvic pain, may cause or exacerbate sexual
function issues.

Pelvic physical therapy — Physical therapists with subspecialty training in pelvic

anatomy and function are very helpful for patients with dyspareunia, provoked pelvic floor
hypertonus (vaginismus), pelvic pain, incontinence, and pelvic organ prolapse. (See
"Myofascial pelvic pain syndrome in females: Pelvic floor physical therapy for
management".)
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Incontinence or prolapse treatment — Both urinary and fecal incontinence are

associated with sexual dysfunction, likely because of fear of involuntary loss of urine or
stool during sexual activity. Incontinence also may be a symptom of a pelvic floor problem
that is contributing to sexual pain. It is important to ask about incontinence in patients
presenting with sexual concerns, as effective treatments are available. (See "Female
urinary incontinence: Treatment".)

Pelvic organ prolapse may adversely affect sexual function due to embarrassment
regarding a visible bulge and physical discomfort during sex resulting from sexual contact
with the cervix or sensation of fullness or pressure in the vagina. Surgery and pessaries
effectively treat prolapse. Pessary use may contribute to a sexual problem, as pessaries
need to be removed prior to penetrative sexual activities, which can reduce spontaneity
and be difficult for patients with limited mobility. (See "Pelvic organ prolapse in females:
Epidemiology, risk factors, clinical manifestations, and management", section on 'Approach
to management'.)

Sexual interest/arousal disorder — Low libido is the most common sexual problem for
females. As it is difficult for researchers to distinguish between sexual interest and arousal,
the past diagnosis of sexual desire disorder has been replaced in the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) by sexual interest/arousal
disorder. Desire for sexual activity is significantly reduced or absent, often including an
absence of sexual thoughts or fantasies. Low libido affects patients of all ages, with a peak
in associated distress at midlife.

When relationship factors are contributing to low sexual desire, counseling the patient
about changes the couple can make in their sexual relationship can lead to improvement.
Discuss with the patient that sexual interest typically decreases with relationship duration,
so encourage interventions that increase novelty. These may include spending a night
away from home, trying a new sexual position, incorporating a device, or having sex in an
unusual location or at a different time of day. Establishing a regular "date night" often
improves sexual satisfaction, as couples that enjoy time together outside of the bedroom
often have more pleasure in the bedroom.

Hormone therapy

Androgens

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Use and limitations — Levels of endogenous androgens do not predict sexual

function for females; however, androgen therapy that increases serum concentrations to
the upper limit of normal has been shown to improve female sexual function in selected
populations of postmenopausal women [8,9]. Testosterone levels in adult males are
approximately 10 to 15 times higher than levels in females [10]. Thus, for postmenopausal
patients, a dose of testosterone should be 10 percent or less of the standard male dose.
Androgen treatments that increase serum concentrations to supraphysiologic levels in the
low male range may significantly increase sexual desire and frequency in females but are
not advised due to potential risks and side effects [11]. (See "Overview of sexual
dysfunction in females: Epidemiology, risk factors, and evaluation", section on 'Role of
androgens'.)

Discussion of androgen therapy with a patient must include a full explanation of the
potential benefits and risks. Patients should understand that data on safety and efficacy
are limited, including data on long-term use, or use without concomitant estrogen therapy.
In addition, they must be informed that none of the commonly used androgen therapies
are approved by the US Food and Drug Administration (FDA) for treating female sexual
dysfunction because of limited clinical trial data, limited efficacy compared with placebo, or
concerns about long-term safety. The clinician should document this discussion in the
medical record.

In our practice, we rarely use testosterone, but will prescribe it when greatly desired by a
peri- or postmenopausal patient with low libido associated with distress who has no
contraindications to testosterone therapy or identifiable etiology for sexual dysfunction
and is otherwise physically and psychologically healthy. Typically, the patient has already
tried other safer interventions prior to the testosterone prescription, including low-dose
vaginal estrogen, relationship interventions (eg, sex therapy, date nights, use of sexual aids
such as vibrators, books), and adjustment of antidepressant medication (when indicated)
[12]. At least one visit with a sex therapist is strongly advised prior to pharmacologic
treatment, as this safe and effective intervention may make pharmacologic therapy
unnecessary or enhance the response to treatment. Testosterone levels should not be
used in determining the etiology of a sexual problem or in assessing efficacy of treatment,
as no clear association between androgen levels and sexual function has been found in
several large, well-designed studies. (See "Overview of sexual dysfunction in females:
Epidemiology, risk factors, and evaluation", section on 'Role of androgens'.)

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Effectiveness

● Postmenopausal patients – Testosterone therapy is the most commonly studied

androgen treatment for female sexual dysfunction. The addition of testosterone to
postmenopausal estrogen (with or without progestin) therapy in patients who
undergo menopause naturally or as a result of oophorectomy (surgical menopause)
has been shown to improve sexual function in systematic reviews of randomized trials
and in most, but not all, subsequent randomized trials [8,13-20]. Testosterone is
primarily used to treat issues with sexual desire, although all aspects of sexual
function generally improve, including arousal and orgasmic response.

Formulations (testosterone, methyltestosterone) and delivery methods (oral,

transdermal patch, topical gel) vary across studies. The largest randomized trials
utilized a transdermal testosterone patch delivering 300 mcg/day testosterone in
postmenopausal women with hypoactive sexual desire disorder (HSDD) [14,17]. The
diagnostic category HSDD was used in the study but has been replaced by female
sexual interest/arousal disorder [21] (see "Overview of sexual dysfunction in females:
Epidemiology, risk factors, and evaluation", section on 'Diagnostic criteria'). Women
enrolled in these trials were physically and psychologically healthy with a satisfying
sexual life prior to menopause and no other etiology for their HSDD, such as
depression or antidepressant use.

Regarding dosing, in general, trials indicate that a transdermal testosterone dose of

300 mcg/day for six months is safe and effective in women who are receiving
concomitant estrogen therapy. Benefits were reported for many aspects of sexuality,
including desire, responsiveness, orgasm, and satisfaction. Pooled data from trials in
surgically and naturally menopausal women show that, compared with those who
received placebo, women who were treated with testosterone reported a small
increase in sexually satisfying events (SSEs) per four weeks (an increase of 1.9 versus
0.9 events over a baseline of approximately three events) [22]. By contrast, results of
two randomized trials reported by the manufacturer of a topical testosterone gel
(LibiGel) showed no significant increase in sexual desire, the number of SSEs, or any
sexual function endpoint compared with placebo, despite achieving testosterone
blood levels similar to those seen in clinical trials of the testosterone patch [19].

These data do not address use in women who are not taking postmenopausal

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hormone therapy. This is clinically important, since postmenopausal estrogen (with or

without progestin) therapy is no longer universally recommended. (See "Menopausal
hormone therapy: Benefits and risks".)

For postmenopausal women who are not using concurrent estrogen therapy, one
large, controlled trial reported similar results as discussed above. In this trial, 814
naturally or surgically postmenopausal women with HSDD were randomly assigned
to receive transdermal testosterone (daily dose of 150 or 300 mcg) or a placebo patch
[15]. The testosterone 300 mcg group reported significantly more SSEs than the
placebo group (an increase of 2.1 versus 0.7 episodes per four weeks); this was not
true for the 150 mcg dose (increase of 1.2 episodes). However, both testosterone
doses were associated with significant improvements in desire and reduction in
distress about sexual dysfunction.

There were no differences in treatment efficacy between women with natural versus
surgical menopause. Regarding safety, breast cancer was diagnosed in four women
who received testosterone compared with none who received placebo. Although two
of the cases likely were present prior to testosterone administration, the authors
concluded that long-term effects of testosterone, including effects on the breast,
remain uncertain.

Another androgen, dehydroepiandrosterone (DHEA), administered systemically, has

been shown to improve sexual interest and satisfaction in some studies of women
with adrenal insufficiency but was ineffective in those who were perimenopausal or
naturally postmenopausal [23]. DHEA has not been studied for treatment of sexual
dysfunction in women with surgical menopause. Although systemic DHEA does not
appear to be an effective treatment for sexual dysfunction in otherwise healthy
women, a vaginally administered DHEA (1%) insert compared with placebo improved
sexual desire, arousal, lubrication, orgasm, and satisfaction, while reducing pain
during intercourse in a randomized trial of 554 postmenopausal women with
moderate to severe vaginal atrophy [24,25]. As systemic androgen and estrogen
levels are minimally elevated with low-dose vaginal DHEA, sexual function benefits
likely reflect the effective treatment of menopausal vaginal atrophy and dyspareunia.

● Premenopausal patients – Testosterone levels in females decline with age and do

not change abruptly at the time of natural menopause. Thus, females in their late 30s

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and 40s have lower androgen levels than younger females.

However, data regarding androgen treatment of premenopausal women are few and
inconclusive [26,27]. As an example, in the best designed randomized trial, 261
women aged 35 to 46 years who complained of decreased sexual satisfaction were
assigned to testosterone (180, 90, or 45 microL transdermal metered spray) versus
placebo [26]. Improvements in number of SSEs compared with placebo were found
only in women treated with 90 microL but not with other testosterone doses. There
were no significant improvements in any other measure of sexuality, including desire,
pleasure, or orgasm. Despite repeated warnings to use contraception, one woman
was found to be pregnant at week 20 of the study. When considering androgen
therapy in females of reproductive age, inadvertent exposure of a developing fetus
must be considered a significant potential risk.

Available androgen preparations and limitations — Prescribing a testosterone

preparation to females has many limitations. Available preparations vary in ability to
deliver an appropriate and consistent dose and have not been tested to confirm safety,
efficacy, and serum testosterone levels. When prescribing a formulation approved for use
in males, the goal is to approximate hormone concentrations of premenopausal patients,
which are approximately 10 percent of male levels [10,12]. Various products in use include:

● Female testosterone patch – As the majority of controlled data on the efficacy and
safety of testosterone therapy for postmenopausal women with female sexual
interest/arousal disorder were obtained using a testosterone transdermal patch
(Intrinsa 300 mcg), these patches would be the preferred product for females electing
testosterone therapy but are no longer available, even in Europe. In the United
States, no androgen therapies for female sexual dysfunction are approved by the
FDA, which declined approval of a testosterone patch for females pending additional
long-term safety data.

● Topical compounded testosterone cream, ointment, or gel

The most convenient testosterone formulation currently available is topical

compounded 1% testosterone cream, ointment, or gel. The patient applies
approximately 0.5 grams daily to the skin of the arms, legs, or abdomen. The Global
Consensus Statement on androgens for females [28] recommends against
compounded testosterone, unless an authorized equivalent preparation is
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unavailable. As of 2020, there is no government-approved testosterone formulation

for females, so options are limited.

Despite the many limitations of compounded hormones, this approach may be

preferable to using testosterone products approved for males, although not all
experts agree [12]. Topical cream or gel should be applied in approximately one-tenth
the male prescribed dose, as testosterone levels in females are approximately 10
percent those of males. This is very difficult to do accurately with available gels dosed
for males in pumps and packets. In addition, the FDA has issued a warning regarding
testosterone gels due to reports of adverse effects in children due to secondary
exposure to the skin of an adult who had recently applied the medication [29,30].

Limitations of prescription custom-compounded topical testosterone formulations

include inconsistent concentrations of testosterone with variable absorption and
bioavailability. Product quality and purity are a concern given limited regulatory
oversight of the compounded hormone industry. Compounding pharmacies typically
supply these products in a marked, needleless syringe to allow for more accurate
dosing, although these controlled administration methods do not overcome the
significant inconsistency in delivered dose between pharmacies or even between
separate lots of product from the same pharmacy. Clinical trials have not evaluated
the safety or efficacy of this product for any indication, including improvement of
female sexual function. If compounded testosterone is used, the compounding
pharmacy should be compliant with purity of Active Pharmaceutical Ingredients (API)
and Good Manufacturing Practice (GMP) to meet industry standards for quality and
safety.

● Male testosterone patch – Transdermal formulations created for males, such as skin
patches (eg, Androderm) and gels (eg, AndroGel), should be prescribed for females
with caution. If they are used, careful dose adjustment is required, as excessive
dosing will result from standard doses prescribed for males. Cutting patches is not
advised as no data are available on dose delivered in cut patches, product stability, or
resulting serum testosterone levels.

● Oral formulations – Use of oral formulations is limited by the potential for adverse
changes in lipids and liver function tests following first-pass hepatic metabolism [12].
Methyltestosterone is available by prescription in the United States in a fixed-dose

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combination with a high dose of oral estrogen. Oral DHEA is available without a
prescription; doses of 25 to 50 mg/day raise circulating androgen levels into the
physiologic range [31]. As this product is subject to minimal regulatory oversight,
hormone content is highly variable [32].

● Injectable or implantable preparations – Use of injectable or implantable

preparations ("pellets") of testosterone are available but not advised for females [12].
Administration is uncomfortable and inconvenient, and dosing is almost always
supraphysiologic. In addition, if side effects occur, removal of the implanted or
injected testosterone is not possible. Testosterone levels remain elevated for a
minimum of one month and often longer.

Adverse effects and contraindications — Androgen therapy in females can

potentially result in androgenic, metabolic, or other adverse health effects [8]. These
medications should not be used in patients with cardiovascular disease, hepatic disease,
endometrial hyperplasia or cancer, or breast cancer and should be used with caution in
patients at high risk for these disorders. Even in the absence of these concerns, androgen
therapy should rarely be used in reproductive-age females, given a low likelihood that
decreased testosterone levels are a principal etiologic factor, the limited data on efficacy,
and the potential for inadvertent exposure of a developing fetus.

Major issues regarding side effects include:

● Cosmetic, androgenic side effects, such as hirsutism and acne, are usually mild;
irreversible, virilizing changes (eg, voice deepening, clitoromegaly) are rare and occur
only with excessive dosing.

● Serum high-density lipoprotein cholesterol concentrations decline slightly in

postmenopausal patients receiving oral testosterone therapy, but it is not known if
the change substantially affects overall cardiovascular risk. Nonoral administration is
lipid neutral.

● Most androgens are aromatized to estrogens; thus, risks of estrogen therapy are also
possible with androgen treatment. A possible association between testosterone
administration and breast cancer risk has been reported [15]. Also, some patients on
testosterone develop abnormal uterine bleeding. Although there is no evidence of an
increased risk of endometrial hyperplasia or cancer [15,33,34], data on long-term use
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and use in naturally menopausal patients not receiving concurrent progestin therapy
are very limited.

Evaluation of the adverse effects of androgens is limited by the lack of data on females
taking testosterone alone (without estrogen). Also, the duration of studies is generally
from 3 to 12 months; therefore, the long-term safety of testosterone therapy cannot be
assured.

Risks of androgen therapy in females are discussed in detail separately. (See "Overview of
androgen deficiency and therapy in females", section on 'Risks and side effects of
androgen therapy' and "Menopausal hormone therapy and the risk of breast cancer",
section on 'Effect of testosterone'.)

Monitoring androgen therapy — Patients on androgen therapy should be

monitored for potential adverse effects. Some effects are cosmetic (eg, hirsutism, acne)
and so are easily detected by the patient. Given potential effects on lipids and liver
function, normal values should be confirmed prior to initiating androgen therapy,
reassessed approximately six months after starting treatment, and then annually
thereafter.

Testosterone is metabolized to estrogen, and thus, abnormal uterine bleeding or breast

symptoms (eg, lump, nipple discharge) may result and require appropriate evaluation.
Annual mammograms should be performed in females receiving androgen therapy. (See
"Overview of the evaluation of the endometrium for malignant or premalignant disease"
and "Breast imaging for cancer screening: Mammography and ultrasonography".)

Measuring a free testosterone level or free androgen index (total testosterone/sex

hormone binding globulin) in females using topical testosterone therapies may be used as
a safety measure, with the goal of keeping the value within the normal range for
reproductive-aged females provided by the testing laboratory.

Estrogens — The Women's Health Initiative, a set of randomized trials in over 27,000
postmenopausal women, found that systemic estrogen with or without progestin therapy
did not improve sexual satisfaction and may be harmful [35]. (See "Menopausal hormone
therapy: Benefits and risks", section on 'Health-related quality of life'.)

Although evidence does not support a role for systemic, postmenopausal hormone

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therapy in the treatment of sexual problems, if a patient with a previously satisfying sex life
presents with sexual problems concurrent with the onset of hot flashes, night sweats,
sleep disruption, and resulting fatigue, treatment of menopausal symptoms with systemic
postmenopausal hormone therapy may lead to improvement in the sexual problem. (See
"Treatment of menopausal symptoms with hormone therapy".)

Tibolone — Tibolone is a synthetic steroid whose metabolites have estrogenic,

progestogenic, and androgenic properties. It was not approved by the FDA due to
concerns about risk of breast cancer, endometrial cancer, and stroke [22] but is used by
postmenopausal patients in Europe and other countries.

In randomized trials, tibolone appears more effective than estrogen/progestin therapy for
treatment of sexual dysfunction in postmenopausal women [36-38]. However, the
beneficial effects of tibolone on sexuality are modest and may not outweigh the risks.
Comparative trials of tibolone versus testosterone have not been performed.

Adverse effects associated with tibolone are discussed in detail separately. (See
"Preparations for menopausal hormone therapy", section on 'Tibolone'.)

Serotonergic or dopaminergic agents — Some psychotropic agents may have a benefit

for female sexual function.

Flibanserin — Flibanserin is the first drug approved by the FDA for female sexual
dysfunction in premenopausal patients [39]. Daily use results in small increases in the
frequency of SSEs and sexual desire in premenopausal patients with low sexual desire that
is associated with distress. The clinical role of flibanserin may be limited by the need for
daily dosing, common adverse effects (eg, somnolence, dizziness), and safety concerns
regarding combining flibanserin with alcohol or certain medications (eg, fluconazole,
antidepressants) [40]; hypersensitivity reactions (eg, anaphylaxis, angioedema) have also
been reported [41].

Flibanserin is a centrally acting serotonin receptor agonist/antagonist that results in

transient decreases in serotonin and increases in dopamine and norepinephrine in certain
regions of the brain [42,43]. It was initially studied as a potential antidepressant, and
although it was ineffective for depression, it appeared to increase sex drive.

Flibanserin was rejected twice for approval by the FDA due to concerns regarding both

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efficacy and safety. It was approved by the FDA in August 2015 for premenopausal patients
with HSDD after review of additional safety information and efforts by consumer groups.
The diagnostic category HSDD was used in the FDA report and in the associated studies,
but is no longer used and has been replaced by the term female sexual interest/arousal
disorder [21]. (See "Overview of sexual dysfunction in females: Epidemiology, risk factors,
and evaluation", section on 'Diagnostic criteria'.)

The best available evidence regarding flibanserin is from a meta-analysis of trials

comparing flibanserin (oral, 100 mg daily) with placebo in premenopausal and
postmenopausal women with HSDD. This meta-analysis included eight double-blind,
randomized trials (three unpublished) with a total of 5914 women [44]. Flibanserin
compared with placebo resulted in a small but statistically significant increase in SSEs per
month (pooled mean difference 0.49, 95% CI 0.32-0.67). In terms of absolute benefit, in
two trials, there were 0.4 to 1.0 additional SSEs per month with flibanserin from an average
baseline of 2.0 to 3.0 per month [45,46]. In the meta-analysis, measures of sexual desire
(Female Sexual Function Index desire, eDiary desire) showed statistically significant
improvement, but these changes were modest, and the clinical significance appears small
[44]. Scores on the validated measure Patient's Global Impression of Improvement showed
minimal improvement to no change. Data from one trial suggest that onset of efficacy with
flibanserin starts at four weeks of use [46].

In the meta-analysis, the risk of adverse events was significantly higher with flibanserin
compared with placebo: dizziness (relative risk [RR] 4.00, 95% CI 2.56-6.27), somnolence
(RR 3.97, 95% CI 3.01-5.24), nausea (RR 2.35, 95% CI 1.85-2.98), and fatigue (RR 1.64, 95% CI
1.27-2.13). Alcohol has been found to increase the risk of adverse events, based on data
provided by the manufacturer [47]. Eight to 13 percent of women treated with flibanserin
discontinued the drug due to adverse effects. Severe adverse effects that may occur with
flibanserin include syncope or hypotension; in one trial, the rates of sedation or
hypotension-related events were 29 percent on flibanserin versus 9 percent on placebo,
and syncope occurred in 0.5 versus 0.3 percent [47].

Women on antidepressants and antiestrogens were excluded from the randomized trials,
and thus safety and efficacy in women on these medications has not been evaluated
[43,45,46,48]. The safety of flibanserin in pregnancy is not known; among the few women
in the trials who became pregnant, no congenital anomalies were reported [45,46,48].

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The FDA approved flibanserin for premenopausal patients with low sexual desire with
associated distress at a daily dose of 100 mg at bedtime with several cautionary notes
(including a black box warning) [49]. Flibanserin is not indicated for the treatment of sexual
dysfunction in postmenopausal patients. Flibanserin can cause hypotension and syncope.
These risks are increased when combined with alcohol or cytochrome P450 3A4 (CYP3A4)
inhibitors (eg, fluconazole). Flibanserin ingestion should be delayed by at least two hours
after alcohol ingestion; patients who consume three or more alcoholic beverages are
advised to skip their evening flibanserin dose [40]. Oral contraceptives and antibiotics
commonly used to treat urinary tract infections in patients also might affect the drug's
metabolism. Use of either alcohol or CYP3A4 inhibitors in combination with flibanserin is
contraindicated.

Flibanserin availability is limited in countries other than the United States and Canada.

Bupropion — If a patient with a distressing sexual problem greatly desires a

pharmacologic intervention, after nonpharmacologic treatments have been tried,
bupropion is often the first choice in our practice. Bupropion is FDA approved to treat
depression and assist with smoking cessation; use for sexual dysfunction, including that
induced by SSRIs, is an off-label indication. As a centrally acting agent, the mechanism of
action is likely similar to that of flibanserin. Bupropion is preferred to flibanserin in our
practice, as long-term safety data are available, and risks and side effects are well
characterized. Generic formulations are available, so cost is low. Bupropion should be
dosed in the morning, and patients should be observed for increased anxiety, insomnia,
and hypertension. Patients must be informed of potential risks and side effects and off-
label nature of use.

One randomized trial of 75 premenopausal women with HSDD and without underlying
depression reported increased sexual pleasure, arousal, and orgasm with bupropion
(sustained release 300 mg/day) compared with placebo [50].

Use of bupropion in patients with depression and SSRI-associated sexual dysfunction is

discussed separately. (See "Sexual dysfunction caused by selective serotonin reuptake
inhibitors (SSRIs): Management", section on 'Females'.)

Buspirone — Some data suggest that buspirone (typically used as an antianxiety

medication) is helpful for decreased libido. Use of buspirone in patients with SSRI-
associated sexual dysfunction is discussed separately. (See "Sexual dysfunction caused by
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selective serotonin reuptake inhibitors (SSRIs): Management", section on 'Treatments with

little to no demonstrated benefit'.)

Other — Apomorphine is a dopamine agonist that has been used for the treatment
of male erectile dysfunction, although it is not FDA approved for this indication. One small
study of limited quality reported improved sexual function in premenopausal women. Use
of this drug is not advised due to limited data on efficacy and significant side effects,
including nausea, vomiting, dizziness, and hypotension [51].

Bremelanotide — Bremelanotide, a melanocortin receptor agonist, was approved by the

FDA in June 2019 for treatment of HSDD in premenopausal patients [52]. The medication is
administered as a subcutaneous injection (1.75 mg) at least 45 minutes before anticipated
sexual activity. Two randomized trials in a total of 1247 premenopausal women with HSDD
found that 24 weeks of bremelanotide compared with placebo resulted in more women
with a meaningful increase in sexual desire (51 versus 21 percent) and improvement in
sexual satisfaction (57 versus 26 percent) [52-54]. There was no significant difference in
number of satisfying sexual events. Serious adverse reactions occurred in 1.1 percent of
women treated with bremelanotide (compared with 0.5 percent with placebo). Common
adverse reactions included nausea (40 percent; mostly with first injection; 13 percent of
women required anti-emetic medications), vomiting (5 percent), flushing (20 percent),
headache (11 percent), and hyperpigmentation (1 percent; possibly permanent). Some
women had a transient increase in blood pressure, and bremelanotide should not be used
in women with uncontrolled hypertension or known cardiovascular disease. Concomitant
use decreases blood levels of oral naltrexone. Bremelanotide is associated with fetal harm
in animal studies, so patients must use effective contraception.

An advantage of bremelanotide compared with flibanserin is that it is taken prior to

anticipated sexual activity rather than every day, potentially reducing risks and side effects
and avoiding the need to take a daily medication. Associated nausea and vomiting may
limit acceptability for some patients. Although not currently approved for postmenopausal
patients, there is no physiologic reason that bremelanotide would not be similarly
effective, although potential cardiovascular adverse events may be more likely in an older
population. Similar to other pharmacologic agents, use should be limited to patients who
experience distress due to low libido with no other etiology for the sexual problem after
other nonpharmacologic interventions have proven ineffective.

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Phosphodiesterase inhibitors — Phosphodiesterase (PDE-5) inhibitors effectively treat

male erectile dysfunction but generally have not proven effective in females.

Studies of sildenafil for treatment of females with sexual dysfunction have reported
inconsistent results [55-59]. The best available evidence is a randomized trial of nearly 800
pre- and postmenopausal women with disorders of desire, arousal, orgasm, and/or
dyspareunia treated with 10 to 100 mg of sildenafil for 12 weeks [55]. Sildenafil was no
more effective than placebo in increasing the frequency of enjoyable sexual events or
improving any aspect of sexual function.

However, positive effects of sildenafil on sexual arousal and orgasm have been
demonstrated in premenopausal women with SSRI-associated sexual dysfunction. A
randomized trial of sildenafil 50 or 100 mg in 98 females with major depression in
remission on SSRIs and new-onset sexual dysfunction found that sildenafil for eight weeks,
compared with placebo, significantly improved scores for global sexual function and
orgasmic response [60]. Sildenafil use did not impact sexual desire and had no effect on
hormone levels or measures of depression. (See "Sexual dysfunction caused by selective
serotonin reuptake inhibitors (SSRIs): Management", section on 'Females'.)

Although there have been no studies on the use of other PDE-5 inhibitors, such as tadalafil
and vardenafil, on SSRI-induced sexual dysfunction, it is likely that they have similar
effectiveness due to their shared mechanism of action.

Randomized trial data also suggest that PDE-5 inhibitors may be helpful in treating sexual
dysfunction in women with diabetes, multiple sclerosis, or spinal cord injuries [61-63].
Further study is needed in these populations.

Potential side effects of PDE-5 inhibitors include headache, flushing, and nausea. These
drugs are contraindicated in patients taking nitrates. Patients must be informed that PDE-5
inhibitor use for females has not been approved by the FDA. (See "Treatment of male
sexual dysfunction".)

Erectile dysfunction is very common in aging males, and females may experience reduced
sexual interest, arousal, and pleasure secondary to a partner's sexual dysfunction. In this
setting, PDE-5 inhibitor use by a male partner with erectile dysfunction may result in
improved sexual function and satisfaction for both members of the couple.

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Orgasmic disorder — Treatment for female orgasmic disorder consists principally of

education, psychosocial interventions, and the use of devices, including vibrators. Vibrators
may improve the ability to achieve orgasm by increasing clitoral blood flow; they can be
purchased at stores and websites specializing in products for sexual pleasure, but patients
should be informed that most chain pharmacy stores also carry vibrators in the section
where lubricants and moisturizers are sold. Some patients may be more comfortable
purchasing these devices without going into a sexual device store.

Female orgasmic disorder is discussed in detail separately. (See "Treatment of female

orgasmic disorder".)

Sexual pain — Sexual pain (also referred to as dyspareunia or genitopelvic

pain/penetration disorder) is managed based on the etiology. Three common causes of
sexual pain in females are GSM, which includes hypoestrogenic vulvovaginal atrophy;
provoked pelvic floor hypertonus (including vaginismus); and vulvodynia. There are also
many other etiologies of sexual pain. (See "Female sexual pain: Evaluation".)

Genitourinary syndrome of menopause — Hypoestrogenism due to menopause is the

main cause of GSM. Menopause may occur naturally around age 51 years or may occur
earlier due to a genetic mutation, autoimmune process, surgery, chemotherapy, or
radiation. Anti-estrogen therapy, including aromatase inhibitors, results in profound
estrogen deficiency and is increasingly used for estrogen-dependent tumors and even for
chemoprevention. Management options for sexual pain associated with GSM include
nonhormonal vaginal lubricants and moisturizers, low-dose vaginal estrogen, vaginal
DHEA, and oral ospemifene (an estrogen agonist/antagonist). Vaginal laser or
radiofrequency devices have been developed, but their safety/efficacy is not established.
The FDA issued a warning regarding the use of these devices for the treatment of
gynecologic problems, including vulvovaginal atrophy [64]. Although many small studies
without a sham control suggested efficacy of vaginal laser for GSM, a large, randomized
trial with a sham control demonstrated no benefit of three treatments of fractional
microablative carbon dioxide laser on vaginal symptom severity. Given high cost, potential
risk, and experimental nature of use, we do not advise laser treatment for GSM except in
research studies [65]. Dyspareunia with GSM is discussed in detail separately. (See
"Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment".)

Provoked pelvic floor hypertonus — Provoked pelvic floor hypertonus (vaginismus) may

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be effectively treated with physical therapy by a therapist with expertise in managing

disorders of the pelvic floor. Specific techniques may include the use of vaginal dilators and
myofascial release of muscle tension in muscles of the pelvic floor, thighs, and abdomen,
with or without biofeedback. Desensitization techniques are then applied to give the
patient control over muscle tonicity/relaxation.

Other therapeutic approaches include sex therapy, progressive relaxation, sensate focus,
electromyography, use of benzodiazepines, hypnotherapy, and botulinum toxin type A
injections [66]. This is discussed in detail separately. (See "Myofascial pelvic pain syndrome
in females: Treatment".)

Vulvar pain syndromes — Vulvar pain syndromes are a common cause of dyspareunia.
Contact dermatitis from products applied to the vulva, incontinence, and daily pad use
contribute to vulvar pain. Identifying and avoiding the irritant and effective management
of incontinence improves pain from these causes. Management of general or local
vulvodynia without a clear etiology includes pelvic physical therapy, psychotherapy, and
topical or systemic medications. This is discussed in detail separately. (See "Vulvar pain of
unknown cause (vulvodynia): Treatment".)

Treatments that are not recommended

Herbal supplements — Many patients are interested in trying over-the-counter herbal

supplements, which are advertised widely and claim to increase sexual desire and
pleasure. Patients should be informed that the safety and efficacy of these products are
unproven, there is minimal regulatory oversight, and they are often costly. Nonetheless,
given a 30 percent predicted placebo response and few reported side effects, patients may
elect a trial of these alternatives after being fully informed of the above limitations.

One such product is a proprietary blend of herbal supplements (Avlimil). Many of the
components of Avlimil are estrogenic, and animal study data suggest that the product may
stimulate growth of estrogen-dependent breast tumors [67].

Another product, a botanical feminine massage oil (Zestra), is applied to the clitoris, labia,
and vagina. A randomized, double-blind crossover trial in 20 women reported increased
sexual arousal, orgasm, and pleasure compared with a placebo oil; the only adverse effect
reported was mild genital burning [68]. Other "warming" vaginal lubricants may increase
sexual pleasure for some women, but may cause vulvovaginal discomfort in women with
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untreated GSM.

FOLLOW-UP

After initiating therapy for sexual dysfunction, patients should be seen for regular follow-
up visits, approximately every three months, until effective interventions are identified and
the sexual problem has improved. Patients may then be seen every 6 to 12 months,
depending on the potential risks of the treatments selected. Patients using pharmacologic
therapies will need to be monitored for drug-related risks and side effects at these visits.
Treatment efficacy is best assessed by patient self-report of improvement of symptoms
and achieving treatment goals.

SPECIAL POPULATIONS

Older adults — Clinicians are increasingly likely to encounter older patients seeking help
with sexual dysfunction. More individuals are living into late life, a significant proportion of
whom remain sexually active. This is discussed in detail separately. (See "Sexual
dysfunction in older adults".)

Cancer survivors — Cancer treatment, including surgery, chemotherapy, radiation,

antiestrogen therapy, and hematopoietic cell transplantation, often impacts sexual
function. This is discussed in detail separately. (See "Overview of sexual dysfunction in
female cancer survivors" and "Sexuality in palliative care".)

RESOURCES FOR CLINICIANS AND PATIENTS

● Books

• The Joy of Sex, by Alex Comfort

• Becoming Orgasmic: A Sexual and Personal Growth Program for Women, by Julia
Heiman and Joseph Lopiccolo

• For Women Only: A Revolutionary Guide to Overcoming Sexual Dysfunction and

Reclaiming Your Sex Life, by Jennifer Berman, Laura Berman, and Elisabeth

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Overview of sexual dysfunction in females: Management

Bumiller

• Getting the Sex You Want: A Woman's Guide to Becoming Proud, Passionate and
Pleased in Bed, by Sandra Leiblum and Judith Sachs

• Come As You Are: The Surprising New Science That Will Transform Your Sex Life,
by Emily Nagoski

• I [heart] Female Orgasm: An Extraordinary Orgasm Guide, by Dorian Solot and

Marshall Miller

• Real Sex for Real Women: Intimacy, Pleasure & Sexual Wellbeing, by Laura Berman

• Hot Monogamy: Essential Steps to More Passionate, Intimate Lovemaking, by

Patricia Love and Jo Robinson

• Dr. Ruth's Sex after 50: Revving Up the Romance, Passion & Excitement, by Ruth
Westheimer

• Passionate Marriage: Keeping Love and Intimacy Alive in Committed

Relationships, by David Schnarch

• Healing Painful Sex: A Woman's Guide to Confronting, Diagnosing, and Treating

Sexual Pain, by Deborah Coady, MD and Nancy Fish, MSW, MPH

● Websites

• American Association of Sexuality Educators, Counselors, and Therapists

• American College of Obstetricians and Gynecologists

• American Urological Association

• Kinsey Institute

• North American Menopause Society – Module on "Sexual Health and

Menopause"

• Sexuality Information and Education Council of the United States

• Society for Sex Therapy and Research

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• Society for the Scientific Study of Sexuality

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and

regions around the world are provided separately. (See "Society guideline links: Female
sexual dysfunction".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces
are longer, more sophisticated, and more detailed. These articles are written at the 10th to
12th grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Sex problems in females (The Basics)" and
"Patient education: Sex as you get older (The Basics)")

● Beyond the Basics topics (see "Patient education: Sexual problems in females (Beyond
the Basics)")

SUMMARY AND RECOMMENDATIONS

● Clinical approach – Females who seek treatment of sexual concerns (eg, lack of
sexual desire, impaired arousal, inability to achieve orgasm, pain with sexual activity)
should be fully evaluated for underlying factors. Evaluation should include a physical
and pelvic examination. Many patients present with multiple issues, and the etiology
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may be multifactorial. Medical or psychiatric conditions that may alter sexual function
(eg, depression, arthritis, genitourinary syndrome of menopause [GSM], pelvic pain,
anemia, sexual issues related to medications, urinary and fecal incontinence) should
be assessed and treated before considering other treatments for sexual dysfunction.
Relationship and partner issues should be addressed in making the management
plan. (See 'Clinical approach' above.)

● Initial interventions – Initial treatment often includes nonpharmacologic options

such as vaginal lubricants and moisturizers, lifestyle changes (eg, reducing stress and
fatigue, increasing quality time with partners, bringing novelty to the sexual
repertoire, improving body image), and couples and/or sex therapy. (See
'Interventions that address multiple issues' above.)

• Referral to a sex therapist or couples counselor is a highly effective intervention

for sexual dysfunction.

• For patients with psychiatric disorders, particularly those on psychotropic

medications, management of sexual function usually requires communication
between the clinician managing the sexual problem and the patient's mental
health team.

• Pelvic physical therapists are often needed to address specific problems, including
pelvic floor hypertonus (vaginismus), pelvic pain, urinary or fecal incontinence, or
pelvic organ prolapse. (See 'Counseling' above and 'Treating pelvic floor
dysfunction' above.)

● Pharmacologic therapy – Pharmacologic therapy should be restricted to patients

who meet diagnostic criteria for a sexual disorder (a sexual problem that is persistent
or recurrent and causes marked distress or interpersonal difficulty) and who did not
respond to nonpharmacologic interventions. The sexual dysfunction must not be
better accounted for by a general medical or psychiatric condition (eg, anxiety and
depression) or due exclusively to the direct physiologic effects of a substance or
medication. (See 'Clinical approach' above.)

• Hormonal pharmacologic options

- For postmenopausal patients with sexual problems that begin with the onset

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of vasomotor symptoms (hot flashes, night sweats, sleep disruption), systemic

estrogen therapy is an option for carefully selected patients. (See 'Estrogens'
above.)

- For postmenopausal patients with dyspareunia due to GSM, options include

nonhormonal vaginal lubricants and moisturizers, low-dose vaginal estrogen
therapy, vaginal dehydroepiandrosterone, or ospemifene. (See 'Genitourinary
syndrome of menopause' above.)

- For postmenopausal patients with hypoactive sexual desire disorder,

testosterone therapy is an option for carefully selected patients. Candidates
for therapy must have no contraindications to taking androgens or estrogens
(as many androgens are aromatized to estrogens), be willing to accept
androgenic side effects, and counseled that this therapy is not approved for
females by the US Food and Drug Administration (FDA) due to a lack of long-
term safety data. A commonly used preparation is compounded 1%
testosterone topical cream or gel; 0.5 grams is applied daily to the skin of the
arms, legs, or abdomen. Dose-adjusted topical testosterone products
approved for males is another option, with an increased possibility of
excessive dosing. (See 'Androgens' above and 'Available androgen
preparations and limitations' above.)

- For premenopausal patients with sexual dysfunction, we do not prescribe

androgen therapy. Androgen therapy does not significantly improve sexual
function (eg, desire, pleasure, orgasm) and can lead to potential adverse
events (eg, inadvertent exposure to a developing fetus if pregnancy occurs).
(See 'Androgens' above and 'Available androgen preparations and limitations'
above.)

• Nonhormonal pharmacologic options

- Bremelanotide – Bremelanotide is a melanocortin receptor agonist approved

for the treatment of low sexual desire with associated distress in
premenopausal patients. It is a subcutaneous injection used, as needed, 45
minutes prior to anticipated sexual activity. Use may increase sexual desire
and sexual satisfaction. Associated nausea and vomiting may limit
acceptability for some patients; hyperpigmentation, potentially permanent,
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occurs in 1 percent of patients. Bremelanotide may increase blood pressure

and should not be used in patients with uncontrolled hypertension or known
cardiovascular disease. Bremelanotide is not indicated for the treatment of
sexual dysfunction in postmenopausal patients. (See 'Bremelanotide' above.)

- Flibanserin – Flibanserin is a centrally acting serotonin receptor

agonist/antagonist for treatment of low sexual desire with associated distress
in premenopausal patients. Daily use results in small increases in the
frequency of sexually satisfying events and sexual desire compared with
placebo. The clinical role of flibanserin may be limited by the need for daily
dosing, common adverse effects (eg, somnolence, dizziness), and safety
concerns regarding combining flibanserin with alcohol or certain medications
(eg, fluconazole, antidepressants). Flibanserin is not indicated for the
treatment of sexual dysfunction in postmenopausal patients. (See 'Flibanserin'
above.)

- Bupropion – Bupropion may be an effective treatment for sexual dysfunction

in patients with or without associated depression, including those with
selective serotonin reuptake inhibitor (SSRI)-induced sexual dysfunction. Use
for female sexual dysfunction is an off-label indication. (See 'Bupropion'
above.)

- Phosphodiesterase inhibitors – Phosphodiesterase (PDE-5) inhibitors are

ineffective for female sexual dysfunction except for patients with sexual
interest/arousal or orgasm disorders associated with use of an SSRI. For
patients in whom stopping the SSRI or switching to another antidepressant is
not advisable, treatment with a PDE-5 inhibitor may improve sexual function;
however, patients must be informed that these medications are not FDA
approved for use in females. (See 'Phosphodiesterase inhibitors' above.)

- Herbal supplements – Use of over-the-counter herbal supplements for

sexual dysfunction should be avoided since the safety and efficacy of these
products are unproven and there is minimal regulatory oversight. (See 'Herbal
supplements' above.)

REFERENCES

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