Table 3

Causes of Female Sexual Dysfunction

CAUSE EXAMPLES SEXUAL SYMPTOMS

Hormonal/endocrine Hypothalamic-pituitary axis Decreased libido/desire,

dysfunction, surgical/medical vaginal dryness, lack of
castration, menopause, chronic arousal
oral contraceptive use,
premature ovarian failure

Musculogenic Hyper- or hypotonicity of pelvic Hypertonicity: sexual pain

floor muscles disorders, including
vaginismus

Hypotonicity: vaginal
hypoesthesia, coital
anorgasmy, urinary
incontinence associated
with sexual activity

Neurogenic Spinal cord injury; disorders of Anorgasmy

the central or peripheral nervous
system (e.g., diabetes, upper
motor neuron injury)

Psychogenic Relationship problems, poor Decreased libido/desire,

body image, decreased self- decreased arousal,
esteem, mood disorders, hypoesthesia, anorgasmy
adverse effect of psychotropic
medication use

Vasculogenic Diminished blood flow to Vaginal dryness,

genitals secondary to dyspareunia
atherosclerosis, hormonal
influences, trauma
Table 4
Sex Hormones and Neurotransmitters Involved in Sexual Functioning
SEXUAL
SEX HORMONE OR FUNCTIONING TYPE OF
NEUROTRANSMITTER AFFECTED EFFECT COMMENTS

Dopamine Desire, arousal Positive May promote willingness to

continue sexual activity after it
is initiated

Estrogen Arousal, desire Positive Estrogen deficiency is

associated with vaginal
atrophy, decreased
lubrication, vasocongestion,
and sensation

Nitric oxide Vasocongestion Positive Adequate levels of estrogen

of clitoral tissue and testosterone may be
needed for nitric oxide to
initiate vasocongestion

Norepinephrine Arousal Positive

Oxytocin Receptivity, Positive Associated with increased

orgasm perineal contractions with
orgasm

Progesterone Receptivity Positive May be antiestrogenic

Prolactin Arousal Negative

Serotonin Arousal, desire Positive Inhibits norepinephrine and

and dopamine; may facilitate
negative uterine contractions during
orgasm, but also may inhibit
orgasm by different
mechanisms

Testosterone Desire, initiation Positive Low circulating levels of

of sexual activity testosterone are not clearly
associated with decreased
sexual desire12

Vasoactive intestinal Vasocongestion Positive

peptide of clitoral tissue
Table 6
Abnormal Physical Examination Findings Related to Female Sexual
Dysfunction
FINDING POTENTIAL CAUSE SEXUAL SYMPTOMS

Genitourinary

Cystocele, rectocele, or Decreased desire (from

uterine prolapse embarrassment), dyspareunia

Fixed, retroverted uterus; Endometriosis Deep dyspareunia

nodules; tenderness along
uterosacral ligaments

Hypertonicity of pelvic Vaginismus, vestibulitis Dyspareunia

muscles

Sparse pubic hair Low androgen level Decreased desire

Tender points along vulvar Vestibulitis Dyspareunia

vestibule

Vaginal discharge Infection Dyspareunia

Vaginal or labial atrophy Low estrogen level Dyspareunia, decreased arousal

Vulvar skin abnormalities Lichen sclerosus, chronic Dyspareunia

candidal vaginitis

Other

Abnormal blood pressure or Atherosclerotic peripheral Decreased arousal

peripheral pulses vascular disease

Galactorrhea Prolactinoma Decreased desire

Musculoskeletal Osteoarthritis, rheumatoid Decreased desire, decreased

abnormalities arthritis, other arousal secondary to difficulty
musculoskeletal conditions with sexual activity or
embarrassment

Neuropathy Neurologic disorder, Decreased desire or arousal,

FINDING POTENTIAL CAUSE SEXUAL SYMPTOMS

diabetes anorgasmy

Pallor Anemia Decreased desire or arousal

Thyroid enlargement Hypothyroidism Decreased desire or arousal