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Female Sexual Dysfunction (FSD)

by Janet Casperson, BS, MSN, ANP-C

Female sexual dysfunction (FSD) is defined as disorders of arousal, orgasm, sexual desire and/or sexual pain which result in significant personal distress. Common names for these disorders include vaginismus, dyspareunia, hypoactive sexual desire disorder, and female orgasmic disorder.

FSD can be age-related; it is estimated that 40-50% of adult women have at least one or more manifestations of female sexual dysfunction. These disorders may or may not have a negative effect of the quality of life or the health of the woman, but when they cause enough personal distress she will seek treatment. Unfortunately, most women with FSD do not seek treatment although there are treatments and options that can help.

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Carol was an outgoing 57-year-old woman whose husband Bob was being treated for ED. As we worked through the process about ED with Bob and Carol, Carol asked, "What about me?" Carol admitted that one of the reasons she was "okay" with Bob's ED and their relationship without sexual intimacy was that she had pain with intercourse (dyspareunia). She had never discussed this with Bob.

Carol admitted that she was hesitant about Bob receiving treatment for ED because of the pain she experienced with sex. She thought it was a natural part of aging and something she would just live with, but living without the pain meant living without sex even though she still desired sexual intimacy. Carol knew that if Bob's ED was successfully treated, sexual intimacy would resume and she would experience the pain again. She knew she needed help.

Examination revealed that Carol had low estrogen levels with vaginal atrophy and dryness. After treatment with topical estrogen replacement and vaginal dilators, Carol is now dilated and better lubricated with her own secretions or, occasionally, a water soluble lubricant. She no longer suffers dyspareunia. Bob's ED is being successfully treated and they are enjoying sexual intimacy and intercourse again. Unfortunately, Carol's case is not an isolated case. Many women have some form of FSD or a combination of different forms of FSD and have not sought treatment.

This Center represents an overview of FSD. It is not intended to be a complete and comprehensive discussion of FSD. The American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) offers current diagnostic criteria for FSD. The DSM-IV classifies FSD into four categories:

Diagnosis of FSD

Diagnosis of FSD uses the APA framework; all of the above diagnoses include "marked personal distress or interpersonal difficulty" as an essential criterion for diagnosis. The above disorders can be life-long, acquired, generalized or situational. Sexual problems may be a symptom of diseases like depression, neurological disorders, genitourinary disorders, or endocrine disorders such as diabetes, menopause, metabolic syndrome, or cardiovascular disease. FSD symptoms can also be related to side effects of medication used for other conditions. Diagnosis of FSD can be a challenge for clinicians because of the lack of proven valid and reliable testing tools and the limited number of evidence-based studies concerning FSD. This is further complicated by the lack of distinctions between normal and abnormal and the fact that many women are reluctant to seek help.

Cardiac Disease and FSD

The relationship between cardiac disease and FSD is similar to the relationship of ED and heart disease. The fact that the heart pumps blood to our vital organs is true in both men and women. If the blood is not getting to those organs or genitals, male or female, they will not function optimally. Women may experience decreased desire, decreased arousal, decreased ability to achieve orgasm and a lack of lubrication which can lead to painful intercourse. Studies have indicated that vascular insufficiency decreases the blood flow to the clitoral and vaginal areas, leading to decrease in lubrication, arousal disorders or dyspareunia. A decrease in pelvic blood flow due to diseases of the aorta or iliac vessels, or trauma to pelvic floor structures can cause smooth muscle fibrosis leading to vaginal dryness and painful sex (dyspareunia).

High Blood Pressure and FSD

Uncontrolled hypertension and antihypertensive medications are both associated with decreased lubrication of the vagina, dyspareunia and orgasmic disorders. Among women who experienced a myocardial infarction, approximately 44% reported a decline in the frequency of sexual intercourse with 27% reporting total abstinence. Sexual arousal disorder is the most common sexual disorder in women following coronary artery bypass surgery.

Metabolic Syndrome and FSD

Recent studies on female sexual dysfunction and metabolic syndrome demonstrated that 43% of all women report some type of FSD. A recent study included 120 premenopausal women, age 20-48, with regular menses and metabolic syndrome and 80 women without metabolic syndrome. The women with metabolic syndrome reported significantly more difficulty with sexual arousal, orgasm and lubrication. The sexual disorders reported most often in women with metabolic syndrome were arousal disorders, orgasmic disorder and lubrication problems. Women with metabolic syndrome also reported an overall decrease in sexual satisfaction. Polycystic Ovary Syndrome (PCOS), a condition commonly associated with infertility, is considered the female variant of the metabolic syndrome.

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Menopause and FSD

In 1948, Kinsey reported that sexuality remains an important part of life for postmenopausal women and this has not changed since Kinsey reported it. Sexual activity in older persons may range from cuddling to sexual intercourse. The issue of FSD in older women will be more prominent as the baby boomers age. It was recently reported that 47% of women age 66-71 are sexually active and 28% of women older than 78 years are sexually active and want to remain that way. The number one reported rationale for the decline of sexual activity in older women is lack of a partner. Other factors that affect the sexuality of older women include partner's age and sexual function, atrophy of sex organs, decreased muscle tone, pain related to chronic illness, hypertension, diabetes mellitus, arthritis, ostomies, stroke and lack of privacy.

It is reasonable to say that sexuality and sexual activity is important to men and women as we age. Female Sexual Dysfunction (FSD), while a common problem, is well worth investigating and treating.

References: See Bibliography

August 2006
Last updated: March 2013

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