gynecology and obstetrics
Overview of Female Sexual Function and Dysfunction
Treatment of Female Sexual Dysfunction
Explanation of the female sexual response Correction of contributing factors Psychological therapies Medications Treatment of sexual dysfunction in women varies by disorder and cause; often more than one treatment is required because disorders overlap. Even if criteria for a particular DSM-5-TR disorder are not completely met, treatment may help. Sympathetic understanding and careful evaluation may themselves be therapeutic. Teaching women about sexual anatomy and physiology, including what is involved in the female sexual response may also help. Treatment may require a multidisciplinary team, including sex counselors, pain specialists, psychotherapists, and/or physical therapists. Contributing factors are corrected if possible, as for the following: Treating mood disorders If women are taking a selective serotonin reuptake inhibitor (SSRI), switching to an antidepressant that has fewer sexual adverse effects (eg,bupropion,mirtazapine,duloxetine) or possibly addingbupropionto an SSRI For substance/medication–induced sexual dysfunction, stopping the abused substance or changing a prescription medication Cognitive-behavioral therapy targets negative self-view resulting from illness (including gynecologic disorders) or from infertility. Mindfulness, an eastern practice with roots in Buddhist meditation, may help. It focuses on nonjudgmental awareness of the present moment. Its practice helps free women from distractions that interfere with attention to sexual sensations. Mindfulness lessens sexual dysfunction in healthy women and in women who have pelvic cancer or provoked vestibulodynia. Women can be referred to community or online resources to learn how to practice mindfulness. Mindfulness-based cognitive therapy (MBCT) combines an adapted form of cognitive-behavioral therapy with mindfulness. As in cognitive-behavioral therapy, women are encouraged to identify maladaptive thoughts, but then to simply observe their presence, realizing that they are just mental events and may not reflect reality. This approach can make such thoughts less distracting. MBCT is used to prevent recurrent depression and can be adapted to treat sexual arousal disorder and sexual interest/arousal disorder as well as the chronic pain of Etiology . Some women (eg, women with a history of sexual trauma) may need more extensive psychotherapy. Estrogen therapycan be used to treat sexual dysfunction in women with genitourinary syndrome of menopause. The atrophic changes in the vulva and vagina can be treated with low-dose vaginal estrogen (tablets, gels, creams, rings). Low-dose systemic estrogen or estrogen plusprogesterone(in women with a uterus) can be used if women have concomitant vasomotor menopausal symptoms (eg, hot flushes).Ospemifene(a selective estrogen receptor modulator) may be useful in treating genitourinary syndrome of menopause in women who cannot apply vaginal estrogen therapy. has not been studied as treatment for sexual interest/arousal disorder, and systemic dehydroepiandrosterone (DHEA) has been shown to be ineffective. Intravaginal prasterone (a DHEA preparation) can be used for postmenopausal women with dyspareunia and Genito-Pelvic Pain/Penetration Disorder ). Current evidence for using androgens to enhance women's sexual response is weak. Some evidence suggests thattestosteronesupplementation may modestly benefit women who have low sexual interest but are able to have satisfactory sexual experiences. Total androgen activity (measured as metabolites) is similar in women with or without sexual interest. , a serotonin-receptor agonist/antagonist, may be used to treat premenopausal women without depression; however, in a systematic review, the quality of evidence for effectiveness and safety was graded low and the beneficial effect was minimal ( Treatment references ). is a melanocortin receptor agonist that has been approved for treatment of low libido in women. It is administered as a subcutaneous injection at least 45 minutes before anticipated sexual activity. Randomized trials found an increase in sexual desire and no increase in sexually satisfying events; potential adverse effects include transient hypertension and skin hyperpigmentation ( Treatment references , Some evidence suggests that women with sexual interest/arousal disorder due to use of SSRIs may benefit from addingbupropion(anorepinephrine-dopaminereuptake inhibitor). Some evidence suggests that if women stopped having orgasms when they started taking SSRIs,sildenafil(a phosphodiesterase type 5 inhibitor) may help them have orgasms again. However, study results have been contradictory;sildenafilis not recommended for this purpose in routine practice. Pelvic floor physical therapy is a mainstay of treatment of women with genito-pelvic pain/penetration disorder. Its aim is to teach women to relax the pelvic floor and decrease reflex tightening. Pelvic floor physical therapy includes pelvic floor muscle training, soft-tissue mobilization and myofascial release, trigger-point pressure, electrical stimulation, biofeedback, and therapeutic ultrasonography. Prescription and nonprescription devices are available for self-dilation in women with tight pelvic muscles, which contribute to dyspareunia in genito-pelvic pain/penetration disorder. Depending on the type of dysfunction, sexual skills training (eg, instruction in masturbation) and exercises to facilitate communication with a partner about sexual needs and preferences can be implemented. Various lubricants and moisturizers can reduce vaginal dryness, which causes dyspareunia. These treatments include food-based oils (eg, coconut oil), silicone-based products, and water-based products. Food-based oils should not be used with condoms, but silicone- and water-based lubricants can be used. If lubricants are needed, clinicians and the woman should discuss which kind of lubricant she should use. Except in small pilot studies, there is scant evidence that devices such as vibrators or clitoral suction devices are effective in women with sexual interest/arousal or orgasmic disorder; however, some of these products are available over the counter and may be tried. 1.Jaspers L, Feys F, Bramer VM, et al: Efficacy and safety offlibanserinfor the treatment of hypoactive sexual desire disorder in women: A systematic review and meta-analysis.JAMA Intern Med176 (4):453–462, 2016. doi: 10.1001/jamainternmed.2015.8565 2.Kingsberg SA, Clayton AH, Portman D, et al:Bremelanotidefor the Treatment of Hypoactive Sexual Desire Disorder: Two Randomized Phase 3 Trials.Obstet Gynecol134(5):899-908, 2019. doi:10.1097/AOG.0000000000003500 3.Clayton AH, Kingsberg SA, Portman D, et al: Safety Profile ofBremelanotideAcross the Clinical Development Program.J Womens Health (Larchmt)31(2):171-182, 2022. doi:10.1089/jwh.2021.0191 