Female sexual dysfunction: Don’t assume it’s a side effect
Watch for medical, psychiatric causes.
- personal or family history of common medical conditions that cause sexual dysfunction, such as diabetes mellitus and hypertension (Table 4). Vascular complications stemming from these disorders can block arousal. Osteoarthritis—which is probably ruled out for Ms. S but is prevalent in postmenopausal women—may cause discomfort or pain that obliterates sexual desire.6
- current or past gynecologic conditions. Many gynecologic disorders can impair sexual function.
Be aware that some women may have comorbid disorders, any of which could decrease sexual function. For these women, finding the root cause is essential to ensuring appropriate, targeted treatment. For example, ask a patient who complains of decreased arousal to explain how she feels during sex. Her answers might reveal symptoms that suggest dyspareunia. Similarly, an older woman who loses interest in sex could have a sexual aversion disorder or could be starting menopause (Box).
Finally, ask how long the sexual dysfunction has persisted, as this will help you rule out causes. For example, diabetes progressively depletes sexual function, whereas medication might precipitate a more acute or abrupt change.
Ms. A, age 63, reached menopause at age 55. She reports no other medical problems when she presents for an annual checkup.
For 6 months, she says, she has had little desire for sex with her husband. During additional questioning, she reports vaginal discomfort and lack of pleasure.
Pelvic exam reveals vaginal wall atrophy and vaginal vault dryness. We suspect that vaginal atrophy secondary to menopause has diminished Ms. A’s libido, as other physical exam and laboratory findings are normal.
Sexual dysfunction is more frequent and is more often irreversible among women who are experiencing or have gone through menopause, compared with younger women.4
Genital tissues have abundant estrogen receptors in the epithelial, endothelial, and smooth muscle cells. Ovarian estradiol production ceases with menopause onset, subjecting genital tissues to atrophy; this in turn decreases lubrication and vaginal moisture. Loss of moisture causes dyspareunia, prompting women to avoid or fear sexual intercourse. Decreased sexual activity leads to further vaginal atrophy, creating a cycle of sexual dysfunction.
Iatrogenic causes, such as bilateral oophorectomy and chemotherapy, also can trigger menopause. In such cases, sexual dysfunction caused by lack of androgen production can be severe.10
As women approach or have completed menopause, hormonal changes—including FSH, LH, estrogen, and progesterone—and chronic medical illnesses such as diabetes and hypertension, are more likely to contribute to sexual dysfunction. In younger women, workup may focus on thyroid dysfunction and medications, such as oral contraceptives.
Low interest? Delayed orgasm? Vaginal pain?
Here’s what you need to find out
| If patient reports… | Ask:* |
|---|---|
| Lack of interest in sex | Has this happened before? |
| Have you started any new medications or changed dosages? | |
| Dreading the prospect of sex with her partner | Are there any physical reasons why this happens? |
| Has this happened before? | |
| What is the nature of your relationship with your partner? | |
| Have you had problems like this with previous partners? | |
| Difficulty becoming aroused | Does this happen only with your partner? |
| Can you become aroused with self-stimulation or use of other objects? | |
| Difficulty reaching or maintaining orgasm | Does this happen only with your partner? |
| Are you able to achieve orgasm with self-stimulation or use of other objects? | |
| Has this happened with other partners? | |
| Vaginal pain during intercourse | Have you noticed vaginal dryness? |
| Has this happened before? | |
| Does this happen with self-stimulation or use of other objects? | |
| * Patient’s answers to questions about specific sexual dysfunction symptoms could suggest concurrent sexual dysfunction disorders. | |
Female sexual dysfunction: 5 medical causes you should not miss
| Diabetes |
| Hypertension |
| Stroke |
| Urinary incontinence |
| Urinary tract infections |
Ordering additional tests
An introductory laboratory evaluation, performed in concert with the patient’s primary care physician, can help assess for common medical causes of sexual dysfunction. Watch for:
- elevated blood pressure, which suggests hypertension
- overweight, which can lead to hyperlipidemia or osteoarthritis
- glycosylated hemoglobin >7%, which could signal diabetes
- prolactin >20 ng/mL, which suggests pituitary dysfunction
- low estrogen and/or follicle-stimulating hormone (FSH) 40 to 200 mlU/mL, which suggest menopause
- elevated estrogen or FSH >5 mlU/mL, which could signal amenorrhea
- low free and total testosterone readings, which may signal an androgen problem
- Elevated thyroid-simulating hormone (TSH), which could point to hypothyroidism.
- Low TSH, which could signal hyperthyroidism.8
