STEPHANIE S. FAUBION, MD, and JORDAN E. RULLO, PhD, mayo Clinic, Rochester, Minnesota

Am Fam Physician. 2015 Aug 15;92(4):281-288.

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patience information: A handout on this subject is obtainable at https://familydoctor.org/familydoctor/en/diseases-conditions/sexual-dysfunction-women.html.

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Sexual dysfunction in women is a common and often distressing problem that has actually a an unfavorable impact on high quality of life and medication compliance. The trouble is often multifactorial, necessitating a multidisciplinary evaluation and also treatment technique that addresses biological, psychological, sociocultural, and also relational factors. Criteria for sex-related interest/arousal disorder require the existence of at the very least three specific symptoms lasting because that at the very least six months. Lifelong anorgasmia may indicate the patient is unfamiliar or uncomfortable through self-stimulation or sexual communication with she partner. Delayed or less intense orgasms might be a natural procedure of aging early to reduced genital blood flow and dulled genital sensations. Genito-pelvic pain/penetration disorder includes fear or anxiety, marked tightening or tensing the the ab and pelvic muscles, or really pain connected with attempts toward vaginal penetration that is persistent or recurrent because that at least six months. Treatment counts on the etiology. Estrogen is reliable for the therapy of dyspareunia linked with genitourinary syndrome the menopause. Testosterone, with and without concomitant use of estrogen, is connected with improvements in sexual functioning in naturally and also surgically menopausal women, although data on permanent risks and benefits space lacking. Bupropion has been presented to improve the adverse sex-related effects associated with antidepressant use; however, data are limited. Psychotherapy or sex treatment is helpful for management of the psychological, relational, and also sociocultural factors impacting a woman"s sexual function. Clinicians can resolve many that these concerns in addition to providing education and validating women"s sexual wellness concerns.


Female sex-related dysfunction is a general term making up several sex-related health involves that deserve to be distressing because that patients, consisting of female sex-related interest/arousal disorder, woman orgasmic disorder, and also genito-pelvic pain/penetration disorder. These sex-related health pertains to are not considered dysfunctions uneven they cause distress. Around 12% of females in the United says report distressing sexual wellness concerns, back as many as 40% report sexual comes to overall.1


SORT: key RECOMMENDATIONS for PRACTICEClinical recommendationEvidence ratingReferences

Bupropion (Wellbutrin) in greater dosages (150 mg twice daily) has been shown to be efficient as an adjunct for antidepressant-induced sexual dysfunction in women.

B

17

Sildenafil (Viagra) may advantage women with sex-related dysfunction induced by selective serotonin reuptake inhibitor or serotonin-norepinephrine reuptake inhibitor use.

B

18

Female genital sex-related pain obstacle are complex and many effectively regulated with a comprehensive, multidisciplinary technique that addresses contributing biopsychosocial factors.

C

19

Group cognitive behavior therapy has actually been shown to efficiently treat low sex-related desire.

C

7

Mindfulness-based interventions have been displayed to successfully treat low sexual desire and arousal, and acquired anorgasmia.

B

7, 25, 26

Directed masturbation is recommended because that lifelong anorgasmia.

A

27–29

Local vaginal estrogen therapy is recommended and preferred over systemic estrogen therapy for therapy of genitourinary syndrome that menopause and related dyspareunia once vaginal dryness is the primary concern. Because of potential adverse effects, the usage of estrogens, particularly systemic estrogens, have to be minimal to the shortest duration compatible with treatment goals.

A

14, 21, 31

Ospemifene (Osphena) is modestly efficient for treatment of dyspareunia.

B

21, 32, 33

Transdermal testosterone, through or without concomitant estrogen therapy, has actually been shown to be reliable for short-lived treatment of low sex-related desire or arousal in natural and also surgically induced menopause.

B

35, 36


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, normal practice, expert opinion, or case series. Because that information about the SORT proof rating system, go to https://www.4476mountvernon.com/afpsort.


SORT: key RECOMMENDATIONS for PRACTICEClinical recommendationEvidence ratingReferences

Bupropion (Wellbutrin) in higher dosages (150 mg double daily) has been displayed to be efficient as one adjunct for antidepressant-induced sex-related dysfunction in women.

B

17

Sildenafil (Viagra) may advantage women with sex-related dysfunction induced by selective serotonin reuptake inhibitor or serotonin-norepinephrine reuptake inhibitor use.

B

18

Female genital sexual pain obstacle are complicated and many effectively controlled with a comprehensive, multidisciplinary technique that addresses contributing biopsychosocial factors.

C

19

Group cognitive habits therapy has actually been presented to properly treat low sexual desire.

C

7

Mindfulness-based interventions have been shown to properly treat low sex-related desire and also arousal, and acquired anorgasmia.

B

7, 25, 26

Directed masturbation is recommended for lifelong anorgasmia.

A

27–29

Local quality estrogen treatment is recommended and also preferred end systemic estrogen treatment for therapy of genitourinary syndrome that menopause and also related dyspareunia when vaginal dryness is the main concern. Because of potential adverse effects, the usage of estrogens, especially systemic estrogens, need to be minimal to the shortest expression compatible with treatment goals.

A

14, 21, 31

Ospemifene (Osphena) is modestly efficient for therapy of dyspareunia.

B

21, 32, 33

Transdermal testosterone, through or without concomitant estrogen therapy, has been shown to be effective for short-lived treatment that low sex-related desire or arousal in natural and surgically induced menopause.

B

35, 36


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, normal practice, expert opinion, or case series. Because that information around the SORT evidence rating system, go to https://www.4476mountvernon.com/afpsort.


The etiology of female sexual dysfunction is multifactorial, encompassing biological, psychological, relational, and also sociocultural factors.2 biological factors may impact sexual duty in a range of ways. Part chronic illnesses, such as vascular disease, diabetes mellitus, neurologic disease, and malignancy, can straight or indirectly influence sexual function (Table 1).3,4 Aging chin is connected with decreased sexual responsiveness, sex-related activity, and also libido.4,5


Table 1.Medical problems That Potentially affect Sexual FunctionConditionType the dysfunctionDesireArousalOrgasmPainComments

Arthritis

+

Decreased mobility and also chronic pain may impair sex-related function

Coronary artery disease

+

Dermatologic problems (e.g., vulvar lichen sclerosus, vulvar eczema, psoriasis)

+

Diabetes mellitus

+

Gynecologic conditions (e.g., sexually sent infections, endometriosis, chronic pelvic pain, pelvic pain complying with childbirth, pelvic body organ prolapse)

+

Hypertension

+

Impact of hypertension or treatment is unclear; one study uncovered an association through low desire

Hypothyroidism

+

+

Increased troubles with lubrication and orgasm

Malignancy and also treatment (e.g., breast, anal, colorectal, bladder, and also gynecologic cancers)

+

+

+

+

Sexual duty may be straight or indirectly influenced by cancer diagnosis and treatment; determinants include cancer diagnosis, condition itself, therapy (surgery, radiation, chemotherapy), and also body image

Neuromuscular disorders, spinal cord injury, multiple sclerosis

+

+

+

+

Direct influence on sex-related response; indirect effect on desire may be mediated by arousal obstacle or pain

Parkinson disease, dementia, head injury

+

Desire may be raised or decreased

Pituitary tumor, hyperprolactinemia

+

Renal failure

Dialysis is associated with sexual dysfunction; no data on which form of sexual dysfunction is affected

Urinary incontinence

+

+

+


Table 1.Medical conditions That Potentially affect Sexual FunctionConditionType that dysfunctionDesireArousalOrgasmPainComments

Arthritis

+

Decreased mobility and chronic pain might impair sex-related function

Coronary artery disease

+

Dermatologic conditions (e.g., vulvar lichen sclerosus, vulvar eczema, psoriasis)

+

Diabetes mellitus

+

Gynecologic problems (e.g., sexually sent infections, endometriosis, chronic pelvic pain, pelvic pain adhering to childbirth, pelvic organ prolapse)

+

Hypertension

+

Impact the hypertension or treatment is unclear; one study uncovered an association v low desire

Hypothyroidism

+

+

Increased difficulties with lubrication and also orgasm

Malignancy and treatment (e.g., breast, anal, colorectal, bladder, and also gynecologic cancers)

+

+

+

+

Sexual duty may be straight or indirectly affected by cancer diagnosis and treatment; components include cancer diagnosis, disease itself, treatment (surgery, radiation, chemotherapy), and body image

Neuromuscular disorders, spinal cord injury, many sclerosis

+

+

+

+

Direct impact on sex-related response; indirect impact on desire might be mediated by arousal disorders or pain

Parkinson disease, dementia, head injury

+

Desire may be raised or decreased

Pituitary tumor, hyperprolactinemia

+

Renal failure

Dialysis is connected with sexual dysfunction; no data on which kind of sexual dysfunction is affected

Urinary incontinence

+

+

+


Hormonal changes developing in midlife may influence a woman"s sexual function. Menopause is significant by a decline in ovarian hormone levels, i m sorry occurs progressively in natural menopause however may be sudden if menopause occurs since of surgery, radiation, or chemotherapy. Lessened vaginal lubrication and also dyspareunia are linked with short estradiol levels; however, the association in between low sex-related desire and also lower estradiol levels has been inconsistent. Testosterone levels execute not correlate v female sexual duty or in its entirety well-being, possibly since of the an obstacle in that s right measuring cost-free and full testosterone levels at the lower finish of the female range.4 back androgens space positively associated with enhancements in all aspects of sex-related functioning (e.g., spatu arousal, quality blood flow, sexual desire, orgasm), over there is no reduced level of testosterone the predicts sex-related dysfunction, and also androgen levels space not supplied to define an androgen deficiency syndrome in women.

Serotonin-enhancing medications have actually an inhibitory result on sex-related function. Sexual dysfunction induced by selective serotonin reuptake inhibitor use is common, through an incidence between 30% and also 70%, and also may include difficulty with sex-related desire, arousal, and orgasm.4 Further, plenty of other commonly prescribed medications might adversely affect sexual functioning, including antiestrogens, such together tamoxifen and also aromatase inhibitors, and oral estrogens, including an unified hormonal contraception (Table 2).6


Table 2.Medications linked with Female sex-related DysfunctionType the dysfunctionMedicationDesire disorderArousal disordersOrgasm disorders

Amphetamines and also related anorectic medications

+

Anticholinergics

+

Antihistamines

+

Cardiovascular and antihypertensive medications

Antilipids

+

Beta blockers

+

Clonidine

+

+

Digoxin

+

+

Methyldopa

+

Spironolactone

+

Hormonal preparations

Antiandrogens

+

+

+

Danazol

+

Gonadotropin-releasing hormone agonists

+

Gonadotropin-releasing hormone analogues

+

+

Hormonal contraceptives

+

Tamoxifen

+

+

Ultra-low-potency contraceptives

+

+

Narcotics

+

Psychotropics

Antipsychotics

+

+

Barbiturates

+

+

+

Benzodiazepines

+

+

Lithium

+

+

+

Monoamine oxidase inhibitors

Selective serotonin reuptake inhibitors

+

+

+

Trazodone

+

Tricyclic antidepressants

+

+

+

Venlafaxine

+

Other

Aromatase inhibitors

+

+

Chemotherapeutic agents

+

+

Histamine H2 blockers and promotility agents

+

Indomethacin

+

Ketoconazole

+

Phenytoin (Dilantin)

+


Adapted with permission indigenous Buster JE. Managing female sexual dysfunction. Fertil Steril. 2013;100(4)905-915.


Table 2.Medications associated with Female sex-related DysfunctionType the dysfunctionMedicationDesire disorderArousal disordersOrgasm disorders

Amphetamines and related anorectic medications

+

Anticholinergics

+

Antihistamines

+

Cardiovascular and antihypertensive medications

Antilipids

+

Beta blockers

+

Clonidine

+

+

Digoxin

+

+

Methyldopa

+

Spironolactone

+

Hormonal preparations

Antiandrogens

+

+

+

Danazol

+

Gonadotropin-releasing hormone agonists

+

Gonadotropin-releasing hormone analogues

+

+

Hormonal contraceptives

+

Tamoxifen

+

+

Ultra-low-potency contraceptives

+

+

Narcotics

+

Psychotropics

Antipsychotics

+

+

Barbiturates

+

+

+

Benzodiazepines

+

+

Lithium

+

+

+

Monoamine oxidase inhibitors

Selective serotonin reuptake inhibitors

+

+

+

Trazodone

+

Tricyclic antidepressants

+

+

+

Venlafaxine

+

Other

Aromatase inhibitors

+

+

Chemotherapeutic agents

+

+

Histamine H2 blockers and also promotility agents

+

Indomethacin

+

Ketoconazole

+

Phenytoin (Dilantin)

+


Adapted v permission indigenous Buster JE. Managing female sex-related dysfunction. Fertil Steril. 2013;100(4)905-915.


The most usual psychological determinants impacting female sexual role are depression, anxiety, distraction, negative body image, sex-related abuse, and emotional neglect. Common contextual or sociocultural determinants that reason or preserve sexual dysfunction incorporate relationship discord, companion sexual dysfunction (e.g., erectile dysfunction), life stage stressors (e.g., transition into retirement, children leaving home), and cultural or religious messages that inhibit sexuality.7


Assessment of female sexual dysfunction is best approached using a biopsychosocial design (eFigure A), and should incorporate a sexual background and physics examination. Laboratory experimentation is typically not necessary to identify causes of sex-related dysfunction.8 Table 3 includes important questions to asking patients throughout a sex-related functioning assessment.8


  Enlarge   Print

eFigure A.

Biopsychosocial model of female sexual dysfunction. Various determinants from different realms have the right to promote or hinder normal sex-related function.

Information from:

Bitzer J, Giraldi A, Pfaus J. Sex-related desire and also hypoactive sexual desire disorder in women. Arrival and overview. Standard operating procedure (SOP component 1). J Sex Med. 2013;10(1):36–49.

Fugl-Meyer KS, Bohm-Starke N, Damsted Petersen C, Fugl-Meyer A, Parish S, Giraldi A. Traditional operating actions for mrs genital sex-related pain. J Sex Med. 2013;101(1):83–93. Latif EZ, Diamond MP. Arriving at the diagnosis the female sexual dysfunction. Fertil Steril. 2013;100(4):898–904.


eFigure A.

Biopsychosocial version of female sexual dysfunction. Various determinants from different realms deserve to promote or hinder normal sex-related function.

Information from:

Bitzer J, Giraldi A, Pfaus J. Sex-related desire and hypoactive sexual desire disorder in women. Introduction and overview. Standard operating procedure (SOP component 1). J Sex Med. 2013;10(1):36–49.

Fugl-Meyer KS, Bohm-Starke N, Damsted Petersen C, Fugl-Meyer A, Parish S, Giraldi A. Traditional operating procedures for woman genital sexual pain. J Sex Med. 2013;101(1):83–93. Latif EZ, Diamond MP. Showing up at the diagnosis that female sexual dysfunction. Fertil Steril. 2013;100(4):898–904.


Table 3.Questions to Facilitate the assessment of Female sex-related FunctioningQuestionInterpretation that “Yes” answers*

Are you right now sexually energetic (with men, women, or both)?

Continue come the following question (if “No,” additionally continue to the next question)

Do friend have any type of sexual wellness concerns?

Continue to the next question

Specifically, any kind of distress related to:

Your level of sexual desire/interest?

Assess for sexual interest/arousal disorder

Your ability to become or continue to be sexually aroused (“turned on,” vaginal lubrication, blood flow/warmth/tingly feeling in genitals)?

Assess for sex-related interest/arousal disorder

Your ability to experience or with the preferred intensity of an orgasm?

Assess for orgasmic disorder

Are you experiencing any genital pain?

Assess for genito-pelvic pain/penetration disorder, genitourinary syndrome the menopause, and also pelvic floor muscle dysfunction

Vaginal dryness or burning?

Assess because that genitourinary syndrome of menopause

Pain through sexual activity (insertional or depths pain)?

Assess because that genitourinary syndrome of menopause and also pelvic floor muscle dysfunction


*—Starting v the 2nd question, if the prize is “No,” the assessment can end.


Table 3.Questions come Facilitate the assessment of Female sexual FunctioningQuestionInterpretation the “Yes” answers*

Are you currently sexually energetic (with men, women, or both)?

Continue to the following question (if “No,” additionally continue come the following question)

Do girlfriend have any type of sexual wellness concerns?

Continue to the following question

Specifically, any kind of distress related to:

Your level of sexual desire/interest?

Assess for sex-related interest/arousal disorder

Your ability to come to be or continue to be sexually aroused (“turned on,” vaginal lubrication, blood flow/warmth/tingly feelings in genitals)?

Assess for sexual interest/arousal disorder

Your capability to endure or reach the wanted intensity of an orgasm?

Assess because that orgasmic disorder

Are girlfriend experiencing any type of genital pain?

Assess for genito-pelvic pain/penetration disorder, genitourinary syndrome of menopause, and pelvic floor muscle dysfunction

Vaginal dryness or burning?

Assess because that genitourinary syndrome of menopause

Pain with sexual task (insertional or depth pain)?

Assess for genitourinary syndrome that menopause and also pelvic floor muscle dysfunction


*—Starting through the 2nd question, if the price is “No,” the assessment can end.


FEMALE sexual INTEREST/AROUSAL DISORDER

The Diagnostic and Statistical hands-on of psychological Disorders, 5th ed. (DSM-5), combines hypoactive sexual desire disorder and female sexual arousal disorder into a solitary disorder: female sex-related interest/arousal disorder.9 Whereas sex-related desire is the an inspiration to have actually sex, sexual arousal describes the physiologic processes of arousal, consisting of vaginal lubrication and genital warmth pertained to blood flow. Women commonly report experiencing these as part of the same process.10 The DSM-5 criteria because that female sex-related interest/arousal disorder space presented in Table 4.9


Table 4.DSM-5 Criteria because that Female sex-related Interest/Arousal Disorder

A. Lack of, or significantly reduced, sexual interest/arousal, as shown up by at the very least three that the following:

1. Absent/reduced interest in sex-related activity.

2. Absent/reduced sexual/erotic think or fantasies.

3. No/reduced initiation of sex-related activity, and typically unreceptive come a partner"s attempts come initiate.

4. Absent/reduced sexual excitement/pleasure during sexual task in practically all or every (approximately 75%–100%) sexual encounters (in determined situational contexts or, if generalized, in all contexts).

5. Absent/reduced sexual interest/arousal in an answer to any internal or outside sexual/erotic cues (e.g., written, verbal, visual).

6. Absent/reduced genital or nongenital sensations during sexual task in nearly all or every (approximately 75%–100%) sex-related encounters (in established situational contexts or, if generalized, in all contexts).

B. The symptom in default A have persisted for a minimum duration of approximately 6 months.

C. The symptom in standard A reason clinically far-reaching distress in the individual.

D. The sexual dysfunction is not better explained through a nonsexual mental disorder or together a an effect of severe relationship distress (e.g., partner violence) or other far-reaching stressors and is not attributable come the impacts of a substance/medication or one more medical condition.

Specify whether:

Lifelong: The disturbance has actually been present due to the fact that the individual ended up being sexually active.

Acquired: The disturbance started after a duration of reasonably normal sex-related function.

Specify whether:

Generalized: Not minimal to certain types of stimulation, situations, or partners.

Situational: just occurs with certain varieties of stimulation, situations, or partners.

Specify current severity

Mild: evidence of soft distress over the symptom in criterion A.

Moderate: proof of center distress end the symptom in criterion A.

Severe: proof of major or too much distress end the symptom in criterion A.


Reprinted through permission indigenous American Psychiatric Association. Diagnostic and Statistical manual of mental Disorders. Fifth ed. Arlington, Va.: American Psychiatric Association; 2013:433.


Table 4.DSM-5 Criteria for Female sex-related Interest/Arousal Disorder

A. Absence of, or substantially reduced, sex-related interest/arousal, as materialized by at the very least three the the following:

1. Absent/reduced interest in sexual activity.

2. Absent/reduced sexual/erotic think or fantasies.

3. No/reduced initiation of sexual activity, and also typically unreceptive come a partner"s attempts to initiate.

4. Absent/reduced sex-related excitement/pleasure throughout sexual activity in virtually all or every (approximately 75%–100%) sex-related encounters (in determined situational contexts or, if generalized, in all contexts).

5. Absent/reduced sex-related interest/arousal in an answer to any internal or external sexual/erotic cues (e.g., written, verbal, visual).

6. Absent/reduced genital or nongenital sensations throughout sexual activity in nearly all or every (approximately 75%–100%) sexual encounters (in identified situational contexts or, if generalized, in every contexts).

B. The symptoms in default A have actually persisted for a minimum term of approximately 6 months.

C. The symptoms in criterion A cause clinically significant distress in the individual.

D. The sex-related dysfunction is not better explained by a nonsexual mental disorder or as a repercussion of severe connection distress (e.g., partner violence) or other far-reaching stressors and also is not attributable to the impacts of a substance/medication or another medical condition.

Specify whether:

Lifelong: The disturbance has been present since the individual ended up being sexually active.

Acquired: The disturbance started after a duration of reasonably normal sexual function.

Specify whether:

Generalized: Not limited to certain types of stimulation, situations, or partners.

Situational: only occurs with certain types of stimulation, situations, or partners.

Specify existing severity

Mild: proof of mild distress end the symptoms in default A.

Moderate: evidence of center distress end the symptoms in default A.

Severe: proof of major or too much distress end the symptom in default A.


Reprinted through permission from American Psychiatric Association. Diagnostic and also Statistical hands-on of mental Disorders. 5th ed. Arlington, Va.: American Psychiatric Association; 2013:433.


It is important to determine whether the patient"s problem with desire or arousal is a dysfunction or a common variation of sexual response. The following examples are not taken into consideration sexual dysfunction: a patience reports little or no spontaneous desire however continues to suffer responsive desire; a patient maintains spontaneous or responsive desire however reports a desire discrepancy between herself and her partner; a patience has diminished physiologic sex-related arousal (e.g., reduced vaginal lubrication or genital blood flow) concerned menopausal transition.

FEMALE ORGASMIC DISORDER

DSM-5 criteria because that female orgasmic disorder encompass a marked hold-up in orgasm, infrequency or absence of orgasm, or less intense orgasm for at the very least six month in 75% to 100% of sex-related interactions.9 developing the visibility of orgasm is important, since many women may not recognize whether they have experienced orgasm.11 The next step is determining whether these difficulties are resulting in distress. Around one-half of ladies who do not continuously reach orgasm throughout sexual task do no report distress.1 If distress exists, the assessment adheres to the biopsychosocial design with the addition of several key questions that will aid in therapy planning: Is this a readjust in previous orgasmic functioning? does this difficulty occur during self-stimulation, partnered sexual activity, or both? walk this challenge occur throughout different sexual activities (e.g., oral, manual, quality penetration) and also with different sex partners?

Orgasmic obstacles may be lifelong (present since sexual debut) or acquired (starting after a period of no dysfunction). Lifelong anorgasmia may suggest the patience is unfamiliar or uncomfortable v self-stimulation or sexual communication with her partner, or lacks enough sex education.12 delay or much less intense orgasms might be related to reduced genital blood flow and also dulled genital sensations emerging naturally through aging. These instances are not taken into consideration sexual dysfunction.

The clinician should determine whether orgasmic difficulties occur just with certain types of stimulation, situations, or partners. If the patient reports an obstacle during partnered sexual activity but not v self-stimulation, it might be the result of poor sexual stimulation.11 biological factors requiring assessment and treatment encompass medical conditions and also use of medications that impact sexual functioning11 (Tables 13,4 and 26).

GENITO-PELVIC PAIN/PENETRATION DISORDER

In the DSM-5, vaginismus and dyspareunia are combined in genito-pelvic pain/penetration disorder. This disorder of sexual pain is identified as fear or anxiety, significant tightening or tensing that the abdominal and pelvic muscles, or really pain through vaginal penetration the is persistent or recurrent because that at the very least six months. This might be lifelong or got after a period of no dysfunction.9 The clinician should identify if the pain occurs v initial quality penetration, depth penetration, or both.


Although female sex-related dysfunction regularly requires multidisciplinary treatment, even the initial visit have the right to be beneficial. Table 5 summarizes the PLISSIT (permission, minimal information, details suggestions, extensive therapy) model for addressing sexual wellness with patients.13


Table 5.PLISSIT model for Addressing Sexual health with WomenStepsExamples that what to say come patients

Permission: provide patient permission come speak around her sex-related health and also to perform what she is currently doing sexually (or may want to do).

“This is important. Thank you because that sharing. Numerous postmenopausal women report a decrease in sexual desire.”

Limited information: Provide an easy accurate sex education and learning (e.g., female sexual solution cycle, impact of aging on sexual function, anatomy).

“Sexual desire transforms with age. ~ menopause you may experience more responsive desire than spontaneous desire.”

Specific suggestions: Provide straightforward suggestions to increase sexual duty (e.g., lubricant use, vibrator use, ways to rise emotional intimacy).

“Your responsive sexual desire may benefit from being much more planful with sexual activity. Talk v your partner around how come be more intentional sexually.”

Intensive therapy: Validate the patient"s concerns and also refer she to a subspecialist (see eTable A because that resources).

“Your sexual health and wellness is important. I"d favor to refer you to someone with field of expertise in sex-related health.”


Table 5.PLISSIT model for Addressing Sexual wellness with WomenStepsExamples that what to say to patients

Permission: offer patient permission come speak about her sex-related health and also to carry out what she is currently doing sexually (or may want to do).

“This is important. Say thanks to you because that sharing. Many postmenopausal females report a decrease in sexual desire.”

Limited information: Provide basic accurate sex education and learning (e.g., female sexual solution cycle, affect of aging on sexual function, anatomy).

“Sexual desire changes with age. After menopause you might experience more responsive desire 보다 spontaneous desire.”

Specific suggestions: Provide basic suggestions to rise sexual function (e.g., lubricant use, vibrator use, methods to rise emotional intimacy).

“Your responsive sex-related desire may benefit from being more planful with sex-related activity. Talk v your partner about how to be an ext intentional sexually.”

Intensive therapy: Validate the patient"s concerns and refer her to a subspecialist (see eTable A because that resources).

“Your sexual health and wellness is important. I"d prefer to refer girlfriend to someone with specialization in sexual health.”


The unique predisposing, precipitating, and maintaining components for a woman"s sex-related dysfunction will identify the therapy plan.7,14 organic factors, such as medication use, are ideal treated by the clinician.15 tactics for regulating antidepressant-induced dysfunction encompass reducing the sheep if possible, switching to an antidepressant through fewer sex-related adverse effects (vs. Proactively initiating an antidepressant v fewer sex-related adverse effects), or adding bupropion (Wellbutrin) as an adjunct.16 A Cochrane review supports the enhancement of bupropion in greater dosages (150 mg double daily) for therapy of antidepressant-induced sex-related dysfunction in women, but added study is needed.17 In one small study, the enhancement of sildenafil (Viagra) diminished sexual dysfunction induced by selective serotonin reuptake inhibitors or serotoninnorepinephrine reuptake inhibitors.18

Female genital sexual pain disorders are complex and many effectively regulated with a comprehensive, multidisciplinary approach that addresses contributing biopsychosocial factors.19 sex-related pain with deeper vaginal penetration suggests the possibility of a musculoskeletal component. This pain may be described as a deeper pelvic pain linked with penetrative sex-related activity, pain that radiates to the low ago or within thigh, or pain that persists for some time after vaginal penetration.20 Pelvic floor dysfunction is optimally treated by a physics therapist trained in treating this condition. Continuous painless sexual activity and sex-related stimulation with the therapeutic usage of a vibrator might also assist maintain vaginal health.21 If a patient reports painful sex-related activity, that is crucial to advise her to stop engaging in this task because it have the right to increase situational anxiety, resulting in tensing that the pelvic floor muscles and also increasing pain. Psychotherapy or sex treatment is advantageous for women who have actually relational or sociocultural components contributing to their pain, and also for those that experience anxiety in conjunction v their pain.22,23 Psychological, interpersonal, and also sociocultural components are most accordingly treated by a mental health subspecialist. Sexual pain throughout initial vaginal penetration may suggest inadequate sex-related arousal prior to penetration, genitourinary syndrome that menopause (formerly termed vulvovaginal atrophy),24 or provoked vestibulodynia.

Group cognitive actions therapy may be effective for low sexual desire.8 Mindfulness-based interventions have actually been shown to successfully treat several species of female sex-related dysfunction, consisting of low sex-related desire and also arousal, and also acquired anorgasmia.7,25,26 command masturbation cultivate is the treatment of choice for lifelong anorgasmia.27–29 eTable A contains resources because that referral and further details on sex-related health.


eTable A.Resources for an ext Information top top Female sex-related Health and also Referral

Resources for clinicians

American combination of Sexuality Educators, Counselors, and also Therapists

http://www.aamft.org

International society for the study of Women"s sexual Health

http://www.isswsh.org

Society for Sex Therapy and Research

http://www.sstarnet.org

Couples therapy

American Association for Marriage and Family Therapy

http://www.aamft.org

Pelvic physical therapy

American Physical treatment Association

http://www.moveforwardpt.com/symptomsconditionsdetail.aspx?cid=4c28867f-b11f-4148-a21c-f8b6c5ac7002#.VP0NO_mjOm4

International Pelvic pain Society

http://www.pelvicpain.org


eTable A.Resources for much more Information on Female sex-related Health and also Referral

Resources because that clinicians

American combination of Sexuality Educators, Counselors, and also Therapists

http://www.aamft.org

International culture for the examine of Women"s sex-related Health

http://www.isswsh.org

Society for Sex Therapy and also Research

http://www.sstarnet.org

Couples therapy

American Association because that Marriage and also Family Therapy

http://www.aamft.org

Pelvic physics therapy

American Physical therapy Association

http://www.moveforwardpt.com/symptomsconditionsdetail.aspx?cid=4c28867f-b11f-4148-a21c-f8b6c5ac7002#.VP0NO_mjOm4

International Pelvic pain Society

http://www.pelvicpain.org


MENOPAUSE

Sexual health comes to are typical in organic or surgically induced menopause, an especially sexual pain regarded genitourinary syndrome that menopause. A Cochrane review confirmed that hormone treatment (estrogen alone or in mix with a progestogen) was associated with a small to moderate advancement in sex-related function, particularly pain, in symptomatic or beforehand menopausal women.30 Estrogen treatment is highly reliable for genitourinary syndrome the menopause and also related dyspareunia; neighborhood vaginal estrogen is wanted if vaginal dryness is the primary concern.14,21,31 Ospemifene (Osphena) is a selective estrogen receptor modulator that has actually been displayed to improve the vaginal maturation index, quality pH, and also symptoms of quality dryness.21,32,33 The U.S. Food and also Drug administration (FDA) has actually approved it for treatment of middle to serious dyspareunia. The path of administration of estrogen can impact sexual function. Oral estrogens increase sex hormone–binding globulin, i beg your pardon reduces available free testosterone and may in order to adversely affect sexual function, whereas transdermal estrogens have no such effect.6

Women v genitourinary syndrome of menopause and also sexual ache may have actually dysfunctional pelvic floor muscles, i beg your pardon may end up being tense or tight together a result of ongoing vaginal dryness and also discomfort or pain with sex-related activity.34 Pelvic floor physical treatment may benefit these women.34

Randomized managed trials involving naturally or operation menopausal women v low sexual desire or arousal have shown improvements in sexual duty with transdermal testosterone treatment (with or there is no concomitant estrogen therapy).35–39 However, overall, data ~ above the advantage of testosterone therapy are limited and inconsistent.35,40,41 The Endocrine society suggests considering a three- come six-month psychological of testosterone therapy for postmenopausal women v low sexual desire connected with distress. However, due to the fact that of the lack of irreversible data top top safety and effectiveness, it does no recommend routine testosterone treatment for women with low androgen levels concerned hypopituitarism, bilateral oophorectomy, or adrenal insufficiency.41 Testosterone treatment is not FDA-approved for use in women, and also using testosterone formulations made for men is discouraged. If treatment is initiated, clinical evaluation and also laboratory surveillance of testosterone level are suggested to evaluate for overuse and also signs that hyperandrogenism (e.g., acne, hair growth).41

SEXUAL DISTRESS without DYSFUNCTION

If a patience reports distress however does not accomplish criteria for sex-related dysfunction, intervention is tho needed. Women that report low desire or arousal, difficulty with orgasm, or insufficient sexual stimulation may advantage from normalization, sexual health education, and referral come a sex therapist.42

The female sexual response cycle (eFigure B) is an essential educational device that clinicians have the right to use once counseling females with sex-related concerns. Women enter this bike of sexual solution with spontaneous sex-related drive (i.e., the interior desire for sex-related activity) or more commonly native a nonsexual state. A woman in a nonsexual state may communicate in a sex-related encounter because that a variety of nonsexual factors (e.g., to please her partner, to feel emotionally connected, out of a feeling of duty). Once sexual activity (with sufficient stimulation) begins, the woman may experience sexual arousal, i beg your pardon may bring about responsive sexual desire and an inspiration for future sexual responsiveness.42 This model delineates spontaneous and responsive desire, normalizes the sex-related experience of arousal coming before desire, and stresses emotionally intimacy together a major motivator for sex-related responsiveness.


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eFigure B

Female sexual an answer cycle. Interrelated determinants work with each other to promote sex-related response.

Adapted through permission indigenous Basson R. Human being sex-response cycles. J Sex Marital Ther. 2001;27(1):34.


eFigure B

Female sexual solution cycle. Interrelated components work together to promote sexual response.

Adapted v permission from Basson R. Human sex-response cycles. J Sex Marital Ther. 2001;27(1):34.


Data Sources: A comprehensive English-language search of numerous databases indigenous 2004 to august 7, 2014, was conducted and also included MEDLINE In-Process & other Non-Indexed Citations, MEDLINE, EMBASE, PsycINFO, Cochrane Database of systematic Reviews, Cochrane central Register of managed Trials, U.S. Preventative Services Task force recommendations, nationwide Guideline Clearinghouse, agency for healthcare Research and Quality proof reports, the Institute because that Clinical Systems improvement guidelines, and also Essential Evidence. Keywords had dyspareunia, libido, orgasm, orgasmic, orgasms, sexual arousal, sex-related desire, and sexual dysfunction. Find dates: respectable to October 2014.


The authors say thanks to Kristi Simmons, mei Clinic study and scholastic Support Services, because that her help in formatting and also proofreading the manuscript.

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