|Year : 2022 | Volume
| Issue : 2 | Page : 128-134
Female sexual dysfunction: A potential minefield
Smitha S Prabhu, Snigdha Hegde, Suhani Sareen
Department of Dermatology and Venereology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
|Date of Submission||22-Jul-2020|
|Date of Decision||19-Oct-2020|
|Date of Acceptance||03-Nov-2021|
|Date of Web Publication||17-Nov-2022|
Dr. Smitha S Prabhu
Additional Professor, Department of Dermatology and Venereology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Female sexual dysfunction (FSD) is a much-neglected aspect of feminine health, especially in patriarchal cultures. We collated data from pertinent published literature on FSD to explore the types, associations, and best possible approach to FSD in the Indian context. We fed search words “female sexual dysfunction,” “sexual health,” “India,” into medical search engines such as PubMed, Google Scholar, Clinical Key, ProQuest, SciVal for locating pertinent articles from which data was synthesized and extracted. Female sexual response is complex and is influenced by physiological, behavioral, social, and cultural factors. The latest Diagnostic and Statistical Manual of Mental Disorders-5 criteria classified FSD into female sexual interest/arousal disorder, female orgasmic disorder and genito-pelvic pain/penetration disorder, along with categories common to both genders like substance/drug induced and other unspecified subsets. Diagnosis requires detailed and specific history taking and clinical evaluation to rule out comorbidities. Treatment is multifaceted and prolonged, involving pharmacological, psychological, and behavioral therapy in both partners. Almost all Indian studies in this field have small sample sizes and none of the studies focused on FSD as the primary complaint. FSD is still an unexplored field of Indian medicine. Although newer treatment options and techniques are being explored, there is much to achieve. We need to develop culturally suitable questionnaires taking into account the Indian female psyche. Management should be holistic and involve focused liaison clinics, including dermatology, gynecology, psychiatry, clinical psychology, and urology specialties.
Keywords: Aversion, female sexual dysfunction, orgasm, sexual health, vaginismus, vulvodynia
|How to cite this article:|
Prabhu SS, Hegde S, Sareen S. Female sexual dysfunction: A potential minefield. Indian J Sex Transm Dis 2022;43:128-34
|How to cite this URL:|
Prabhu SS, Hegde S, Sareen S. Female sexual dysfunction: A potential minefield. Indian J Sex Transm Dis [serial online] 2022 [cited 2023 Jan 31];43:128-34. Available from: https://ijstd.org/text.asp?2022/43/2/128/361333
| Introduction|| |
Female sexual health is a much-neglected aspect of the overall well-being of women, especially in patriarchal cultures. In addition to physiological factors, emotional, physical, and social aspects also play a role in maintaining sexual health. Although under-reported, female sexual dysfunction (FSD) is very prevalent and involves a complex interplay of psychosocial and physiological factors.
In this article, we attempt to discuss FSD and explore the various causes and treatment options available suitable to the Indian cultural context.
| Methodology|| |
We collated and extracted data on FSD worldwide after putting in the search words, “female sexual dysfunction,” “sexual health” into various medical search engines.
| Discussion|| |
Female sexual response
Female sexual response has various phases [Table 1], which are affected by emotional, neurovascular, endocrine, and psychosocial responses, all of which overlap [Figure 1]. Female arousal and orgasm depend more on cognitive, emotional, and behavioral aspects, as opposed to male arousal, which is more physiological.
It is difficult to establish the exact incidence or prevalence of FSD. The most common age group to be affected is 51–59 years, i.e., perimenopausal. It may be associated with lower educational status, interpersonal conflict with partner, comorbidity such as diabetes mellitus, hypertension, and vulvar inflammatory diseases.
| Classification|| |
The latest Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria, DSM-5 classification of FSD, include major types being include female orgasmic disorder, female sexual interest/arousal disorder and genito-pelvic pain/penetration disorder. Categories common to both genders include substance/drug induced and other unspecified subsets [Table 2].
| Clinical Presentations|| |
Symptoms may overlap between types.
Female orgasmic disorder
Here, sexual arousal/excitement is normal, but orgasm is absent, reduced, or significantly delayed on any type of stimulation, leading to mental distress. This often coexists with other forms. Women experiencing pain or low sexual arousal usually find it difficult to achieve orgasm. Orgasmic dysfunction increases with age.
Female sexual interest/arousal disorder
There is reduced or absent sexual drive, which leads to psychological stress and decreased quality of life. This is greater in women after surgical menopause.
Various contributory factors include lack of:
- Sexual drive (biological component) refers to lack of natural desire for sex and is dependent on hormones such as estrogen, progesterone, dopamine, melanocortin, etc., or changes in the hypothalamus or limbic system of the brain
- Motivation (the cognitive component): There is no interest in indulging in any sexual activity, including masturbation, sexual fantasies, or thoughts. The reasons include low self-esteem, intervening thoughts, guilt, lack of emotional intimacy, workplace, financial or emotional stress, changes in body shape, associated psychiatric disorders, fear of venereal diseases, fear of partner's premature or delayed ejaculation, or previous failure to achieve orgasm, pregnancy, lactation, and alcoholism
- Responsiveness to sexual stimuli (response component): there is no positive response toward their partner's initiation and there are thoughts of avoiding sexual intercourse.
Nonsexual distractions include mood instability, work/family pressure, low self-esteem, religious upbringing, anxiety, emotional instability, or depression.
Sexual arousal disorder is further classified into various types [Table 3].
Genitopelvic pain/penetration disorders
Here, pain or physical discomfort is the major component.
Persistent or recurrent pain occurs on attempted penovaginal insertion, or penetration, or even with movements during intercourse. Severity depends on woman's pain threshold and partner's persistence. It has underlying organic or psychological causes.
There is involuntary, reflex contraction of the pelvic, abdominal, back, and leg muscles along with thigh adduction and is associated with fear of pain on attempted entry of penis, tampon, speculum, or even digit into the vagina. The difficulties persist despite the woman's willingness for intercourse. It usually exhibits at first sexual intercourse. Such women enjoy nonpenetrative sexual stimulation, but reflex perineal tightening starts when penetration is initiated. This can cause severe distress to both partners. Structural abnormalities of the pelvic floor and vagina must be ruled out before labeling a case as vaginismus.
It is defined as “vulvar pain without a clear identifiable cause, which lasts for >3 months, and may have potential precipitating or correlating factors,” and is a subset of mucocutaneous pain syndrome/atypical pain syndrome. It can be localized (vestibulodynia, clitorodynia, hemi vulvodynia), generalized or mixed and can be primary or secondary in onset. It may occur spontaneously or be provoked by contact or intercourse. Pain may be persistent, intermittent, immediate, or delayed contact. Vestibulodynia is the most common and may be associated with imperceptible to mild erythema.
Various causes include inflammation of vulva or vestibule following dermatitis, infections like candidiasis, herpes simplex and zoster, trichomoniasis, neoplasia, systemic illnesses such as systemic lupus erythematosus, Sjogren's syndrome, Crohn's disease, Behcet's disease, hormonal changes, neurological diseases or injury or pelvic trauma, and loss of pelvic muscle tone.
Pelvic organ prolapse and urinary incontinence may precipitate FSD of any kind.
| Indian Scenario|| |
There are small-scale questionnaire-based studies sporadically reported in Indian literature; none are based on self-reporting by females. One study found FSD to occur at an earlier age and more frequently in women with depression. One of the earliest studies states that “frigidity was found to be associated with sexual ignorance, marital strife, fear of pregnancy, and tiredness.” Another south Indian study reported orgasmic dysfunction in 28.6% of women. A study of 149 married women reports FSD in 73.2%, with difficulties in lubrication (96.6%), arousal (91,3%), orgasm (86.6%), desire (77.2%), and pain (64,4%) predominating. Older age and lesser education were found to be significantly associated. A study in 153 married women found the prevalence to be 55.55%, with associated factors being the longer duration of marriage (>16 years), upper-middle-class status, and middle-grade education. In postmenopausal women, 80.9% had sexual dysfunction, with joint family structure, lower socioeconomic and educational factors being major determinants.
All the studies stressed up on counseling and treating the underlying etiology.
| Sequelae of Female Sexual Dysfunction|| |
Conclusive data on the prognosis of FSD are not available. A systematic review of various treatment modalities and prognosis concluded that the most substantial effect was with hormonal regimes, and though specific domains of FSD improved no treatment, either pharmacologic or psychotherapeutic, demonstrated complete disease resolution. Prognosis depends upon the ability of the female and her partner to recognize and seek help, type of FSD, i.e., whether primary or secondary, whether situational or generalized and on the severity of FSD. The best possible response is in younger individuals and those with partner support, whereas FSD due to structural deficit in older women and those without partner support tend to persist. Sequelae of FSD include psychological distress in both partners, psychosomatic symptoms, aversion to sex, and in the extremes of cases, childlessness.
| Approach to A Patient|| |
The five Es of successful sexual questioning/counseling include: experience, etiquette, empathy, ethnic/cultural understanding, environment, which is suitable.
| History Taking in Female Sexual Dysfunction|| |
The aim is to establish the type of dysfunction and assess the predisposing, precipitating, and maintaining factors.
The art of history taking is very important to circumvent the social stigma, embarrassment, and psychosocial conditioning of Indian women. Rapport is established by beginning with nonthreatening general questions, and it is important to appear calm, confident, sympathetic, and nonjudgmental.
The patient should be asked to describe her problem in her own words. Has it always been there, or has occurred recently? Is it present in all situations, or in certain situations and with certain persons, whether she has had a normal sexual relationship prior, and can a certain incidence or event be associated with the onset of the problem, are some pertinent questions to be asked after gaining the confidence of the woman.
Specific and screening questionnaires,,, may be given, depending upon the patient's level of education and understanding [Table 4].
Patient's as well as partner's attitude to sexual intercourse should be understood: whether she is frightened, repulsed, or feels guilty.
Other pertinent history like past sexual abuse and trauma should be sought. Duration of the condition, whether it was sudden in onset or gradual, any relationship to childbirth, sexual abuse, pelvic surgery, or menstrual problems should be noted.
A detailed medical and psychiatric history in self and partner should be obtained [Table 4].
| Clinical Examination|| |
The following should be undertaken:
- Assess medical, endocrinological, and uro-gynecological health
- Pelvic and genital examination to rule out rare cases of hermaphroditism, genital defects, pelvic floor abnormalities, and any vulvovaginal diseases, estrogen deficit atrophy
- A focused and detailed examination is highly indicated in dyspareunia, vaginismus, previous pelvic trauma
- Tone of pelvic and vaginal muscles
- Test for perineal sensation, pain on touching, or vaginal insertion of gloved finger
- Cotton swab test (gently touching the perineum and vulva with a Q tip or cotton swab in an orderly manner to denote areas of pain and tenderness) in suspected vulvodynia
- Rule out the following before labeling as vulvodynia/dyspareunia
- Infections (candidiasis, postherpetic neuralgia)
- Inflammation (early lichen sclerosus or lichen planus)
- Malignancy (vulvar Paget's, vulvar intraepithelial neoplasia)
- Neurological or pelvic trauma, previous obstetric and gynecological surgeries
- Iatrogenic factors (chemotherapy, radiotherapy)
- Hormonal problems.
- A bimanual pervaginal palpation and speculum examination of the vagina and cervix
- Pap smear and tests for STIs (if indicated)
- Laboratory investigations - fasting blood glucose, TSH, lipid profile, serum sex hormone assays.
A methodical and thorough history and examination, as summarized in [Table 4], goes a long way to reassure the patient that her concern is genuine, even though no pathology is detected.
| Treatment of Female Sexual Dysfunction|| |
A combined approach utilizing pharmacotherapy, psychotherapy, and targeted sexual therapy is required,,, [Table 5].
Lack of a single causative factor, overlap of multiple dysfunctions, and limited expertise complicate management. It calls for a patient-centered and “couple centric” approach with an understanding of the patient's background, knowledge, attitude, and misconceptions about sexuality and fertility. Interpersonal issues with a partner should be addressed before starting medical management. Marital counseling should aid improved communication in sexual and general areas.
The role of religion in FSD should be explored (premarital sex is sinful, sex should be only for procreation, and religious treatments sought earlier) and negative influence mitigated by proper psychotherapy. Attention to general health and well-being, abstinence from smoking and alcohol should also be advocated.
Psychotherapy by trained personnel can mitigate sexual stigma to a great extent.
It is mainly used in female sexual interest/arousal disorder and Genitopelvic Pain/Penetration Disorders, [Table 6]. Hormonal treatment is based on hormone replacement with estrogen (topical or systemic), androgen supplementation, and the use of selective estrogen receptor modulators like tibolone and Ospemifene.
Hormone replacement therapy is mostly used in postmenopausal vaginitis and not primarily for FSD. Tibolone, though available is costlier, and Ospemifene is not available in the Indian drug market.
Nonhormonal treatment includes bupropion, fibanserin,,, prostaglandins, apomorphine,, phentolamine mesylate.
Bremalanotide Supplements such as Gingko Biloba Extract, ArginMax (containing ginseng, ginkgo, damiana, L-arginine, multivitamins, and minerals), L-arginine have been tried in FSD. L-arginine (nitric oxide precursor) Yohimbine (alpha-2 blocker) combination is currently undergoing investigation in female arousal disorders.
| Physiotherapy and Devices|| |
Eros-Clitoral Therapy Device (Eros-CTD, NuGen, Inc.), which increases blood flow to clitoris by gentle suction is an FDA-approved device for FSAD. This improves arousal. Intravaginal introduction of dilators with progressively increasing diameters aid women with vaginismus. These dilators are used twice daily for 15 min each, and once comfort is achieved with reasonable sized dilators, penile penetration by the partner may be attempted.
Physiotherapy involving gentle massage of introitus and clitoris, pelvic muscle exercises, which include alternative contraction and relaxation are also tried. Progressive muscle relaxation involves the patient alternatively contacting and relaxing her pelvic floor muscles around the examiner's finger.
| Recent Trends|| |
Cosmetic procedures such as laser treatments for vaginal tightening and surgical labiaplasty for symmetrical labia are useful in subsets of dysfunction associated with low self-esteem.
The “O shot” comprises autologous platelet-rich plasma (PRP) injected into the lower anterior vaginal wall, slightly bulging it up to aid “vaginal orgasms.”
Intraclitoral and intravaginal PRP, though not statistically significant, has shown improvement in pain, overall sexual functioning, and patient satisfaction.,
Botulinum injection and onabotulinum toxin A (50-300 U) transvaginal injection into the pelvic floor nerves prevents vaginal muscle spasm, thereby helping in the treatment of vaginismus and dyspareunia. “Monalisa fractional micro-ablative carbon-dioxide laser” has given good results in all FSD categories. Three treatments are scheduled 4 weeks apart.
This depends on the underlying cause and whether the dysfunction is primary or secondary, or situational; it also depends on psychosocial interaction between partners and compliance to treatment. Treatment is often prolonged. Lacunae in FSD management and Recommendation for Indian context: Most Indian females are ignorant about their sexual functioning and are reluctant to approach caregivers due to embarrassment, social stigma, and hesitancy to disclose to the partner. Female sex education, raising community awareness about sexual health and a scientific and empathetic approach actively involving both partners in treatment will go a long way in improving the scenario. The use of appropriate questionnaires and checklists stresses the importance of the condition and helps the patient be at ease. Management should be multifaceted and include behavioral, physical, and pharmacological treatment. The establishment of FSD liaison clinics involving dermatologists, gynecologists, urologists, psychiatrists as well as clinical psychologists is imperative for a holistic approach.
More research needs to be done for the development of regional and culture-specific questionnaires and treatment options.
Professor Shrutakirthi D. Shenoi, for sparkling our interest in this much neglected field of Female Sexual Dysfunction.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tsai TF, Yeh CH, Hwang TI. Female sexual dysfunction: Physiology, epidemiology, classification, evaluation and treatment. Urol Sci 2011;22:7-13.
Bitzer J. (2016) The Female Sexual Response: Anatomy and Physiology of Sexual Desire, Arousal, and Orgasm in Women. In: Lipshultz L., Pastuszak A., Goldstein A., Giraldi A., Perelman M. (eds) Management of Sexual Dysfunction in Men and Women. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-3100-2_18
. Available at: The Female Sexual Response: Anatomy and Physiology of Sexual Desire, Arousal, and Orgasm inWomen | SpringerLink [Last accessed on 2020 Jul 05].
American Psychiatric Association. DSM-5: Diagnostic and Statistical Manual for Mental Disorders. 5th
ed. USA: American Psychiatric Press; 2013.
Conaglen HM, Conaglen JV. Drug-induced sexual dysfunction in men and women. Aust Prescr 2013;36:42-5.
Basson R, Wierman ME, van Lankveld J, Brotto L. Summary of the recommendations on sexual dysfunctions in women. J Sex Med 2010;7:314-26.
Bornstein J, Goldstein AT, Stockdale CK, Bergeron S, Pukall C, Zolnoun D, et al.
2015 ISSVD, ISSWSH and IPPS consensus terminology and classification of persistent vulvar pain and vulvodynia. Obstet Gynecol 2016;127:745-51.
Roy P, Manohar S, Raman R, Sathyanarayana Rao TS, Darshan MS. Female sexual dysfunction: A comparative study in drug naive 1(st) episode of depression in a general hospital of South Asia. Indian J Psychiatry 2015;57:242-8.
] [Full text]
Agarwal AK. Frigidity: A clinical study. Indian J Psychiatry 1977;19:31-7. [Full text]
Kar N, Koola MM. A pilot survey of sexual functioning and preferences in a sample of English-speaking adults from a small South Indian town. J Sex Med 2007;4:1254-61.
Singh JC, Tharyan P, Kekre NS, Singh G, Gopalakrishnan G. Prevalence and risk factors for female sexual dysfunction in women attending a medical clinic in south India. J Postgrad Med 2009;55:113-20.
] [Full text]
Mishra VV, Nanda S, Vyas B, Aggarwal R, Choudhary S, Saini SR. Prevalence of female sexual dysfunction among Indian fertile females. J Midlife Health 2016;7:154-8.
Jain N, Mehra R, Goel P, Chavan BS. Sexual health of postmenopausal women in north India. J Midlife Health 2019;10:70-4.
Weinberger JM, Houman J, Caron AT, Anger J. Female sexual dysfunction: A systematic review of outcomes across various treatment modalities. Sex Med Rev 2019;7:223-50.
American College of Obstetricians and Gynecologists' Committee on Practice Bulletins – Gynecology. Female sexual dysfunction: ACOG practice bulletin clinical management guidelines for obstetrician-gynecologists, Number 213. Obstet Gynecol 2019;134:e1-18.
Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, et al.
The Female Sexual Function Index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000;26:191-208.
Derogatis LR, Rosen R, Leiblum S, Burnett A, Heiman J. The Female Sexual Distress Scale (FSDS): Initial validation of a standardized scale for assessment of sexually related personal distress in women. J Sex Marital Ther 2002;28:317-30.
Hatzichristou D, Rosen RC, Derogatis LR, Low WY, Meuleman EJ, Sadovsky R, et al.
Recommendations for the clinical evaluation of men and women with sexual dysfunction. J Sex Med 2010;7:337-48.
Reed BD. Vulvodynia: Diagnosis and management. Am Fam Physician 2006;73:1231-8.
Mohapatra S, Rath N, Agrawal A, Verma J. Management of female sexual dysfunction. Delhi Psychiatry J 2014;17:243-7.
Hucker A, McCabe MP. A qualitative evaluation of online chat groups for women completing a psychological intervention for female sexual dysfunction. J Sex Marital Ther 2014;40:58-68.
Avery-Clark C, Weiner L. A traditional masters and Johnson behavioral approach to sex therapy. In: Peterson ZD, editor. The Wiley Handbook of Sex Therapy 2017. Wiley-Blackwell. Chapter 11. Pp 163-89. DOI:10.1002/9781118510384
Cayan F, Dilek U, Pata O, Dilek S. Comparison of the effects of hormone therapy regimens, oral and vaginal estradiol, estradiol+drospirenone and tibolone, on sexual function in healthy postmenopausal women. J Sex Med 2008;5:132-8.
Constantine G, Graham S, Portman DJ, Rosen RC, Kingsberg SA. Female sexual function improved with ospemifene in postmenopausal women with vulvar and vaginal atrophy: Results of a randomized, placebo-controlled trial. Climacteric 2015;18:226-32.
Katz M, DeRogatis LR, Ackerman R, Hedges P, Lesko L, Garcia M Jr., et al.
Efficacy of flibanserin in women with hypoactive sexual desire disorder: Results from the BEGONIA trial. J Sex Med 2013;10:1807-15.
Caruso S, Agnello C, Intelisano G, Farina M, Di Mari L, Cianci A. Placebo-controlled study on efficacy and safety of daily apomorphine SL intake in premenopausal women affected by hypoactive sexual desire disorder and sexual arousal disorder. Urology 2004;63:955-9.
Kendirci M, Hellstrom WJ. Intranasal apomorphine. Nastech Pharmaceutical. IDrugs 2004;7:483-8.
Rubio-Aurioles E, Lopez M, Lipezker M, Lara C, Ramírez A, Rampazzo C, et al.
Phentolamine mesylate in postmenopausal women with female sexual arousal disorder: A psychophysiological study. J Sex Marital Ther 2002;28 Suppl 1:205-15.
Simon JA, Kingsberg SA, Portman D, Williams LA, Krop J, Jordan R, et al.
Long-term safety and efficacy of bremelanotide for hypoactive sexual desire disorder. Obstet Gynecol 2019;134:909-17.
Meston CM, Rellini AH, Telch MJ. Short- and long-term effects of Ginkgo biloba
extract on sexual dysfunction in women. Arch Sex Behav 2008;37:530-47.
Ito TY, Polan ML, Whipple B, Trant AS. The enhancement of female sexual function with ArginMax, a nutritional supplement, among women differing in menopausal status. J Sex Marital Ther 2006;32:369-78.
Meston CM, Worcel M. The effects of yohimbine plus L-arginine glutamate on sexual arousal in postmenopausal women with sexual arousal disorder. Arch Sex Behav 2002;31:323-32.
Phillips NA. Female sexual dysfunction: Evaluation and treatment. Am Fam Physician 2000;62:127-36, 141-2.
Rosenbaum TY. Pelvic floor involvement in male and female sexual dysfunction and the role of pelvic floor rehabilitation in treatment: A literature review. J Sex Med 2007;4:4-13.
Runels C, Melnick H, Debourbon E, Roy L. A pilot study of the effect of localized injections of autologous platelet rich plasma (PRP) for the treatment of female sexual dysfunction. J Womens Health Care 2014;3:3-6.
Sukgen G, Ellibeş Kaya A, Karagün E, Çalışkan E. Platelet-rich plasma administration to the lower anterior vaginal wall to improve female sexuality satisfaction. Turk J Obstet Gynecol 2019;16:228-34.
Kleinplatz PJ. History of the treatment of female sexual dysfunction(s). Annu Rev Clin Psychol 2018;14:29-54.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]