Sexual Dysfunction

Biological factors commonly contribute to decreased desire by direct or indirect mechanisms. Medical conditions such as cancer, high blood pressure, and diabetes and their treatment have been strongly associated with decreased sexual desire. Hormone imbalance, such as that which occurs after having a baby or during perimenopause, can also affect sexual desire. Menopausal signs such as vaginal dryness and atrophy that cause painful intercourse are an underlying factor. Aging can also influence sexual desire: studies have shown that middle-aged women have the highest prevalence of decreased sexual desire with associated stress; the intensity of sexual desire can decrease because of lower levels of testosterone and indirect changes from the loss of estrogen. These factors, along with psychosocial factors that present during this time in a woman’s life, influence sexual function during perimenopause.

Psychological factors play an important role in sexual desire, perhaps more than biological factors at times.
Depression and anxiety and their treatment with medications such as selective serotonin reuptake inhibitors (SSRIs) and anti-anxiety agents are associated with decreased sexual desire. Sexual abuse and childhood trauma are also known to negatively affect sexual desire.

Social factors can affect sexual desire significantly enough to justify taking them into strong consideration when addressing female sexual dysfunction. Cultural, social, and religious values can negatively influence a woman’s sexual desire. Relationship factors such as conflict, stressors such as financial hardship, career pressures, and family obligations can also contribute.

Because some women are hesitant to initiate a discussion about their sexual concerns, it is important that the physician address them routinely as part of a comprehensive women’s health visit. Only one third of women with distressing sex problems seek help. The gynecologist is poised to provide this help: he/she can open a dialogue that allows a woman to discuss issues and concerns that she may otherwise not disclose for fear of embarrassment or perception that it is not important.

Although time can be limited in the clinical setting, it is important that women be asked the questions that help determine the nature of the problem. Conditions revealed in the medical history can be identified as possible contributors to decreased sexual desire. Gynecologic history can provide additional information about the cause of low sexual desire. Many gynecologic factors exist: menstrual irregularities and the hormonal imbalances that may be their cause, sexually transmitted infections, history of pelvic surgery, urinary incontinence, and, as mentioned, vaginal dryness and painful intercourse can all contribute to the problem.

Physical Exam

Although many women with low sexual desire will have normal findings on physical exam, the gynecologic exam can be particularly informative. The finding of vulvovaginal atrophy is common, but other findings can be very important: pelvic floor muscle contraction and pelvic floor prolapse (bladder, vaginal, rectal prolapse).

Laboratory evaluation is not usually helpful in the diagnosis of low sexual desire, however, if physical findings warrant, lab tests can help, particularly if in cases of low thyroid function (hypothyroidism). Measurement of androgens, like testosterone, are not meaningful because levels have not been shown to correlate with low sexual desire.

Office-based counseling by the gynecologist

The complicated etiology of low sexual desire often requires a multifaceted intervention. Before initiating treatment, it is important to set realistic goals and expectations.

The value of basic sex education should not be forgotten. Many women demonstrate a lack of knowledge about basic reproductive anatomy and physiology. Learning from diagrams and models can help women gain a better understanding of their bodies so they can more effectively communicate their concerns about their sexual health.

Women should be reminded that leading a healthy lifestyle through diet, exercise, avoiding smoking, and minimizing stress can improve overall well-being and self-esteem, which can improve a woman’s response to sexual stimuli or activity. Also encouraging them to promote intimacy with one’s partner through shared activities can help.

Women who are not helped by office-based counseling should be referred to counselors or therapists with expertise in sexual problems. Women who have lifelong symptoms, or ongoing personal, interpersonal, and sociocultural issues should be promptly referred to an expert in sexual medicine.

There are currently two FDA-approved medications for the treatment of low sexual desire in women: Addyi and Vyleesi.

Medications approved for vaginal atrophy can be used to improve low sexual desire caused by painful intercourse. These medications include localized estrogen therapy and Ospemifene (a selective estrogen receptor modulator, or SERM).

Although not FDA-approved, testosterone is widely prescribed off-label for postmenopausal women in the United States. Substantial evidence suggests that testosterone therapy improves sexual well-being in postmenopausal women with low sexual desire. Data on testosterone treatment in premenopausal women are not as strong. Testosterone therapy remains controversial and should be taken with caution, but it is a viable option in appropriate candidates. The most common formulation is a transdermal gel.