1. Female Sexual Dysfunction (FSD)
Susan R Davis
Chair of Women’s Health
Women’s Health Research Program
Monash University, Melbourne, Australia

2. WHO Definition
Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles and relationships.
While sexuality can include all of these dimensions, not all of them are always experienced or expressed.

3. Sexual health is a state of physical, emotional, mental and social well-being related to sexuality;
it is not merely the absence of disease, dysfunction or infirmity

4. FSD is associated with significant decreases in health-related quality of life
Large negative effects on mental health, vitality, social function
Affected women are more likely to be
depressed,
dissatisfied with their home life,
dissatisfied with emotional and physical relationship with their sexual partner.
The overall effect of HSDD on quality of life is similar in magnitude to that of diabetes and back pain Biddle et al 2009

5. Female Sexual Dysfunction (FSD) DSM-V released 2013
CLASSIFICATION OF
Female Sexual Dysfunction (FSD) DSM-V released 2013
Sexual Interest/Arousal Disorder
Orgasmic disorder
Genito-Pelvic Pain/Penetration Disorder
Persistent arousal disorder

6. The definition of FSD is evolving
Agreement on main issues being:
Desire; arousal; orgasm; sexual pain with personal distress being a criterion for dysfunction
Need to consider other conditions:
Dyspareunia
Secondary to medical or psychiatric illness, medication/substance induced.
Persistent sexual arousal disorder in women

7. Prevalence of FSD
The most commonly reported sexual problems in women relate to sexual desire and interest, pleasure, and global satisfaction (Laumann 1999; Hayes 2008; Moreira 2008).

8. Prevalence of sexual problems associated with distress*
in a cross-sectional study of American women
Shifren et al Obstet Gynecol 2008
DESIRE
AROUSAL
ORGASM
ANY
Responses (n)
28,447
28,461
27,854
28,403
Distressing problem (n)
2868
1556
1315
3456
Age stratified prevalence (%)
18-44 YEARS
8.9
( )
3.3
( )
3.4
( )
10.8
( )
45-64 YEARS
12.3
( )
7.5
( )
5.7
( )
14.8
( )
>64 YEARS
7.4
( )
6.0
( )
5.8
( )
( )
*Female Sexual distress score 15 or more

9. The Prevalence of Sexual Dysfunction in Malaysian Women Sidi et al J Sex Med. 2007
Mean age 39.2 (10.5);
Prevalence of FSD : 29.6% (68/230) ( defined as score ≤55 on the MVFSFI )

10. Factors associated with sexual dysfunction:
Obstet Gynecol 2006;2008
Factors associated with sexual dysfunction:
Higher education level
Poor health
Being in a significant relationship
Daily/ weekly urinary incontinence
Depression
Past sexual abuse

11. Important considerations
Relationship stress
Body Image/ self esteem
Individual and partner’s understanding of anatomy and sexuality
Lack of adequate sexual stimulation needs consideration
Cultural and religious beliefs
Concurrent medical conditions (& partner)
Concurrent psychological conditions (eg: depression)

12. Female desire-arousal disorder
To make this diagnosis, a lack of sexual interest/arousal for a minimum duration of approximately 6 months as manifested by at least 4 of the following indicators must be present:
Absent/reduced frequency or intensity of
interest in sexual activity
sexual/erotic thoughts or fantasies
of sexual excitement/pleasure during sexual activity on all or almost all (approximately 75%) sexual encounters
of genital and/or nongenital sensations during sexual activity on all / almost all (approximately 75%) sexual encounters
Absent/reduced frequency of initiation of sexual activity and is typically unreceptive to a partner's attempts to initiate
Absent sexual interest/arousal or infrequently elicited by any internal or external sexual/erotic cues (e.g., written, verbal, visual)

13. Prevalence of low desire in postmenopausal women: consistent across western countries and between studies
Low desire
Low desire + distress (HSDD)
Sweden,
age y
42% NM
46% SM
9% natural M
12% surgical M
Fugl-Meyer 1999
4 EU Countries
age y
33% all women
14% all women
Dennerstein 2006
USA
9.3% natural M
12.3% surgical M
Rosen 2009

14. Estradiol (E) Testosterone (T) Progesterone Prolactin Oxytocin
Endogenous hormones potentially influencing female sexual desire/arousal
Estradiol (E)
Testosterone (T)
Progesterone
Prolactin
Oxytocin
Endorphins
Melanocortins
Davis 2003

15. Effect of hysterectomy on hormones and sexual function
Most studies suggest hysterectomy alone does not generally adversely affect sexual functioning
Bilateral oophorectomy lowers testosterone levels in pre- and postmenopausal women
Decline in libido greater after oophorectomy than after hysterectomy alone Nathorst-Boos et al 1992

16. Anorgasmia
The second most frequently reported sexual dysfunction in women.
20-30% of women report inability to achieve orgasm
(Simon JS et Arch Sex Behav 2001; Harris JM J Sex Med 2008)
Anorgasmia is rarely addressed in the clinical setting of a general practice.
A study of 170 patients presenting at a general practice clinic found that only 2% of all sexual dysfunctions reported were being documented
Anorgasmia can be
- lifelong (has never achieved orgasm) or
- acquired (has achieved orgasm in the past but is no longer able),
- generalized or situational, and
- due to physical, psychological, or combined factors

17. Orgasmic disorders in women
To make this diagnosis, at least 1 of the 2 following symptoms must have been present for a minimum duration of approximately 6 months and be experienced on all or almost all (approximately 75%) occasions of sexual activity:
■ Marked delay in, infrequency or absence of orgasm
■ Markedly reduced intensity of orgasmic sensation

18. Orgasmic dysfunction associated with
The Prevalence of Orgasmic dysfunction in Malaysian Women Sidi et al Asia Pac J Public Health : 298
136 scored ≤4 on the orgasmic domain Malay Version of FSFI (0-10) = prevalence of orgasmic difficulties 59.1%
Orgasmic dysfunction associated with
- > 45 years of age (p < .001),
- Non-Malay (P = .042),
- lower academic status (P = .001),
- married >14 years ( P < .001),
- > 4 children (P < .001),
- married to an older husband (aged >55 years) (P <001)
- having sexual 1 to 2 times a week (P < .001),
- Menopausal (P = .001)

19. Anorgasmia is associated with
Relationship issues
Past sexual abuse Bartoi et al J Sex Marital Ther 1998;24:75–90.
Chronic disease
- Multiple Sclerosis Zorzon M et al Mult Scler 1999;5:418–27.
- Cardiovascular disease risk: hypertension, and peripheral vascular disease, smoking, diabetes
- Renal failure
Urinary incontinence
Psychotrophic medications: antidepressants, antipsychotics and mood stabilizers- up to 1/3 of women on SSRIS
Stimmel GL et al. CNS Spectr 2006;11:24–30.
Pelvic disorders - post Sx; irradiation; trauma…

20. Sexual pain disorders
Dyspareunia - etiology can be difficult to diagnose
vaginal atrophy,
vaginismus,
vulvodynia,
vestibulitis,

21. Genito-Pelvic Pain/Penetration Disorder
Persistent or recurrent difficulties for a minimum duration of approximately 6 months with one or more of the following:
Marked difficulty having vaginal intercourse/penetration
Marked vulvovaginal or pelvic pain during vaginal intercourse/penetration attempts
Marked fear or anxiety either about vulvo-vaginal or pelvic pain on vaginal penetration
Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration

22. Persistent genital arousal disorder in women
First described in 2001
Characterized by excessive and unrelenting sexual arousal in the absence of desire.
Associated with
restless legs syndrome, overactive bladder syndrome, and urethra hypersensitivity
MRI shows pelvic varices of different degree in the vagina (91%), labia minora and/or majora (35%), and uterus (30%)
Hyperesthesia sensory neuropathy of the pudendal nerve and dorsal nerve of clitoris
Waldinger et al J Sex Med Oct;6(10):

23. Impact of FSD

24. WOMEN WITH FSD CONTINUE TO BE SEXUALLY ACTIVE Number of sexual events/month according to sexual satisfaction and menopausal status
Davison et al J. Sex Med 2009
n, sexual
events
per
month
*p<0.001 * *
PREMENOPAUSAL POSTMENOPAUSAL

25. DYSPAREUNIA increases across the menopause frequency of intercourse is constant* *
Avis et al Menopause 2009

26. Wellbeing is lower in pre- and postmenopausal women with low sexual satisfaction*
* p<0.001 * * * *
Davison at J Sex Med 2009

27. Assessment Biopsychological assessment current circumstances
partner status
employment
Sexual experiences
adequacy of sexual stimulation, both contextural and physical
Health history, medications, drug use
Medical examination including genital and pelvic examination particularly for loss of sensitivity or pain disorders

28. Laboratory investigations
Menstrual irregularity/amenorrhoea
E2, FSH, prolactin
? Androgen profile
Fatigue
Thyroid function
Iron stores
fasting glucose
Others as indicated – e.g. for STIs

29. Management of low libido
Management of psychosocial issues
Review medications (anti-depressants)
Treatment of vaginal atrophy
Tibolone (see management of menopause)
Androgen
EVIDENCE OF EFFICACY LIMITED NO JUSTIFICATION FOR USE
TESTOSTERONE

30. Management Current circumstances Individual psychological factors
Relationship issues
Sexual health knowledge
Individual psychological factors
Body image and self-esteem
Experience of sexual abuse/trauma
Negative attitudes, inhibitions and anxieties
Health related factors
Mental health
Physical health
Medication side effects particularly antidepressants and antipsychotics

31. Treatment of vaginal atrophy
Local application of oestrogen alleviates vaginal dryness and lowers vaginal pH
Oestradiol pessaries
Oestriol cream/pessaries
Vaginal Moisturizers
The polycarbophil-based water insoluble compounds (Replens®)carry multiple times their weight in water. When used intra-vaginally 2x/week they lower vaginal pH and alleviate itching and dryness. Hyaluronic acid-based preparations also provide good symptom relief and objective evidence of improved vaginal health
Vaginal lubricants
alleviate vaginal dryness and prevent dyspareunia during sexual activity
Only effective when used i.e. no benefit between applications

32. Testosterone therapy
Physiology of testosterone
Indications for use

33. Testosterone declines with age, not menopause
Davison et al JCEM 2005

34. Other causes of low testosterone
Use of the oral contraceptive pill: switches off ovarian testosterone production and increases sex hormone binding globulin levels so free testosterone levels lower
Systemic oral glucocorticoid therapy- suppresses adrenal androgen production
Panhypopituitism
Anti-androgen therapy

35. surgically postmenopausal women on estrogen
EFFICACY OF TESTOSTERONE FOR HYPOACTIVE SEXUAL DESIRE DISORDER DEMONSTRATED IN LARGE studies of:
surgically postmenopausal women on estrogen
naturally postmenopausal women on estrogen + progestin
postmenopausal women on no hormone therapy
premenopausal women
Studies consistently show benefits of transdermal testosterone vs placebo for sexual satisfaction, desire, arousal, pleasure AND orgasm

36. Primary indication for testosterone therapy for women:
Treatment of persistent low libido that profoundly impairs quality of life
testosterone improves sexual desire, arousal and sexual satisfaction in premenopausal and postmenopausal women presenting with loss of sexual desire
NOTE- substantial overlap between desire and arousal in women

37. Deciding who not to treat
Treatment is a TRIAL so rather than exclude women from a trial decide who not to treat
Women unlikely to benefit:
Young women with normal ovarian function- other issues
Women in poor relationships
Need to understand if the relationship stress is 1’ or 2’ to FSD
Women on high dose oral estrogen therapy- high SHBG
Women with other sexual difficulties
Women who have never experienced satisfactory sexual function

38. Contraindications androgenic alopecia/hirsutism/acne
hormone dependent malignancy
potential contraindication
very low SHBG levels - need to be very judicious in dosing

39. International Menopause Society
Guidelines
There is no diagnosis of “androgen sufficiency syndrome”
There is evidence that testosterone therapy will improve sexual outcomes for women diagnosed with hypoactive sexual desire disorder (HSDD)
Women can be considered candidates for a trial of treatment after full clinical assessment
Testosterone formulations for men should NOT be used
Compounded testosterone not advisable
There is no evidence for a benefit of DHEA in women with intact adrenal function (adrenal fatigue is not a diagnosis)