brand logo

This is a corrected version of the article that appeared in print.

Am Fam Physician. 2008;77(5):635-642

A more recent article on sexual dysfunction in women is available.

Patient information: See related handout on this topic at

Author disclosure: Dr. Frank owns stock in Pfizer, manufacturer of Viagra.

Female sexual complaints are common, occurring in approximately 40 percent of women. Decreased desire is the most common complaint. Normal versus abnormal sexual functioning in women is poorly understood, although the concept of normal female sexual function continues to develop. A complete history combined with a physical examination is warranted for the evaluation of women with sexual complaints or concerns. Although laboratory evaluation is rarely helpful in guiding diagnosis or treatment, it may be indicated in women with abnormal physical examination findings or suspected comorbidities. The PLISSIT (Permission, Limited Information, Specific Suggestions, Intensive Therapy) or ALLOW (Ask, Legitimize, Limitations, Open up, Work together) method can be used to facilitate discussions about sexual concerns and initiation of treatment. Developments in the treatment of male erectile dysfunction have led to investigation of pharmacotherapy for the treatment of female sexual dysfunction. Although sexual therapy and education (e.g., cognitive behavior therapy, individual and couple therapy, physiotherapy) form the basis of treatment, there is limited research demonstrating the benefit of hormonal and nonhormonal drugs. Testosterone improves sexual function in postmenopausal women with hypoactive sexual desire disorder, although data on its long-term safety and effectiveness are lacking. Estrogen improves dyspareunia associated with vulvovaginal atrophy in postmenopausal women. Phosphodiesterase inhibitors have been shown to have limited benefit in small subsets of women with sexual dysfunction.

Female sexual dysfunction is a complex and poorly understood condition that affects women of all ages. Sexual function has been reconceptualized as a cyclic (rather than a linear) process that emphasizes social, psychological, hormonal, environmental, and biologic factors.1 Sexual problems can be classified as sexual complaints, dysfunction, or disorders. Disorders encompass dysfunction associated with personal distress; therefore, abnormal function or sexual discontent can exist without a disorder being present.2

Clinical recommendationsEvidence ratingReferences
Local estrogen therapy is recommended for the treatment of dyspareunia associated with vulvovaginal atrophy.C8
Testosterone added to hormone therapy improves sexual function in surgically or naturally menopausal women.B2529
Sexual pain disorders should be treated with a multidimensional and multidisciplinary approach if the cause is unknown or not easily treated.C9


Female sexual complaints are common; the 1992 National Health and Social Life Survey showed a prevalence of 43 percent.3 A more recent international survey of 27,500 men and women 40 to 80 years of age found that 39 percent of sexually active women reported a problem with sexual activity.4 It is difficult to accurately determine prevalence because studies use different definitions of normal and abnormal sexual function and use heterogeneous populations.5,6 The most common sexual complaint in women is decreased desire, followed by orgasmic dysfunction.3,4 Table 1 presents prevalence data for female sexual dysfunction disorders.6,7

DisorderEstimated prevalence*
Sexual desire disorders
Hypoactive sexual desire disorder10 to 46 percent
Sexual aversion disorderRare
Female sexual arousal disorder6 to 21 percent
Female orgasmic disorder4 to 7 percent (general population)
5 to 42 percent (primary care setting)
Sexual pain disorders
Dyspareunia3 to 18 percent (general population)
3 to 46 percent (primary care setting)
9 to 21 percent (postmenopausal women)
Vaginismus0.5 to 1 percent (general population)
Up to 30 percent (primary care setting)

Definition and Classification

Traditionally, female sexual dysfunction has been classified into four categories by the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV): sexual desire, sexual arousal, orgasmic, or sexual pain disorders.7 However, the definition of normal female sexual functioning has been critically examined, and the accepted definition and classification of female sexual dysfunction have subsequently been revised.1

In 2004, the Second International Consensus of Sexual Medicine accepted revised definitions of female sexual dysfunction (Table 28). Noting whether symptoms, which may meet the definition for a sexual dysfunction, cause distress allows the physician to assess the clinical importance of the symptoms.8 Female sexual dysfunction may be further defined as lifelong (primary) or acquired (secondary) and as situational (occurs only in certain circumstances or with certain partners) or generalized (occurs in all situations and with all partners).8,9

There have been some concerns that female sexual dysfunction, as defined by the DSM-IV and the Second International Consensus of Sexual Medicine, has been created by the pharmaceutical industry to introduce pharmacologic treatment into a nonmedical arena, namely sexual functioning.10

Sexual desire/interest disorder: absent or diminished feelings of sexual interest or desire, absent sexual thoughts or fantasies, and a lack of responsive desire; motivations for attempting to become sexually aroused are scarce or absent; lack of interest is considered to be beyond the normal decrease experienced with increasing age and relationship duration
Subjective sexual arousal disorder: absent or diminished feelings of sexual arousal from any type of sexual stimulation; however, vaginal lubrication or other signs of physical response occur
Genital sexual arousal disorder: complaints of impaired genital sexual arousal, which may include minimal vulvar swelling or vaginal lubrication from any type of sexual stimulation and reduced sexual sensations from caressing genitalia; however, subjective sexual excitement occurs with nongenital sexual stimuli
Combined genital and subjective arousal disorder: absent or diminished feelings of sexual arousal from any type of sexual stimuli plus complaints of absent or impaired genital sexual arousal
Persistent genital arousal disorder: spontaneous, intrusive, and unwanted genital arousal in the absence of sexual interest and desire; arousal is unrelieved by orgasms and persists for hours or days
Women's orgasmic disorder: despite self-report of high sexual arousal or excitement, there is lack of orgasm, markedly diminished intensity of orgasmic sensations, or marked delay of orgasm from any kind of stimulation
Dyspareunia: persistent or recurrent pain with attempted or completed vaginal entry and/or penile-vaginal intercourse
Vaginismus: persistent or recurrent difficulties with vaginal entry of a penis, finger, or other object, despite the woman's expressed desire to participate
Sexual aversion disorder: extreme anxiety or disgust at the anticipation of or attempt at any sexual activity

Biology and Pathophysiology

A number of potential causative and contributing factors to female sexual dysfunction have been identified (Table 311), reflecting the complex interplay of physiologic, psychological, emotional, and relational components. Normal sexual function is partially dependent on the effects of sex hormones and neurotransmitters on the central and peripheral nervous systems (Table 42,11,12). 2

CauseExamplesSexual symptoms
Hormonal/endocrineHypothalamic-pituitary axis dysfunction, surgical/medical castration, menopause, chronic oral contraceptive use, premature ovarian failureDecreased libido/desire, vaginal dryness, lack of arousal
MusculogenicHyper- or hypotonicity of pelvic floor musclesHypertonicity: sexual pain disorders, including vaginismus
Hypotonicity: vaginal hypoesthesia, coital anorgasmy, urinary incontinence associated with sexual activity
NeurogenicSpinal cord injury; disorders of the central or peripheral nervous system (e.g., diabetes, upper motor neuron injury)Anorgasmy
PsychogenicRelationship problems, poor body image, decreased self-esteem, mood disorders, adverse effect of psychotropic medication useDecreased libido/desire, decreased arousal, hypoesthesia, anorgasmy
VasculogenicDiminished blood flow to genitals secondary to atherosclerosis, hormonal influences, traumaVaginal dryness, dyspareunia
Sex hormone or neurotransmitterSexual functioning affectedType of effectComments
DopamineDesire, arousalPositiveMay promote willingness to continue sexual activity after it is initiated
EstrogenArousal, desirePositiveEstrogen deficiency is associated with vaginal atrophy, decreased lubrication, vasocongestion, and sensation
Nitric oxideVasocongestion of clitoral tissuePositiveAdequate levels of estrogen and testosterone may be needed for nitric oxide to initiate vasocongestion
OxytocinReceptivity, orgasmPositiveAssociated with increased perineal contractions with orgasm
ProgesteroneReceptivityPositiveMay be antiestrogenic
SerotoninArousal, desirePositive and negativeInhibits norepinephrine and dopamine; may facilitate uterine contractions during orgasm, but also may inhibit orgasm by different mechanisms
TestosteroneDesire, initiation of sexual activityPositiveLow circulating levels of testosterone are not clearly associated with decreased sexual desire12
Vasoactive intestinal peptideVasocongestion of clitoral tissuePositive

Sexual desire may be the traditional spontaneous desire from sexual thoughts, dreams, and fantasies; or it may be secondary to cognitive motivation.8,13 In some women, particularly those in long-term relationships, nonsexual motivators (e.g., emotional closeness, feeling loved) may lead to sexual desire.1

With sexual arousal, the genitals experience vasocongestion, which promotes vaginal lubrication, engorgement, and lengthening; dilation of the vaginal wall; and engorgement of the clitoris and vestibulovaginal bulbs. The physiologic effects of arousal are poorly correlated with subjective arousal. Therefore, a woman with an arousal disorder may have genital vasocongestion in response to sexual stimuli but not experience a subjective sense of arousal.1 Women can have physical satisfaction without experiencing an orgasm. A positive physical experience promotes future motivation and receptiveness.1

Evaluation and Diagnosis

Evaluation of sexual complaints may be limited by time constraints, physician or patient discomfort, difficulty with diagnosis, lack of available referral services, and limited treatment options.14 If time precludes a thorough evaluation at first presentation, the complaint should be acknowledged and the patient should receive follow-up.15

Physicians are often uncomfortable with and poorly educated about obtaining a comprehensive sexual history,2 even though this is an important component of primary health care.16 There are a number of validated self-report and interview-based tools for assessing female sexual dysfunction, but they are primarily used in research settings.17 The Brief Sexual Symptom Checklist is a self-report tool that may be useful in the primary care setting18 as an adjunct to a comprehensive sexual history.13 The checklist includes four basic questions to determine the patient's satisfaction with her sexual function, details about specific sexual problems, and the willingness of the patient to discuss these problems with the physician.18

Discussions about sexuality should begin with open-ended questions. If a sexual concern is elicited, a focused history includes menstrual, obstetric, reproductive, and sexual histories; status of current relationships and sexual activity; family and personal beliefs about sexuality; and history of sexual trauma or abuse.2,8 Additional elements of the history include medical and surgical history; medication use, including over-the-counter medications and herbal supplements; alcohol, tobacco, and illicit drug use; family history; and birth control method. Several medical conditions and medications are associated with sexual dysfunction.2,11,19

The PLISSIT (Permission, Limited Information, Specific Suggestions, Intensive Therapy) model is used to initiate discussions about sexual dysfunction and its management.15 The ALLOW (Ask, Legitimize, Limitations, Open up, Work together) model facilitates completion of the sexual history and initiation of treatment or further evaluation. Table 5 summarizes these models.15 [ corrected]

Ask the patient about sexual function and activity
Legitimize problems, and acknowledge that dysfunction is a clinical issue
Identify limitations to the evaluation of sexual dysfunction
Open up the discussion, including potential referral
Work with the patient to develop goals and a management plan
Obtain permission from the patient to discuss sexuality (e.g., “I ask all my patients about their sexuality, is that okay to do with you now?”)
Give limited information (e.g., inform the patient about normal sexual functioning)
Give specific suggestions about the patient's particular complaint (e.g., advise the patient to practice self-massage to discover what feels good to her)
Consider intensive therapy with a sexual health subspecialist

Although physical examination findings are often normal,15 a complete examination, including a focused pelvic examination, can identify pathology and provide patient education about normal anatomy and reassurance that no abnormality is present.1 The pelvic examination can detect evidence of low hormone levels, infection, hypo- or hypertonicity of pelvic floor muscles, adhesions, and tenderness. The remaining physical examination focuses on mental status; blood pressure and peripheral pulse measurements; and musculoskeletal, thyroid, breast, and neurologic abnormalities. Table 6 presents an overview of abnormal examination findings.2,13,15 Abnormal findings are more likely in older women, in women with known gynecologic pathology or chronic systemic disease, and in women who have not received regular medical care.15

FindingPotential causeSexual symptoms
Cystocele, rectocele, or uterine prolapseDecreased desire (from embarrassment), dyspareunia
Fixed, retroverted uterus; nodules; tenderness along uterosacral ligamentsEndometriosisDeep dyspareunia
Hypertonicity of pelvic musclesVaginismus, vestibulitisDyspareunia
Sparse pubic hairLow androgen levelDecreased desire
Tender points along vulvar vestibuleVestibulitisDyspareunia
Vaginal dischargeInfectionDyspareunia
Vaginal or labial atrophyLow estrogen levelDyspareunia, decreased arousal
Vulvar skin abnormalitiesLichen sclerosus, chronic candidal vaginitisDyspareunia
Abnormal blood pressure or peripheral pulsesAtherosclerotic peripheral vascular diseaseDecreased arousal
GalactorrheaProlactinomaDecreased desire
Musculoskeletal abnormalitiesOsteoarthritis, rheumatoid arthritis, other musculoskeletal conditionsDecreased desire, decreased arousal secondary to difficulty with sexual activity or embarrassment
NeuropathyNeurologic disorder, diabetesDecreased desire or arousal, anorgasmy
PallorAnemiaDecreased desire or arousal
Thyroid enlargementHypothyroidismDecreased desire or arousal

Laboratory evaluation is rarely helpful in guiding the diagnosis or treatment of female sexual dysfunction. However, a focused evaluation is appropriate, particularly if the history or examination suggests a medical condition.13 Although some experts advocate testing hormone levels in postmenopausal women or in women with decreased desire or arousal,11 there is no reliable correlation between hormone levels and sexual function.12,13,20

Psychiatric Comorbidities

Sexual dysfunction may be the manifestation of psychiatric illness or an adverse effect of psychotropic medication use.11 If a woman has sexual complaints while taking a psychotropic medication, a detailed history is necessary to identify the etiology.21 Use of selective serotonin reuptake inhibitors (SSRIs) is a common cause of medication-induced female sexual dysfunction, although all antidepressant classes can cause dysfunction.22 SSRIs most commonly cause delayed or absent orgasm and decreased libido.22 The incidence of SSRI-induced sexual dysfunction is estimated to be 30 to 50 percent.23

Treatment of medication-induced sexual dysfunction includes dosage reduction; drug holidays; switching to or adding a medication with a lower incidence of sexual adverse effects (e.g., bupropion [Wellbutrin], mirtazapine [Remeron]); behavior strategies; waiting for tolerance to the medication to develop; delaying medication administration until after sexual activity; and individual and couple therapy.21,22


Treatment of female sexual dysfunction is complicated by the lack of a single causative factor, limited proven treatment options, physician unfamiliarity with available treatments, overlap of different types of dysfunction, limited availability of treatment, and limited expertise in the treatment of female sexual dysfunction.14 Although patient education and therapy are the foundation of treatment, limited research has demonstrated the benefit of pharmacotherapy ( see online Table A).


Many women consider normal sexual function to be the traditional desire-arousal-orgasm process. Physicians can alleviate sexual concerns by educating patients about what is “normal.” For example, women who expect to feel desire for sexual stimulation may be reassured that desire can encompass a need for emotional intimacy through sexual activity rather than a need for sexual activity itself.1 Education about normal anatomy is another important component in addressing sexual concerns. Use of a handheld mirror during a gynecologic examination can demonstrate to the patient normal and abnormal physical findings and facilitate a discussion about the physiologic basis of sexual functioning.24 Women may be reassured that normal sexual functioning is widely variable.13


Hypoactive sexual desire disorder is the most common type of female sexual dysfunction3,4,15,19 and often has a psychological or physiologic cause. Nonpharmacologic treatment is aimed at education, therapy, and treatment of contributing factors. As understanding about normal female sexual function develops, it is important to educate women about how desire may change with increasing age or relationship duration.8 Therapy emphasizes lifestyle changes such as stress management, adequate rest, and regular exercise.15

Pharmacologic treatment is limited. One of the most commonly studied medications is testosterone. Although decreased androgen levels do not correlate well with hypoactive sexual desire disorder,12 testosterone (usually 300 mcg daily applied transdermally; transdermal application is not approved by the U.S. Food and Drug Administration [FDA] for use in women) has been shown to benefit sexual desire in postmenopausal women receiving hormone therapy.2529 Topical and systemic estrogen improves vaginal lubrication in postmenopausal women with vaginal atrophy, but the therapy has not been shown to consistently increase desire or arousal.9,13,30 Phosphodiesterase inhibitors have not been shown to improve diminished desire.31 One small, poor-quality study demonstrated improved desire with bupropion treatment.32


Because physiologic and subjective arousal may be unrelated,8 education is a key component in the treatment of female sexual arousal disorder.15 Another treatment option is the Eros Clitoral Therapy Device, made by UroMetric. The device is FDA-approved and is designed to improve arousal by increasing blood flow to the clitoris with gentle suction.11,33 Two small, short-term studies have shown that the device benefits women with sexual arousal disorder.33,34 Lubrication may decrease dyspareunia associated with diminished desire.15

Phosphodiesterase inhibitors have been shown to have limited benefit in subgroups of women with sexual arousal disorder31; however, most women do not appear to benefit from the treatment.


Anorgasmy has been successfully treated with directed masturbation, cognitive behavior therapy, and sensate focus.35 Cognitive behavior therapy focuses on decreasing anxiety and promoting changes in attitudes and sexual thoughts, which increase the ability to achieve orgasm and to gain satisfaction from orgasm.35 Sensate focus is a form of sexual therapy that guides a woman and her partner through a series of exercises, moving from nonsexual to sexual touching.35

Although a few small studies and case reports have suggested that phosphodiesterase inhibitors have a role in the treatment of orgasmic disorder, most studies have not shown a benefit. A pilot study of men and women showed that bupropion was effective for orgasm achievement.36


Dyspareunia has many potential etiologies, including infection, vaginal atrophy, and endometriosis.24 Addressing the underlying cause is the first step in treatment. If the cause is unknown or not easily treated, treatment is multidimensional and multidisciplinary and reflects the interplay of physiologic, emotional, and relational factors.9,24,37

Physiotherapy (e.g., hands-on techniques, biofeedback, pelvic floor electrical stimulation, perineal ultrasonography, use of vaginal dilators) is a treatment option for sexual pain disorders such as vulvar vestibulitis and vaginismus.9,37 Psychotherapy is tailored to the patient's individual issues, and inclusion of her sex partner should be encouraged.9

In the treatment of vaginismus, psychotherapy addresses the patient's fears about vaginal penetration and allows her to gain increasing comfort with her genitals and, eventually, vaginal penetration.9 Cognitive behavior therapy (provided in a group setting over six months) that focuses on pain's relationship to anxiety, muscle contractions' relationship to pain perception, and general sexual education has been shown to decrease pain with intercourse and improve sexual satisfaction in women with vulvar vestibulitis.38

An educational pelvic examination may be particularly beneficial in patients with sexual pain disorders. During the examination, the physician gains permission from the patient to continue with each step of the pelvic examination, maintaining a willingness to stop at any point. The physician explains the process of the examination, offers the speculum for the patient to hold or look at, and teaches the patient how to relax her pelvic floor muscles.24 With systematic desensitization, a woman is taught relaxation exercises and is gradually exposed to insertion of a finger or vaginal dilator.9,38 A Cochrane review of vaginismus treatment determined that there is limited evidence from uncontrolled studies demonstrating the effectiveness of systematic desensitization with vaginal dilators or hypnotherapy.39

Pharmacologic therapy of sexual pain disorders includes treatment of the underlying cause, such as estrogen for vaginal atrophy 8,25 or medication for vulvovaginal candidiasis. Vulvar vestibulitis is treated with tricyclic and other antidepressants, anticonvulsants, and topical agents; however, there are limited data to support pharmacologic treatment of sexual pain disorders.26

Continue Reading

More in AFP

More in PubMed

Copyright © 2008 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions for copyright questions and/or permission requests.