Description

• According to the DSM-5, FSD is defined as sexual concerns arising from desire, arousal, orgasm, or sexual pain leading to personal distress for >6 months and present >75% of the time (1).
• FSD often arises from four domains: female sexual interest and arousal, female orgasmic, genito-pelvic pain/penetration, or substance/medication-induced (2).
• FSD can be lifelong, acquired, generalized, or situational depending on the underlying cause.
• Note: For purposes of this article, discussion will focus on individuals assigned female at birth who identify as female, with the understanding that sexual dysfunction can occur across all genders with similar and unique challenges as those described below.

Epidemiology

According to data from the American College of Obstetricians and Gynecologists, 43% of women disclose sexual function concerns, of whom 12% endorse it causing personal distress (2).

Etiology and Pathophysiology

The female sexual response follows a nonlinear model requiring motivation, arousal (physical and subjective), willingness, and neural inputs (2). Thus, pathophysiology of sexual dysfunction is complex and multifactorial, with underlying cause varying between patients. These may include:

• Changes in sex hormones: Sex hormones are important in creating a neurochemical sexual response in the central nervous system and urogenital level, leading to changes in lubrication, clitoral engorgement, pelvic neurovasculature, and pelvic floor function.
• Central nervous system: Neuroendocrine circuits impact the emotional and behavioral aspects of sexual function including arousal, orgasm, and desire (3).
• Comorbid illness: Comorbidities such as diabetes, cardiovascular disease, malignancy, or neurologic disease can impact the above processes as well as psychological view of themselves and their sexuality.
• Psychological: Mood disorders, stress, alcohol/substance use impact the above model of the female sexual response.
• Iatrogenic: Multiple medications impact sexual functioning (2).
• Individual factors: Sleep, relationship concerns, body image, trauma, societal attitudes toward sexuality, and more all impact the above model of female sexual response (3).

Risk Factors

Sexual dysfunction in women is a multifactorial issue, often including a combination of biologic and psychosocial causes.

• Menopause: changing body image, genitourinary syndrome of menopause
• Education: lack of knowledge about sexual stimulation and response
• Psychological: mood disorders, personality disorders, substance abuse, or psychopathies
• Chronic medical problems: cardiovascular, endocrine, dermatologic, neurologic, malignancy, medication effects
• GYN issues: childbirth, pelvic floor or bladder dysfunction, endometriosis, uterine fibroids, chronic vulvovaginal candidiasis/vaginal infections, female genital mutilation, breastfeeding
• Relationship factors: safety, intimate partner violence, discrepancies in partners’ expectations, cultural attitudes towards sexuality, sexual trauma (2)

General Prevention

Ways to help evaluate for, support, and assist in prevention include:

• Practice trauma-informed care in clinic.
• Perform sexual dysfunction screening at routine visits.
• Normalize FSD in discussion.
• Assess patient safety at every visit (2).

Commonly Associated Conditions

History of sexual trauma, marital/relationship discord, psychiatric disorders, malignancy, menopause, pregnancy/childbirth, abnormal uterine bleeding, pelvic pain, incontinence, pelvic organ prolapse