Female Sexual Dysfunction Treatment & Management

Reassurance and education, when appropriate, go far in allaying patient concerns and improving treatment success. Setting reasonable goals and expectations is important, and the provider may explain that improvement may take time and require multiple visits.  Sexual dysfunction, particularly when it is of long duration, is unlikely to resolve quickly. Usually starting with the problem bothering the patient the most is most helpful, although this order may need to be changed at the provider’s discretion. ^{[2, 3, 12, 20, 16]   [11]}

The PLISSIT  model has also been found to be helpful. ^[21] In this model, the health care provider first gives the patient P ermission to discuss the sexual problem, then provides L imited I nformation to the patient about the sexual problem. S pecific S uggestions are next, where the healthcare provider provides concrete next steps to the patient, followed by a referral for I ntensive T herapy if needed, so the patient can pursue a long-term appropriate solution that meets the stated treatment goals. For example, if a patient presents to a healthcare provider with a complaint of perimenopausal low sexual desire, the provider can provide the patient with P ermission and L imited I nformation by saying, “Many people have trouble discussing this common problem near menopause, but I am glad that you were able bring this up with me today.” A S pecific S uggestion could be that, “Successful long-term sexual relationships need a sufficient amount of variety and novelty, where partners are encouraged to spend ample time together and independently.” ^[11]  Additional information on treatment options may be provided, including resources and reading information. ^{[12, 4]} The provider could also refer the patient to a sex therapist in the area or have the patient return for a visit solely devoted to the sexual problem, for continued counseling and monitoring of progress. ^[11]

Treatment of sexual dysfunction depends on the underlying disorder. As mentioned above, treatment may include counseling, education, and reassurance. Once correctable causes have been addressed or ruled out, medical intervention may be considered. Recommendations are given separately below for each category of female sexual disorder.

Female Sexual Interest/Arousal Disorder

Because Female Sexual Interest/Arousal Disorder (FSIAD) may be a side effect of medications, a frequent solution is adjustment of other prescriptions. Although a host of pharmaceuticals have been implicated in impacting sexual desire and arousal (including antihistamines, beta blockers, diuretics, and hormonal contraceptives), the most common culprits are selective serotonin reuptake inhibitor (SSRI) antidepressants.  Sexual dysfunction is noted in as many as 56% of women who are prescribed SSRIs, and 70% of women who discontinue their prescription cite this effect as the primary reason. Improvements in sexual function may result from lowering the prescribed SSRI dose, or from changing to a different class of antidepressant such as bupropion or mirtazapine. However, it is important to do so in conjunction with a mental health care provider in order to avoid the detrimental effects of suddenly discontinuing antidepressant medication. ^{[22, 14]}

One medication that is FDA-approved to treat Female Sexual Interest/Arousal Disorder is flibanserin, a 5HT1A/2B agonist/antagonist. It is indicated for premenopausal women with low sexual desire. It is taken nightly and requires daily use. Due to the risk of syncope and hypotension, use of alcohol is proscribed for women on this medication. ^[23]

The FDA approved bremelanotide in June 2019 for acquired, generalized hypoactive sexual desire disorder (HSDD) in premenopausal women. It is administered as a subcutaneous injection about 45 minutes before an anticipated sexual activity. Approval was based on clinical trials that demonstrated both improvement in sexual desire score and decrease in distress score relative to placebo. ^{[24, 25, 26]}

Supplemental androgens have not been approved in the US for sexual dysfunction. However, multiple randomized controlled trials have demonstrated a positive effect of testosterone in improving sexual desire in postmenopausal patients complaining of decreased libido, particularly in surgically menopausal women. Most evidence supports the use of transdermal preparations of testosterone which are not available in the US, but which may be compounded from commercially available preparations that are approved for men. Virilizing side effects are a concern for women exposed to high and prolonged levels of androgens, so use of such medication should include routine monitoring for androgen excess during brief courses of treatment at the lowest effective level. ^{[27, 28, 11]}

Genitopelvic Pain/Penetration Disorder

When sexual pain is insertional and associated with vaginal dryness, treatment may be helpful to reverse vaginal atrophy. Women with peri- or post-menopausal atrophy may benefit from topical estrogen, which improves vaginal epithelial integrity, reduces sensitivity and improves elasticity of the vaginal tissues. Topical estrogen is available as a cream, tablet, or continuous-release ring. Topical prasterone (DHEA) has recently been FDA-approved for the same indication, and can be applied nightly as a vaginal suppository. Ospemifene, an oral selective estrogen receptor modulator, is also approved to treat dyspareunia by reversing genital atrophy. ^{[29, 13, 23, 14, 27]}

Nonestrogen lubricants and moisturizers may also be helpful for patients with Genitopelvic Pain/ Penetration Disorder. These products are available over the counter, and are generally risk-free. These include silicone- or water-based solutions that are required with each sexual act (lubricants), or hydrophilic agents applied intermittently (moisturizers), which may relieve dryness independent of coitus. ^[2]

Fractional CO2 laser treatment has also been proposed as a therapy for sexual pain related to vaginal atrophy, but adequate studies have not been completed and this modality is not FDA-approved. ^[11]

When sexual pain is associated with restrictive disease from vaginismus or narrowing of the introitus, additional therapy may be needed. Pelvic floor physical therapy may be necessary in conjunction with specific counseling to help with painful muscular contraction of the vaginal muscles.  For patients with restrictive disease due to atrophy or radiation injury, dilator therapy is another useful tool. ^[2]

Surgical care may be appropriate occasionally for patients with deep dyspareunia associated with a distinct pelvic diagnosis, for example adenomyosis, endometriosis, or adhesive disease. When such an issue is suspected, laparoscopy may be useful as a diagnostic test.

Vestibulectomy is an effective surgical treatment for women with provoked vulvodynia localized to the vaginal vestibule in sufferers who have failed other forms of medical management. Patients should be counseled about the risks and benefits of surgery, and the limitations in offering relief from sexual pain. ^{[2, 11]}

Female Orgasmic Disorder

Inhibition of orgasm is another common side effect of SSRIs. As with FSIAD, women with orgasmic dysfunction may benefit from an adjustment in antidepressant therapy. Again, consideration must be given to the balance between the medication side effects and benefits of continuing effective antidepressants.

Although phosphodiesterase 5 inhibitors such as sildenafil have been effective for treating arousal and orgasmic difficulties in men, there is little evidence for an effect in women. Nevertheless, such medication may be useful in certain circumstances, such as in women with inhibited arousal on SSRIs. ^[11]

When orgasm and arousal difficulties are associated with insufficient or ineffective genital stimulation, education related to ensuring stimulation may be helpful. ^[9]  Some women may be unaware of the importance of clitoral stimulation in inducing arousal, and education regarding clitoral anatomy can be useful. An FDA-approved battery-powered suction device intended to increase arousal and improve orgasm by increasing blood flow and engorgement may be helpful for some patients; however, it is unclear whether this device has advantages over other over-the-counter vibrators. Drawing attention to the importance of adequate stimulation may include education on foreplay, lubricants, vibrators, and similar implements that may be useful for stimulation.

Patients with relationship stagnation, infidelity, or other relationship problems, and/or survivors of abuse may benefit from psychological counseling referral. Some may need couple’s therapy, while other patients may request individual therapy. Psychiatric referral is helpful for patients with poorly controlled psychiatric conditions or those with psychiatric medications that may have sexual side effects.

Referral to a gastroenterologist, urogynecologist, urologist, or pelvic floor physical therapist is helpful for patients with gastrointestinal or urologic conditions that are suspected causes of their sexual pain. Pelvic organ prolapse and fecal, flatus, or urinary incontinence may be discovered upon thorough history-taking, and these problems may cause embarrassment or distress with negative effects on sexual health.

Patients for whom sexual pain is thought to arise from a musculoskeletal etiology often benefit from pelvic floor physical therapy. Because not all physical therapists have been trained in this specialized form of care, it is important to identify therapists who are appropriately certified.

Patients may benefit from routine exercise with moderate physical exertion 150 minutes per week, or 75 minutes per week of high intensity exertion, as appropriate for the patient.

There is evidence that continued sexual activity is protective against later development of sexual dysfunction in menopausal women. ^[30]  Although this association may partly reflect a lower risk of FSD-related problems in those who are able to remain sexually active, it is physiologically plausible that sexual stimulation leads to increased blood flow and preserved elasticity that may protect against vulvovaginal atrophy and its sexual sequelae. ^[11]

Although there are no formal guidelines to recommend an interval at which sexual dysfunction patients should be followed after successful treatment, patients may benefit from an appointment to evaluate treatment progress every 3-6 months while improving, and then yearly thereafter. ^[11]