Clinical Review

Evaluation and Management of Female Sexual Dysfunction

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Patients often fail to bring it up, and clinicians may be reluctant to discuss it, but ignoring sexual dysfunction can disrupt a woman’s most intimate relationships.


 

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IN THIS ARTICLE

  • Causes of pain
  • Screening
  • Multimodal treatment

Care of women with sexual disorders has made great strides since Masters and Johnson began their study in 1957. In 2000, the Sexual Function Health Council of the American Foundation for Urologic Disease devised the classification system for female sexual dysfunction, which was officially defined in the Diagnostic and Statistical Manual of Mental Disorders-IV-TR.1 There are now definitions for sexual desire disorders, sexual arousal disorders, orgasmic disorder, and sexual pain disorders.

Female sexual dysfunction (FSD) has complex physiologic and psychologic components that require a detailed screening, history, and physical examination. Our goal in this review is to provide primary care providers with insights and practical advice to help screen, diagnose, and treat FSD, which can have a profound impact on patients’ most intimate relationships.

UNDERSTANDING THE TYPES OF FSD

Most women consider sexual health an important part of their overall health.2 Factors that can disrupt normal sexual function include aging, socioeconomics, and other medical comorbidities. FSD is common in women throughout their lives and refers to various sexual dysfunctions including diminished arousal, problems achieving orgasm, dyspareunia, and low desire. Its prevalence is reported to be as high as 20% to 43%.3,4

The World Health Organization and the US Surgeon General have released statements encouraging health care providers to address sexual health during a patient’s annual visits.5 Unfortunately, despite this call to action, many patients and providers are initially hesitant to discuss these problems.6

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) provides the definition and diagnostic guidelines for the different components of FSD. Its classification of sexual disorders was simplified and published in May 2013.7 There are now only three female dysfunctions (as opposed to five in DSM-IV):

  • Female hypoactive desire dysfunction and female arousal dysfunction were merged into a single syndrome labeled female sexual interest/arousal disorder.
  • The formerly separate dyspareunia (painful intercourse) and vaginismus are now called genitopelvic pain/penetration disorder.
  • Female orgasmic disorder remains as a category and is unchanged.

To qualify as a dysfunction, the problem must be present more than 75% of the time, for more than six months, causing significant distress, and must not be explained by a nonsexual mental disorder, relationship distress, substance abuse, or a medical condition.

Substance- or medication-induced sexual dysfunction falls under “Other Dysfunctions” and is defined as a clinically significant disturbance in sexual function that is predominant in the clinical picture. The criteria for substance- and medication-induced sexual dysfunction are unchanged and include neither the 75% nor the six-month requirement. The diagnosis of sexual dysfunction due to a general medical condition and sexual aversion disorder are absent from the DSM-5.7

Continue to: A common symptom

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