Sexual dysfunction is defined as a disturbance in, or pain during, the sexual response. This problem is more difficult to diagnose and treat in women than it is in men because of the intricacy of the female sexual response. In 1998, the Sexual Function Health Council of the American Foundation of Urologic Disease revised preexisting definitions and classifications of FSD.² Medical risk factors, etiologies, and psychological aspects were classified into four categories of FSD: desire, arousal, orgasmic disorders, and sexual pain disorders:

• Hypoactive sexual desire is the persistent or recurrent deficiency (or absence) of sexual fantasies or thoughts and/or the lack of receptivity to sexual activity.
• Sexual arousal disorder is the persistent or recurrent inability to achieve or maintain sufficient sexual excitement, expressed as a lack of excitement or a lack of genital or other somatic responses.
• Orgasmic disorder is the persistent or recurrent difficulty, delay, or absence of attaining orgasm after sufficient sexual stimulation and arousal.
• Sexual pain disorder includes dyspareunia (genital pain associated with sexual intercourse); vaginismus (involuntary spasm of the vaginal musculature that causes interference with vaginal penetration), and noncoital sexual pain disorder (genital pain induced by noncoital sexual stimulation).

Each of these definitions has three additional subtypes: lifelong versus acquired; generalized versus situational; and of organic, psychogenic, mixed, and unknown etiologic origin.

Approximately 40 million American women are affected by FSD.³ The National Health and Social Life Survey, a probability sample study of sexual behavior in a demographically representative cohort of US adults ages 18 to 59, found that sexual dysfunction is more prevalent in women (43%) than in men (31%), and decreases as women age.⁴ Married women have a lower risk of sexual dysfunction than unmarried women. Hispanic women consistently report lower rates of sexual problems, whereas African American women have higher rates of decreased sexual desire and pleasure than do Caucasian women. Sexual pain, however, is more likely to occur in Caucasians. This survey was limited by its cross-sectional design and age restrictions, since women more than 60 years old were excluded. Also, no adjustments were made for the effects of menopausal status or medical risk factors. Despite these limitations, the survey clearly indicates that sexual dysfunction affects many women.

FSD has both physiologic and psychological components. It is important to first understand the normal female sexual response in order to understand sexual dysfunction.

Physiologically, sexual arousal begins in the medial preoptic, anterior hypothalamic, and limbic-hippocampal structures within the central nervous system. Electrical signals are then transmitted through the parasympathetic and sympathetic nervous systems.³

Physiologic and biochemical mediators that modulate vaginal and clitoral smooth-muscle tone and relaxation are currently under investigation. Neuropeptide Y, vasoactive intestinal polypeptide, nitric oxide synthase, cyclic guanosine monophosphate, and substance P have been found in vaginal-tissue nerve fibers. Nitric oxide is thought to mediate clitoral and labial engorgement, while vasoactive intestinal polypeptide, a nonadrenergic/noncholinergic neurotransmitter, may enhance vaginal blood flow, lubrication, and secretions.⁵

Many changes occur in the female genitalia during sexual arousal. Increased blood flow promotes vasocongestion of the genitalia. Secretions from uterine and Bartholin's glands lubricate the vaginal canal. Vaginal smooth muscle relaxation allows for lengthening and dilatation of the vagina. As the clitoris is stimulated, its length and diameter increase and engorgement occurs. In addition, the labia minora promote engorgement due to increased blood flow.

FSD is psychologically complex. The female sexual response cycle was first characterized by Masters and Johnson in 1966 and included four phases: excitement, plateau, orgasm, and resolution.⁶ In 1974, Kaplan modified this theory and characterized it as a three-phase model that included desire, arousal, and orgasm.⁷ Basson proposed a different theory for the female sexual response cycle,⁸ suggesting that the sexual response is driven by the desire to enhance intimacy (Figure 1). The cycle begins with sexual neutrality. As a woman seeks a sexual stimulus and responds to it, she becomes sexually aroused. Arousal leads to desire, thus stimulating a woman's willingness to receive or provide additional stimuli. Emotional and physical satisfaction are gained by an increase in sexual desire and arousal. Emotional intimacy is then ultimately achieved. Various biological and psychological factors can negatively affect this cycle, thus leading to FSD.

Sexual dysfunction presents in a variety of ways. It is important to elicit specific signs and symptoms since many women make generalizations about their sexual problems, describing the trouble as a decrease in libido or overall dissatisfaction. Other women may be more specific and recount pain with sexual stimulation or intercourse, anorgasmia, delayed orgasm, and decreased arousal. Postmenopausal women with estrogen deficiency and vaginal atrophy may also describe a decrease in vaginal lubrication.

History
An accurate diagnosis of FSD requires a thorough medical and sexual history. Issues such as sexual preference, domestic violence, fears of pregnancy, human immunodeficiency virus, and sexually transmitted diseases must be discussed. In addition, specific details of the actual dysfunction, identifying causes, medical or gynecologic conditions, and psychosocial information must be obtained.⁹ FSD is often multifactorial, and the presence of more than one dysfunction should be ascertained. Patients may be able to provide insight into the cause or causes of the problem; however, various tools are available to assist with obtaining a good sexual history. The Female Sexual Function Index (FSFI) is one such example.¹⁰ This questionnaire contains 19 questions and categorizes sexual dysfunction in the domains of desire, arousal, lubrication, orgasm, satisfaction, and pain. The FSFI and other similar questionnaires can be filled out before the appointment time in order to expedite the process.

FSD needs to be categorized according to the onset and duration of symptoms. It is also imperative to determine whether the symptoms are situational or global. Situational symptoms occur with a specific partner or in a particular setting, whereas global symptoms relate to an assortment of partners and circumstances.

A variety of medical problems can contribute to FSD (Table 1).¹¹ Vascular disease, for example, may lead to decreased blood flow to the genitalia, causing decreased arousal and delayed orgasm. Diabetic neuropathy may also contribute to the problem. Arthritis may make intercourse uncomfortable and even painful. It is essential to aggressively treat these diseases and inform patients of how they can affect sexuality.

There are many gynecologic causes of FSD, contributing to physical, psychological, and sexual difficulties (Table 2).⁹ Women who have undergone gynecologic surgeries, ie, hysterectomies and excisions of vulvar malignancies, may experience feelings of decreased sexuality because of alterations in or loss of psychological symbols of femininity. Women with vaginismus may find vaginal penetration painful and virtually impossible. Alterations in hormones during pregnancy or the postpartum period may lead to a decrease in sexual activity, desire, and satisfaction, which may be prolonged by lactation.¹²

Prescription and over-the-counter medications should be reviewed in order to identify any contributing agents (Table 3).^13,14 Consideration should be given to dosage adjustments, medication alterations, and even drug discontinuation, if possible. In addition, use of recreational drugs, alcohol, and alternative therapies should be discussed.

Psychosocial and psychological factors should also be identified. For example, a woman with a strict religious upbringing may have feelings of guilt that decrease sexual pleasure. A history of rape or sexual abuse may contribute to vaginismus. Financial struggles may preclude a woman's desire for intimacy.

Physical Examination
A thorough physical examination is required to identify disease. The entire body and genitalia should be examined. The genital examination can be utilized to reproduce and localize pain that is encountered during sexual activity and vaginal penetration.¹⁵ External genitalia should be inspected. Skin color, texture, thickness, turgor, and the amount and distribution of pubic hair should be assessed. Internal mucosa and anatomy should then be examined and cultures taken if indicated. Attention should be given to muscle tone, location of episiotomy scars and strictures, tissue atrophy, and the presence of discharge in the vaginal vault. Some women with vaginismus and severe dyspareunia may not endure a normal speculum and bimanual examination; a "monomanual" examination using one to two fingers may be better tolerated.⁹ The bimanual or monomanual examination can give information about rectal disease, uterine size and position, cervical motion tenderness, internal muscle tone, vaginal depth, prolapse, ovarian and adenexal size and location, and vaginismus.

Laboratory Tests
Although no specific laboratory tests are universally recommended for the diagnosis of FSD, routine Pap smears and stool guaiac tests should not be overlooked. Baseline hormone levels may be helpful when indicated, including thyroid-stimulating hormone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), total and free testosterone levels, sex hormone-binding globulin (SHBG), estradiol, and prolactin.

The diagnosis of primary and secondary hypogonadism can be assessed with FSH and LH. An elevation of FSH and LH may suggest primary gonadal failure, whereas lower levels suggest impairment of the hypothalamic-pituitary axis. Decreased estrogen levels can lead to decreased libido, vaginal dryness, and dyspareunia. Testosterone deficiencies can also cause FSD, including decreased libido, arousal, and sensation. SHBG levels increase with age but decrease with the use of exogenous estrogens.¹⁶ Hyperprolactinemia may also be associated with decreased libido.

Other Tests
Some medical centers have the capacity to perform additional testing, although many of these tests are still investigational. The genital blood flow test uses duplex Doppler ultrasonography to determine peak systolic and diastolic velocities of blood flow to the clitoris, labia, urethra, and vagina. Vaginal pH can serve as an indirect measurement of lubrication. Pressure-volume changes can identify dysfunction of vaginal tissue compliance and elasticity. Vibratory perception thresholds and temperature perception thresholds may offer information regarding genital sensation.³ Clitoral electromyography may also be beneficial in evaluating the autonomic innervation of the corpus clitoris.¹⁷ These tests may be helpful in guiding medical therapy.

Once a diagnosis is made, suspected causes should be addressed. For example, diseases such as diabetes or hypothyroidism must be aggressively treated. Consideration should also be given to changes in medications or dosages.

Patients should be educated about sexual function and dysfunction. Information about basic anatomy and the physiologic changes associated with hormonal fluctuations may help a woman better understand the problem. There are many good books, videos, websites, and organizations available that can be recommended to patients (Table 4).

If no exact cause can be identified, basic treatment strategies should be applied. Patients should be encouraged to enhance stimulation and avoid a mundane routine. Specifically, the use of videos, books, and masturbation can help maximize pleasure. Patients should also be encouraged to make time for sexual activity and communicate with their partners about sexual needs. Pelvic muscle contraction during intercourse, background music, and the use of fantasy may help eliminate anxiety and increase relaxation. Noncoital behaviors, such as massage and oral or noncoital stimulation, should also be recommended, especially if the partner has erectile dysfunction. Vaginal lubricants and moisturizers, positional changes, and nonsteroidal anti-inflammatory drugs may reduce dyspareunia.¹⁸

Hypoactive Sexual Desire
Desire disorders are often multifactorial and may be difficult to treat effectively. For many women, lifestyle issues such as finances, careers, and family commitments may greatly contribute to the problem. In addition, medications or another type of sexual dysfunction, ie, pain, may contribute to the dysfunction. Individual or couple counseling may be of benefit, as there is no medical treatment geared toward this specific disorder.

Hormone replacement therapy can affect sexual desire. Estrogen may benefit menopausal or peri-menopausal women. It can enhance clitoral sensitivity, increase libido, improve vaginal atrophy, and decrease dyspareunia. In addition, estrogen can improve vasomotor symptoms, mood disorders, and symptoms of urinary frequency and urgency.¹⁹ Progesterone is necessary for women with intact uteri using estrogen; however, it may negatively affect mood and contribute to decreased sexual desire.

Testosterone appears to directly influence sexual desire, but data are controversial regarding its replacement in androgen-deficient premenopausal women. Indications for testosterone replacement include premature ovarian failure, symptomatic premenopausal testosterone deficiency, and symptomatic postmenopausal testosterone deficiency (includes natural, surgical, or chemotherapy-induced).¹⁹ Currently, however, there is no national guideline for testosterone replacement in women with sexual dysfunction. In addition, there is no consensus regarding what is considered normal or therapeutic levels of testosterone therapy for women.¹⁵

Before initiating therapy, potential side effects and risks of treatment should be discussed. Androgenic side effects can occur in 5% to 35% of women taking testosterone and include acne, weight gain, hirsutism, clitorimegaly, deepening of the voice, and lowering of high-density lipoprotein cholesterol.²⁰ Baseline levels of lipids, testosterone (free and total), and liver function enzymes should be obtained in addition to a mammogram and Pap smear if indicated.

Postmenopausal women may benefit from 0.25 to 2.5 mg of methyltestosterone (Android, Methitest, Testred, Virilon) or up to 10 mg of micronized oral testosterone. Doses are adjusted according to symptom control and side effects. Methyltestosterone is also available in combination with estrogen (Estratest, Estratest H.S.). Some women may benefit from topical methyltestosterone or testosterone propionate compounded with petroleum jelly in a 1% to 2% formula. This ointment can be applied up to three times per week.^9,19 It is important to periodically monitor liver function, lipids, testosterone levels, and androgenic side effects during treatment.

There are various over-the-counter herbal products that advertise improvement in female sexual dysfunction and restoration of hormone levels. Although evidence is conflicting, many of these products lack sufficient scientific studies required to support the manufactures' claims of efficacy and safety.^21,22 Patients should be cautioned about the potential for side effects and drug-to-drug interactions with these products.

Tibolone is a synthetic steroid with tissue-specific estrogenic, progestogenic and androgenic properties. It has been used in Europe for the past 20 years in the prevention of postmenopausal osteoporosis and in the treatment of menopausal symptoms, including sexual dysfunction. It is not yet available in the United States, but is actively being studied.²³

Sexual Arousal Disorder
Inadequate stimulation, anxiety, and urogenital atrophy may contribute to arousal disorder. A pilot study of 48 women with arousal disorder showed that sildenafil (Viagra) significantly improved subjective and physiologic parameters of the female sexual response.²⁴ Other treatment options for arousal disorder include lubricants, vitamin E and mineral oils, increased foreplay, relaxation, and distraction techniques. Estrogen replacement may benefit postmenopausal women, as urogenital atrophy is one of the most common causes of arousal disorder in this age group.

Orgasmic Disorder
Women with orgasmic disorders often respond well to therapy. Sex therapists encourage women to enhance stimulation and minimize inhibition. Pelvic muscle exercises can improve muscle control and sexual tension, while the use of masturbation and vibrators can increase stimulation. The use of distraction, ie, background music, fantasy, and so forth, can also help minimize inhibition.⁹

Sexual Pain Disorder
Sexual pain can be classified as superficial, vaginal, or deep. Superficial pain is often due to vaginismus, anatomic abnormalities or irritative conditions of the vaginal mucosa. Vaginal pain can be caused by friction due to inadequate lubrication. Deep pain can be muscular in nature or associated with pelvic disease.¹⁵ The type(s) of pain a woman experiences can dictate therapy, thus making an aggressive approach to an accurate diagnosis imperative. The use of lubricants, vaginal estrogens, topical lidocaine, moist heat to the genital area, NSAIDs, physical therapy and positional changes may help to minimize discomfort during intercourse. Sex therapy may benefit women with vaginismus, as it is often triggered by a history of sexual abuse or trauma.

The complexity of sexual dysfunction in women makes the diagnosis and treatment very difficult. Disorders of desire, for example, are difficult to treat, while other disorders, such as vaginismus and orgasmic dysfunction, easily respond to therapy. Numerous women suffer from FSD; however, it is unknown how many women are successfully treated.

Until recently, there has been limited clinical or scientific research in the field of FSD. Although some progress has been made, additional research is needed to assess treatment efficacy and establish national treatment guidelines.

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