Clinical Expert Series

Female Sexual Dysfunction

Pharmacologic and Therapeutic Interventions
Lindsay J. Wheeler, MD, and Saketh R. Guntupalli, MD

Female sexual dysfunction is associated with personal distress and includes female sexual
interest and arousal disorder (including former hypoactive sexual desire disorder), female
orgasmic disorder, genitopelvic pain and penetration disorder, and substance- or medication-
induced sexual dysfunction. These disorders are remarkably common among women, with an
estimated prevalence of 20–40%. It is our responsibility as obstetrician–gynecologists to identify
risk factors and screen for female sexual dysfunction. Appropriate screening allows for further
exploration into sexual function and dysfunction and, ultimately, determination of associated
Downloaded from http://journals.lww.com/greenjournal by BhDMf5ePHKbH4TTImqenVI2V1DuJ82ZXEsbhwQJfrfwSoGJ3TvEVoeLZvRgCpRtS on 07/05/2020

distress. Treatment often involves addressing the underlying issue through therapy or medical
management. For female sexual interest and arousal disorder, treatment generally includes
cognitive behavioral therapy, often with a mindfulness focus, and consideration of pharma-
ceutical management. Female orgasmic disorder is treated with education and awareness, as
well as therapy. Evaluation for underlying etiology is particularly critical for genitopelvic pain and
penetration disorder to allow treatment of an underlying condition. Finally, substance- or
medication-induced sexual dysfunction is best managed by cessation of the implicated sub-
stance and consideration of adjunctive therapy if dysfunction is related to antidepressants.
Female sexual dysfunction is often overlooked in clinical practice; however, there are effective
medical and psychological options for management.
(Obstet Gynecol 2020;136:174–86)
DOI: 10.1097/AOG.0000000000003941

F emale sexual dysfunction is defined as a sexual prob-

lem associated with personal distress. According
to the Diagnostic and Statistical Manual of Mental Dis-
orders, Fifth Edition (DSM-5), “sexual dysfunctions
are a heterogeneous group of disorders that are typ-
ically characterized by a clinically significant distur-
bance in a person’s ability to respond sexually or to
experience sexual pleasure; an individual may have
several sexual dysfunctions at the same time.”1 Sex-
From the Division of Gynecologic Oncology, Department of Obstetrics and
Gynecology, University of Colorado Anschutz Medical Campus, Aurora,
Colorado.
Each author has confirmed compliance with the journal’s requirements for
authorship.
Corresponding author: Saketh R. Guntupalli, MD, Division of Gynecologic
Oncology, Department of Obstetrics and Gynecology, University of Colorado
School of Medicine, Aurora, CO; email: Saketh.Guntupalli@ucdenver.edu.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2020 by the American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/20
ual dysfunction may be lifelong or acquired and may
be generalized or situational.
Sexual dysfunction is common among women. An
international survey of 13,882 women aged 40–80
years across 29 countries found that up to 26–43%
reported low sexual desire and 18–41% reported inabil-
ity to achieve orgasm.2 In the United States, the PRE-
SIDE (Prevalence of Female Sexual Problems
Associated with Distress and Determinants of Treat-
ment Seeking) study surveyed 30,000 women, investi-
gating not only the prevalence of sexual dysfunction,
but also the associated distress. It demonstrated that
43% of women reported low desire, low arousal, or
difficulties with orgasm; of those women, 22% reported
sexually related personal distress.3 Obstetrician–
gynecologists (ob-gyns) serve as the first line for ques-
tions and concerns regarding sexual health and related
distress. It is critical that we engage in open dialogue
regarding sexual health and wellness with our patients
and aid in addressing their concerns across the lifespan.
The American College of Obstetricians and
Gynecologists has dedicated focus on women’s sexual

174 VOL. 136, NO. 1, JULY 2020 OBSTETRICS & GYNECOLOGY

© 2020 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
health issues in recent years, with Committee Opinion
No. 706 published in 2017, providing an overview on
approach to sexual health in the clinic, and, subse-
quently, Practice Bulletin No. 213, published July
2019, which provides an excellent review of female
sexual dysfunction.4,5 We will work to build off of
these existing resources and provide further details
on therapeutic management in this Clinical Expert
Series article.
BACKGROUND
Models of Sexual Response
Human sexual response is a highly individual and
emotional process. Historically, sexual response has
been defined by a series of models to describe the
physiologic changes seen during the course of arousal
and response. The Masters and Johnson Model delin-
eated four phases of sexual response, including excite-
ment, plateau, orgasm, and resolution. This approach
was then modified by Kaplan to include desire before
excitement and orgasm. However, subsequent studies
found that these models were predominantly based on
male sexual response, that not all women experienced
desire, and that many women experienced overlapping
of the phases in a less linear progression.6,7 In 2003,
Basson et al6 advocated for expansion and revision of
the definition of sexual response and dysfunction in
women. It is now recognized that, rather than progress-
ing in a linear sequence from desire to arousal to orgasm
and resolution, these phases may overlap and the
sequence may vary.7,8 It is generally understood that,
despite the biological foundation of sexual health, sexual
functioning is experienced in a far more complex con-
text, with influences of environment and relationships.1,8
Physiology
The physiology of female sexual desire and arousal is
complex and multifactorial. It is thought to involve
a combination of parasympathetic and sympathetic
stimulation, as well as sex hormones and environ-
mental and psychological factors.
Sexual arousal begins in the central nervous
system, mediated by the medial preoptic, anterior
hypothalamic region, and other related limbic-
hippocampal structures.9 Sexual arousal and erotic
stimulation lead to release of vasodilators, nitric oxide
and vasointestinal polypeptide, from both parasympa-
thetic and sympathetic nerves.8 Acetylcholine is sim-
ilarly released, which blocks vasoconstrictive
mechanisms and leads to additional release of nitric
oxide.8 The release of these neurotransmitters leads to
vaginal vasocongestion and relaxation of vaginal
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smooth muscle, allowing expansion, and dilation of
the arterioles increases transudation of interstitial
fluid, promoting lubrication.8,10
Estrogens play a critical role in female sexual
response and function. Estrogen is thought to affect
cells throughout the nervous system, with vasopro-
tective and vasodilatory effects.9 Decrease in estrogen
leads to thinning of the vaginal mucosal epithelium
and atrophy of the smooth muscle. Thus, with the
decline in estrogen during menopause, either natural
or surgical, changes in sexual function are common.
There are some studies evaluating the role of estrogen
levels and vasocongestion that suggest the relationship
is more complex and that low estrogen may make
postmenopausal women more vulnerable to sexual
dysfunction, but is not entirely causative.8,11 Testos-
terone is similarly thought to play a role in female
sexual arousal and function; however, low serum lev-
els have not been demonstrated to be associated with
decreased sexual interest or arousal.12 Testosterone
and dopamine supplementation have been found to
improve response, suggesting some role for these
pathways.13,14
APPROACH TO SEXUAL HEALTH IN
THE CLINIC
The American College of Obstetricians and Gynecol-
ogists published Committee Opinion No. 706 in July
2017, recommending:
• Clinical conversations should acknowledge the
contributions of sexuality, relationships, and sexual
behavior to overall health.
• Ob-gyns should focus on the positive aspects of
sexuality, not only the disease processes.
• Discussions of sexual health and aging within the
framework of well-woman care should include the
evolution of sexual health issues across a lifespan.4
Sexual health is a critical aspect of self-identity
and is influenced by biology, psychology, culture,
environment, and relationships, among other factors.
Sexual health develops and changes with a patient
through the lifespan and can be affected by life events,
including medical intervention, reproductive experi-
ences, relationships, and normal physiologic changes
and, thus, must be re-evaluated routinely as part of
well-woman care.4
Comprehensive sexual health care is best ap-
proached as an open dialogue, starting with a sexual
history focusing on positive aspects of sexuality, as
well as identifying opportunities for risk reduction and
possible areas of distress. Questions are best asked in
an open-ended format using gender-neutral terminol-
ogy.4 Specific questions regarding desire, arousal, and
Wheeler and Guntupalli Female Sexual Dysfunction 175
orgasm may help delineate potential areas of dysfunc-
tion, though it is considered dysfunctional only if the
patient finds it distressing. It is the responsibility of the
ob-gyn to normalize and validate the range of “com-
plex normal experiences.”4 However, when a point of
distress is identified, further exploration may allow for
diagnosis and treatment.
An initial approach to a patient with possible
sexual dysfunction is reviewed in ACOG Practice
Bulletin No. 213, “Female Sexual Dysfunction,” and
includes comprehensive history, physical examina-
tion, and diagnosis based on Diagnostic and Statistical
Manual of Mental Disorders (DSM) criteria.5 Addition-
ally, a physician or advanced practice health care pro-
fessional may use a model developed by psychologist
Jack Annon in 1974, known as the PLISSIT model.
PLISSIT stands for permission, limited information,
specific suggestions, and intensive therapy.15 It sug-
gests starting by asking for permission to discuss sex-
ual issues if a concern is raised, then offering targeted
information or education, then specific suggestions for
how to address the problem, and, finally, consider-
ation for more intensive therapy should it be indi-
cated. The PLISSIT model will be discussed further
in the section on treatment of female orgasmic
dysfunction.
RISK FACTORS FOR SEXUAL DYSFUNCTION
The etiology of sexual dysfunction is complex and
multifactorial. Medical and psychiatric conditions,
medications, fatigue and stress, age and menopausal
status, and relationship and environmental factors
may all play a role (Box 1).
Medical comorbidities, specifically gynecologic
conditions, may affect sexual function. Sexual func-
tion can be affected by pregnancy and the postpartum
period.5,16 This is thought to be multifactorial, with
both hormonal and anatomic changes after delivery,
as well as the difficulty of caring for a newborn. Ac-
cording to a review by Leeman et al, postpartum sex-
ual dysfunction affects 40–80% of women.16 Although
results have been inconsistent, sexual health after
delivery does not seem to be affected by mode of
delivery (reviewed by Leeman, et al).16,17 Infertility
similarly affects intimacy, with 43–90% of women
with infertility reporting sexual dysfunction.18 Gyne-
cologic conditions, including pelvic organ prolapse,
endometriosis, and gynecologic cancers, can also
affect sexual health and play a role in sexual dysfunc-
tion.19,20 There has been some question regarding the
effect of hysterectomy on sexual health; however,
a narrative review of 10 studies, performed by Danesh
et al21 in 2015, found that the majority of studies
176 Wheeler and Guntupalli Female Sexual Dysfunction
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Box 1. Common Etiologies and Risk Factors for
Female Sexual Dysfunction
Anxiety disorder
Diabetes
Depression
Female genital mutilation
Genitourinary syndrome of menopause
History of sexual abuse
Hypertension
Hysterectomy
Intimate partner violence
Medications (psychotropic medications [selective
serotonin reuptake inhibitors], antihypertensives, his-
tamine blockers, hormonal medications)
Negative sexual attitudes
Neurologic disease
Personality traits of perfectionism and self-dislike
Postpartum period
 Breastfeeding
 Obstetric trauma
Premature ovarian failure
Psychologic sequelae of gynecologic cancer and
breast cancer
Relationship discord
Stress—emotional or environmental
Stress urinary incontinence
Substance use disorder
Reprinted with permission from Female sexual dysfunction.
ACOG Practice Bulletin No. 213. American College of
Obstetricians and Gynecologists. Obstet Gynecol
2019;134:e1–18.
demonstrated an improvement in sexual functioning
after hysterectomy, particularly for benign conditions.
The writers reinforce the importance of preoperative
counseling on the possible effect of hysterectomy on
sexual health, though any dysfunction generally im-
proves with time. Other medical conditions, including
obesity, hypertension, and neurologic disease, have
also been demonstrated to affect sexual health.
The PRESIDE study found that depression and
anxiety are associated with increased risk for sexual
dysfunction.3 Some would argue that mental health is,
in fact, the most important risk factor for sexual dys-
function.22 Unfortunately, the medications used to treat
these conditions, including benzodiazepines, selective
serotonin reuptake inhibitors (SSRIs), and mood stabil-
izers, are known for their adverse effect on sexual
arousal and ability to achieve orgasm.22,23 Care should
be taken to identify the effect of mental health on sex-
ual function and optimization of both psychological
and pharmacotherapy for these patients.
Age and menopause are difficult to differentiate
as potential risk factors, but the PRESIDE study found
OBSTETRICS & GYNECOLOGY
that the highest rates of sexual dysfunction were in the
45–64-year age group.3 Vaginal atrophy and dyspar-
eunia have been found to increase after menopause,
understandably related to decreased estrogen. The
PRESIDE study looked specifically at natural meno-
pause compared with surgical menopause and found
that decreased arousal and difficulty with orgasm were
worse after surgical menopause than natural meno-
pause.3 Thus, age and both surgical and natural men-
opause should be considered risk factors for sexual
dysfunction.
Finally, relationships and environment have a crit-
ical influence on sexual health. Multiple studies have
demonstrated that dissatisfaction with a partner and
lack of emotional well-being were associated with
sexual dysfunction, leading to distress in the patient.8
Additionally, a history of childhood sexual abuse or
adult sexual assault increase the risk of sexual dys-
function.22,24 This may present with dyspareunia; dif-
ficulties with interest, arousal, or orgasm; or
avoidance of sex.24 Although rates of sexual dysfunc-
tion are higher among women with sexual abuse, it is
critical to not assume that all women with sexual dys-
function have an abuse history. However, given the
increased risk of sexual dysfunction in survivors, elic-
iting a trauma history is a crucial step in the effort to
better understand the underlying etiology of the sex-
ual dysfunction.24
TYPES OF SEXUAL DYSFUNCTION
According to the DSM-5, female sexual dysfunction
includes four primary diagnoses: female sexual inter-
est and arousal disorder (includes former hypoactive
sexual desire disorder), female orgasmic disorder,
genitopelvic pain and penetration disorder, and sub-
stance- or medication-induced sexual dysfunction.
When making any of these diagnoses, the following
factors should be considered in the course of evalu-
ation: partner factors (partners health or sexual
problems), relationship factors (poor communication,
discrepancies in desire for sexual activity), individual
vulnerability factors (poor body image, history of
sexual or emotional abuse), psychiatric comorbidity
(depression, anxiety) or stressors (job loss, bereave-
ment), cultural and religious factors (inhibitions
related to prohibitions against sexual activity, attitudes
toward sexuality), and medical factors.1
Female Sexual Interest and Arousal Disorder
Female sexual interest and arousal disorder is a broad
category of female sexual dysfunction that is charac-
terized by a lack of interest in sexual activity or
difficulty with arousal. This was previously defined as
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two separate groups in the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition: desire and
interest. Given that they often present as two distinct
diagnoses and it is easier to specify treatment, some
groups prefer to maintain these definitions.25
When considering female sexual interest and
arousal disorder, women may report absent or
reduced interest in sexual activity or erotic thoughts.
They may also note a reluctance to initiate sexual
activity and lack of response to initiation from
a partner. When considering the arousal side of the
spectrum, women may experience reduced or absent
sexual excitement or pleasure, or even sensation,
during sexual activities. The DSM suggests that these
features should be present 75–100% of the time to
make the diagnosis. It may be specified whether it
takes place in specific contexts (situational) or if it is
generalized across all sexual encounters.1 To give
a patient a diagnosis of sexual interest and arousal
disorder, the lack of desire or arousal must be accom-
panied by distress. It is important to remember that
there are a variety of ways this disorder may present;
a woman may be distressed by a persistent lack of
interest in sexual activity, or, despite a desire for sex-
ual activity, she may not be able to become sexually
excited.1 For the sake of this review, we will use the
terminology female sexual interest and arousal disorder, as
defined by the DSM-5, though the DSM-5 uses the
diagnosis female sexual interest/arousal disorder, under-
standing that a patient may fall on either the arousal
or interest end of the spectrum.
Fluctuations in sexual interest and arousal can be
a normal response to changes in a woman’s life, par-
ticularly with stress, fatigue, environmental changes,
or new medical diagnoses. To meet criteria for female
sexual interest and arousal disorder, the symptoms
must cause distress and be present for at least 6
months.1
Female sexual interest and arousal disorder is
often associated with difficulties achieving orgasm and
pain with sexual activity. Other associated issues in
women with sexual interest and arousal disorder
include body dysmorphia, impaired intimate relation-
ships, and low self-worth.26
Female sexual interest and arousal disorder is the
most common cause of female sexual dysfunction and
is often the most difficult to treat. The etiologies of
sexual interest and arousal disorder are varied, and
the diagnosis may be made only after organic or
medical causes are excluded (medication-induced,
poorly controlled diabetes, and neuropathy, among
others). Other etiologies of female sexual interest and
arousal disorder include history of sexual abuse and
Wheeler and Guntupalli Female Sexual Dysfunction 177
trauma or intimate partner violence. Medical prob-
lems that can induce or exacerbate these symptoms
include hormonal imbalances, such as hyperprolacti-
nemia, hypoandrogenism, polycystic ovarian syn-
drome, and cancer. Cancer in particular has been
shown to be a substantial risk factor for the develop-
ment of female sexual interest and arousal disorder.20
Psychiatric diagnoses, mainly major depressive disor-
der, has also been associated with sexual interest and
arousal disorder.22 Finally, environmental factors,
including relationship stress, history of sexual abuse,
and partner sexual functioning, are important possible
etiologies to consider.
The exact prevalence of female sexual interest
and arousal disorder is unknown, but the PRESIDE
data suggest that low desire was seen in 38.7% of
respondents and low arousal was reported in 26.1%;
sexually related personal distress was reported in
22.8% of respondents. They found that rates of
reported sexual dysfunction increased with age, but
associated sexual distress was most common in
younger and middle-aged women.3
Female Orgasmic Disorder
Female orgasmic disorder occurs in women when
orgasm or significant sexual pleasure is not achieved
despite significant stimulation. This is clinically dif-
ferent from female sexual interest and arousal disor-
der in that women have the desire and are able to be
aroused but are unable to achieve climax or attain
orgasm. It may also present as a markedly reduced
intensity of orgasm. To meet formal criteria, these
features must be present with all or almost all (75–
100%) sexual encounters, persist for 6 months, and
cause significant distress to the patient.1
The etiologies of orgasmic disorder are multifac-
torial. It is important to first evaluate for medical
conditions or substances or medications that may lead
to difficulty with orgasm, because iatrogenic causes
are thought to play the biggest role. The use of SSRIs
is known to delay or inhibit orgasms in women.23
Concomitant medical conditions including diabetes,
hypertension, or other chronic illnesses may lead to
difficulty with orgasm. Nerve damage from radical
hysterectomy or other nerve injuries can affect ability
to achieve orgasm. Illicit drug use including alcohol
and chronic opioid use may also play a role. Once
these conditions are ruled out, interpersonal context
must be evaluated, including relationship distress, inti-
mate partner violence, or other significant stressors.
Although the effect on sexual health and ability or
orgasm may be substantial, a patient would not tech-
nically meet criteria for female orgasmic disorder if
178 Wheeler and Guntupalli Female Sexual Dysfunction
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
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there is an acute exacerbating factor. Finally, it is
important to evaluate whether the patient’s sexual
stimulation is sufficient, because many women require
clitoral stimulation to achieve orgasm; if she is able to
achieve orgasm by clitoral stimulation alone, it would
not be a true orgasmic disorder. If none of the above
conditions are met, the patient is considered to have
a true orgasmic disorder, though, even if there is
a clear etiology for the orgasmic disorder, the sexual
dysfunction must still be addressed.
Prevalence of orgasmic difficulties varies from 10
to 40%, but this does not take into account presence of
distress. The PRESIDE study found that 20% of
women surveyed reported orgasm difficulties, and
more than 5% of women reported distress related to
orgasm dysfunction.3
Genitopelvic Pain and Penetration Disorder
Genitopelvic pain and penetration disorder encom-
passes the symptoms of dyspareunia and vaginis-
mus.27 It is characterized by persistent difficulty with
vaginal intercourse or penetration, vulvovaginal or
pelvic pain during intercourse or penetration at-
tempts, fear or anxiety about pain in anticipation of
intercourse, and marked tensing or tightening of pel-
vic floor during attempted penetration. A patient re-
quires only one of these four components to make
a diagnosis of genitopelvic pain and penetration dis-
order, because only one of these symptoms is often
sufficient to cause significant distress.1 Similar to other
female sexual disorders, to meet criteria for the diag-
nosis, these symptoms must be present for at least 6
months and cause significant distress.1
Genitopelvic pain and penetration disorder in-
cludes intercourse as well as any vaginal penetration,
including gynecologic examinations and tampon
insertion. Vulvovaginal or pelvic pain during inter-
course should be evaluated thoroughly, because it
may be elicited on examination. It may be more
specifically characterized as deep or superficial or by
the type of pain (ie, shooting or burning). Fear or
anxiety in anticipation of intercourse is often reported
by women with a history of pain during intercourse
and may lead to avoidance. In other cases, there is no
history of pain, but the fear of pain still leads to
avoidance, and the disorder behaves more like
a phobia. Finally, tensing of the pelvic floor is often
a reflexive spasm of the pelvic muscles in response to
attempted penetration.1
Genitopelvic pain and penetration disorder is
often associated with female sexual interest or arousal
disorder, though not always. Patients may demon-
strate avoidance patterns similar to phobias, including
OBSTETRICS & GYNECOLOGY
avoidance of gynecologic examination. It is not
uncommon that, despite having symptoms for many
years, women may present for care only when trying
to conceive. Although the exact prevalence of genito-
pelvic pain and penetration disorder is unknown, 15%
of women report recurrent pain during intercourse.1
Genitopelvic pain and penetration disorder is
very difficult to treat, because the etiologic cause is
usually multifactorial and difficult to isolate. Common
reasons for pain during intercourse include organic
causes such as endometriosis, vaginitis, menopause
causing vaginal dryness, malignancy, and infection.27
A history of gynecologic cancer may increase risk for
genitopelvic pain and penetration disorder, because
postsurgical and posttreatment changes may cause
new potential sources of pain. Anatomic variations
including septate uterus should also be considered in
the differential diagnosis. Other factors include psy-
chological or environmental conditions, including
depression and past sexual trauma or early childhood
sexual abuse.
In many cases, genitopelvic pain and penetration
disorder will be associated with an underlying medical
condition, such as lichen sclerosis, endometriosis,
vulvovaginal atrophy, or pelvic inflammatory disease.
Wright et al encourage taking a systematic approach to
diagnosis and to consider etiologies in three categories:
irritative, anatomic, and infectious.27 Irritative etiolo-
gies include vaginal dryness, atrophic vaginitis, vulvar
dermatoses, and vulvodynia and vestibulitis. Anatomic
etiologies include endometriosis, leiomyomas, pelvic
organ prolapse, malignancy, and postsurgery and treat-
ment scarring. Infectious etiologies can include sexu-
ally transmitted infections, pelvic inflammatory
disease, and vulvovaginal candidiasis.27 In some cases,
treatment of the underlying condition will lead to
improvement in the genitopelvic pain and penetration
disorder. The key to distinguishing the etiology of this
disorder is taking a thorough history to determine the
aggravating symptoms and assessing the quality of sex-
ual activity that elicits pain; then the appropriate
workup for potential irritative, anatomic, or infectious
causes can guide treatment.
Substance- or Medication-Induced
Sexual Dysfunction
According to the DSM, substance- or medication-
induced sexual dysfunction is a clinically significant
disturbance in sexual function, with evidence from
evaluation of the patient that the symptoms developed
during or soon after intoxication with the substance or
initiation of a given medication.1 The involved sub-
stance or medication must be capable of causing the
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noted sequelae. The changes in sexual function should
demonstrate a temporal relationship with the causa-
tive agent; for example, symptoms start with initiation
of medication and improve with dose reduction or
cessation. If symptoms persist for at least 1 month
after cessation or withdrawal, a non–substance- or
medication-induced sexual disorder should be
considered.
Many substances can cause sexual dysfunction,
including alcohol, cocaine, anxiolytics, sedatives, and
opioids. Similarly, withdrawal from these substances
can affect sexual function. The medications that are
most likely to cause sexual dysfunction are antide-
pressants (particularly SSRIs) and antipsychotics, and
there are some data for oral contraceptives. Selective
serotonin reuptake inhibitors are particularly associ-
ated with difficulty with orgasm, the prevalence
depending on the specific medication, though it is
estimated that 22–58% of women using antidepres-
sants will suffer sexual side effects.6 Time from initia-
tion of the medication to start of side effects may be as
rapid as 8 days. For some, the dysfunction will resolve
after 6 months of use. Approximately 50% of patients
taking antipsychotics will report adverse sexual side
effects, including inhibited desire and decreased
lubrication.
TREATMENT OF SEXUAL DYSFUNCTION
Female Sexual Interest and Arousal Disorder
Management of female sexual interest and arousal
disorder is guided by the history and generally
includes both psychological intervention and consid-
eration of pharmaceutical intervention.
Psychological Approach
Cognitive behavioral therapy is a critical part of the
treatment of female sexual interest and arousal
disorder. Cognitive behavioral therapy can assist
patients in identifying and modifying factors that
contribute to or exacerbate sexual dysfunction. This
could include examining maladaptive thoughts,
unreasonable expectations, behaviors that reduce
interest or trust in the relationship, or insufficient
stimuli while simultaneously working to improve the
emotional closeness of the couple.8 The focus of this is
on the development and natural evolution of sexual
activity rather than a focus on intercourse and
orgasm.28 Patients are taught to not focus on end re-
sults of sexual desire, but rather on activities that
achieve intimacy and pleasure with their partner.
Though there are minimal data to support these tech-
niques, Trudel et al29 published a study in 2001 eval-
uating a short-term cognitive behavioral therapy
Wheeler and Guntupalli Female Sexual Dysfunction 179
approach to women with hypoactive sexual desire
disorder (as defined at the time) and found a significant
improvement in symptoms and subsequent improve-
ment in behavioral, cognitive, and marital function-
ing. Mindfulness is also an appropriate technique in
this realm.25 Sex therapy can also take it one step
further with sensate focus techniques, which focus
on being present during intimate exchanges and even-
tual progression toward sexual touch.8 Psychotherapy
is used when the drivers of female sexual interest and
arousal disorder seem to be more deeply rooted con-
flicts with self-image or sexual trauma.
Pharmaceutical Approach
Hormonal therapy has been used historically for
sexual interest and arousal dysfunction in women.
There have been a series of placebo-controlled trials
evaluating transdermal testosterone in women with
surgically induced menopause, and each of the studies
found a moderate increase in satisfying sexual activity
and sexual desire and response, as well as significant
reductions in distress.13,30 The majority of studies
have been completed in naturally postmenopausal
women simultaneously taking estrogen supplementa-
tion, though others have focused on postmenopausal
women taking only testosterone, both of which found
a moderate improvement in number of satisfying sex-
ual episodes over the course of a month.31,32 In 2017,
Achilli et al published a systematic review and meta-
analysis of seven randomized controlled trials on the
use of transdermal testosterone, with a standardized
dose of 300 micrograms compared with placebo, in
more than 3,000 postmenopausal women. They found
short-term efficacy, with improvement in the number
of sexually satisfying experiences, sexual activity,
number of orgasms, and sexual desire, and a signifi-
cant reduction in personal distress, in both naturally
and surgically menopausal women.33 The meta-
analysis found no significant difference in the rate of
adverse effects, though they did find increased inci-
dence of acne and increased hair growth among pa-
tients using transdermal testosterone.33 However,
safety and efficacy data are limited, because most
studies evaluated use for only 6 months.5
The Endocrine Society published a clinical prac-
tice guideline recommending transdermal testoster-
one for short-term use in postmenopausal patients
with female sexual interest and arousal disorder. They
recommend counseling regarding unknown risks of
long-term use and continuous monitoring for evi-
dence of androgen excess.34 Given only modest
improvement seen in the existing literature and lim-
ited data regarding long-term side effects, testosterone
180 Wheeler and Guntupalli Female Sexual Dysfunction
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
is not currently approved by the U.S Food and Drug
Administration (FDA) for treatment of women with sex-
ual dysfunction.27,35 Furthermore, the physiologic trans-
dermal dosing evaluated in the majority of these studies
is not available in the United States and thus requires
compounding.34,35 The Global Consensus Position
statement from multiple societies does caution regarding
compounding and the risk of supraphysiologic doses of
testosterone, as well as testosterone administered
through pellets.36 For premenopausal women with
female sexual interest and arousal disorder, there are
isolated studies evaluating the role of transdermal testos-
terone; however, the evidence is considered insufficient
to recommend testosterone-based treatment.5,37
When considering nonhormonal interventions,
bupropion, a dopamine and norepinephrine agonist,
has been studied for treatment of female sexual
interest and arousal disorder. In 2004, Seagraves
et al published a randomized, double-blind, placebo-
controlled trial of 66 nondepressed patients and found
that bupropion had a significant effect on increasing
measures of sexual arousal, orgasm completion, and
sexual satisfaction.38 In 2019, a phase IB/IIA study
was published to evaluate dose tolerability for a new
pharmaceutical, a combination of the stimulating and
excitatory dopamine–norepinephrine reuptake inhib-
itor bupropion and the sedating and inhibitory sero-
tonergic agonist–antagonist trazodone. It was an
open-label, active control study that found that most
patients both tolerated and responded to the moderate
dose of the combination drug, paving the way for
phase III evaluation.39 Based on these studies, off-
label use of bupropion remains a key nonhormonal
option for the management of female sexual interest
and arousal disorder.
Sildenafil citrate, a potent selective inhibitor of
phosphodiesterase 5, has been shown to enhance
genital blood flow and vaginal and clitoral vaso-
congestion.8,40 Several studies have evaluated its
potential as an off-label agent to treat female sexual
interest and arousal dysfunction, with varying results.
An early study looking at sexual dysfunction in post-
menopausal women did identify an improvement in
vaginal lubrication and clitoral sensitivity; however, it
did not find an overall improvement in function.41 A
subsequent study by Berman et al42 focused specifi-
cally on female sexual arousal disorder, independent
of evidence of dysfunction in sexual interest, and
found through a double-blind, placebo controlled
approach that sildenafil lead to improvement on the
Female Intervention Efficacy Index, thus demonstrat-
ing an immediate improved outcome in patients with
arousal-specific dysfunction. A more recent study
OBSTETRICS & GYNECOLOGY
focused specifically on women with antidepressant-
associated sexual dysfunction, which will be discussed
further under treatment for substance- or medication-
induced sexual dysfunction.43
For a review of all off-label pharmaceuticals
available to treat sexual interest and arousal dysfunc-
tion in women, please see Table 1.
Flibanserin, a 5-hydroxytryptamine (5-HT) mod-
ulator, specifically a 5-HT1A agonist and 5-HT2A
antagonist, was the first pharmaceutical approved by
the FDA for hypoactive sexual desire disorder, the
sexual interest component of female sexual interest
and arousal disorder.44 In 2019, Simon et al45 pub-
lished a pooled analysis that evaluated flibanserin 100
mg once daily at bedtime compared with placebo in
premenopausal women with hypoactive sexual desire
disorder, which was evaluated across three multicen-
ter studies. The primary tools for evaluation were the
number of satisfying sexual events over 28 days, the
Female Sexual Function Index-Desire Domain score,
and a modified Female Sexual Distress Scale score.
The analysis ultimately included 2,465 women with
a mean age of 36 years and a mean duration of hypo-
active sexual desire disorder of 56 months. The mean
number of satisfying sexual events over 28 days was
2.1 with flibanserin compared with 1.2 with placebo
(P,.001). The change in Female Sexual Function
Index-Desire Domain and Female Sexual Distress
Scale scores was also significantly improved with fli-
banserin.45 Adverse events were evaluated, with som-
nolence and dizziness in 12% and 10% of participants,
respectively. The authors concluded that flibanserin
was well tolerated, improved sexual desire, and
reduced sexual distress associated with hypoactive
sexual desire disorder in premenopausal women.45
A recent evaluation of safety for flibanserin with
a focus on sedation- and hypotension-related side ef-
fects, confirms that flibanserin is well tolerated and
effective.44 There had been concern about the possi-
ble influence of alcohol on flibanserin side effects,
particularly hypotension; however, a subsequent
study found no appreciable dose response between
flibanserin and alcohol.46 Thus, the FDA changed
their recommendation to update the box warning
regarding alcohol and instead caution that care must
be taken with alcohol but that it does not need to be
avoided entirely. Specifically, they recommend delay-
ing taking flibanserin for 2 hours after last alcohol
consumption and delay further alcohol consumption
after flibanserin until the next morning.47
Bremelanotide (Vyleesi) is a melanocortin 4
receptor agonist and was the second pharmaceutical
to be approved by the FDA for treatment of the sexual
interest component of female sexual interest or
arousal dysfunction.48 Bremelanotide is a subcutane-
ous auto-injection, administered into the thigh or
abdomen 45 minutes before sexual activity. Dosing
can be repeated every 24 hours, but it should not be
used more than eight times in 1 month.49 The RE-
CONNECT studies evaluated bremelanotide as a sub-
cutaneous injection. These two phase-III trials
included premenopausal patients with reported hypo-
active sexual desire disorder, the majority of whom
also experienced decreased arousal. Both studies
showed improvement in primary endpoints: Female
Sexual Function Index-Desire Domain score, indicat-
ing greater increase in desire, and Female Sexual Dis-
tress Scale score, indicating improvement in sexual
distress.50 Bremelanotide was also associated with sta-
tistically significant improvement in the sexual satis-
faction, lubrication, orgasm, and arousal domains.50
Although the number of satisfying sexual events was
not significant in either trial, they were higher in the
bremelanotide group, raising the question of true clin-
ical benefit.48,50 Most adverse effects were mild or
moderate, most commonly nausea, facial flushing, or
headache. Adverse effects were responsible for 18% of
participants discontinuing or interrupting treatment.48

Table 1. Off-Label Pharmaceuticals for Female Sexual Interest and Arousal Disorder

Medication Mechanism Dose Side Effects

Testosterone14,30,32– Androgen, stimulation of 150 micrograms/d or 300 Hair growth, acne (though not
35 neurotransmitters to increase libido micrograms/d transdermal patch seen in all studies)
(not available in the United States)
Bupropion*,38–40 Dopamine and norepinephrine agonist 150 mg daily, increased to 300 mg Anxiety, irritability, headache,
daily OR 150 mg twice daily seizures
Sildenafil Phosphodiesterase 5 inhibitor, 50 mg or 100 mg tablets, 1 h before Headache, flushing, nausea;
citrate†,41–43 increases genital blood flow and sexual encounter contraindicated in patients
vaginal and clitoral vasocongestion taking nitrate therapy
* Particular benefit when concern for selective serotonin reuptake inhibitor–induced sexual dysfunction.
†
Particular benefit with selective serotonin reuptake inhibitor–induced sexual dysfunction and sexual arousal disorder.

VOL. 136, NO. 1, JULY 2020 Wheeler and Guntupalli Female Sexual Dysfunction 181

© 2020 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
A subsequent long-term safety and efficacy analysis of
272 patients was performed, which found no new
safety concerns and confirmed sustained response to
the intervention.51
For a review of FDA-approved pharmaceuticals
available to treat sexual interest and arousal dysfunc-
tion in women, please see Table 2.
Female Orgasmic Disorder
Female orgasmic disorder is defined as either primary,
when a patient has never had an orgasm, or second-
ary, when she has had an orgasm in the past but
currently has not had an orgasm for approximately 6
months and it causes her distress.1 Primary female
orgasm disorder may be related to childhood expo-
sures or trauma and thus may be best addressed by
psychotherapy.27 Primary female orgasm disorder
may also be related to an underlying medical condi-
tion, such as neurologic injury, in which case the
underlying medical condition needs to be addressed.
Finally, primary female orgasm disorder may be idi-
opathic, which is more difficult to treat. Secondary
female orgasmic dysfunction may be caused by psy-
chosocial changes (eg, new relationship conflict, body
image), new underlying medical conditions including
neurologic or vascular disorders, and medications
including SSRIs. If the change in sexual function is
preceded by the start of a new medication or an acute
interpersonal stressor, the diagnosis of female orgas-
mic disorder is ruled out; however, symptoms may
still require attention.52
Clinical interviewing is a critical aspect of evalu-
ation for orgasmic disorders, including characteriza-
tion of nature, onset, and chronicity of difficulty with
orgasms.52 Wright and O’Connor27 recommend use
of the PLISSIT model—permission, limited informa-
tion, specific suggestions, intensive therapy. Permis-
sion includes conversation with the patient regarding
normalization of sexual behaviors. Limited informa-
tion is available regarding behaviors that could
improve sexual arousal, as well as evaluation of pos-
Table 2. U.S. Food and Drug Administration–Approved Pharmaceuticals for Female Sexual Interest and
Arousal Disorder
Medication Mechanism Dose
Flibanserin45 5-HT1A agonist, 5-HT2A 100-mg nighttime oral Hypotension (possibly exacerbated with alcohol),
(Addyi) antagonist dose
Bremelanotide50,51 Melanocortin 3 and 4 1.75-mg
(Vyleesi) receptor agonist subcutaneous
injection
182 Wheeler and Guntupalli Female Sexual Dysfunction
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
sible medications or underlying conditions that may
affect ability to achieve orgasm. Specific suggestions
include lubricants, specific positions, and modifica-
tions to sexual encounters that may assist in ability
to achieve orgasm. Finally, intensive therapy includes
referral to a sex therapist to further evaluate and treat
possible sources of the dysfunction, including tools to
decrease anxiety around sex and the use of sensate
focus exercises, depending on the needs of the cou-
ple.27 Women who have never had an orgasm in any
context tend to be younger and have less experience
with sexual activity. This is in contrast to women with
acquired anorgasmia, for whom it is critical to deter-
mine the context of the change, including medical,
psychological, and relational factors.52
Treatment of female orgasmic dysfunction is
predominantly cognitive and behavioral, along with
psychoanalytic therapy. Education is a key compo-
nent of intervention for female orgasmic disorder.
This includes education about anatomy and physiol-
ogy, variations in sexual response, and forms of
stimulation used to reach orgasm.52 Directed mastur-
bation, which includes a series of exercises focused on
self-awareness and exploration, is intended to
improve comfort with the erotic areas of the body.52
Sensate focus, as described for female sexual interest
and arousal disorder, is also used for female orgasmic
disorder. Additionally, a single-arm, prospective study
has evaluated the use of vibratory stimulation for
women with arousal and orgasmic disorders and dem-
onstrated increased lubrication, orgasm, and genital
sensation after 3 months of use in the majority of
patients.53 Thus, the use of vibrators may be consid-
ered in conjunction with cognitive therapeutic support
and more directive sexual therapy techniques such as
directed masturbation and sensate focus.
Genitopelvic Pain and Penetration Disorder
Treatment of genitopelvic pain and penetration dis-
order is dependent on the underlying etiology, if one
is identified. Genitourinary syndrome of menopause
Side Effects
fatigue, dry mouth, nausea
Hypertension, bradycardia, nausea, flushing, headache,
injection site reactions
OBSTETRICS & GYNECOLOGY
affects more than 50% of midlife and older women
and is the most common cause of genitopelvic pain
and penetration disorder in postmenopausal
women.54 Previously known as vulvovaginal atrophy,
genitourinary syndrome of menopause is considered
to be more medically accurate and all-encompassing
of the genitourinary changes seen with menopause.54
Genitourinary syndrome of menopause is defined as “a
collection of symptoms and signs associated with
a decrease in estrogen and other sex steroids involv-
ing changes to the labia majora/minora, clitoris, ves-
tibule/introitus, vagina, urethra and bladder.the
syndrome may include but is not limited to genital
symptoms of dryness, burning, and irritation; sexual
symptoms of lack of lubrication, discomfort or pain,
and impaired function; and urinary symptoms of
urgency, dysuria and recurrent urinary tract infec-
tions.”54 Atrophic vaginitis may also be seen when
bacterial overgrowth is noted in the setting of genito-
urinary syndrome of menopause.
Vulvovaginal atrophy may also be seen in post-
partum women and in women taking antiestrogenic
medication. Findings on physical examination includ-
ing thinning of the vaginal mucosa, loss of labial
fullness, and loss of vaginal rugae, or a vaginal pH of
4.5 or greater (if no infection), are consistent with
atrophy.
Patients with genitourinary syndrome of meno-
pause or other forms of vulvovaginal atrophy may be
treated with vaginal moisturizers, such as Replens
(Glycerin-Min Oil-Polycarbophil) or KY Liquibeads,
and lubricants, such as KY or Pjur, all available over-
the-counter or online. Vaginal moisturizers and lu-
bricators appear to be effective for many women and
are recommended as the first line of therapy. Vaginal
estrogen often serves as the second line. It is started at
a low dose, with the intention to decrease systemic
absorption. Vaginal estrogen may be delivered as
estradiol (E2) tablets (10 micrograms E2), E2 ring (7.5
micrograms E2 daily, released over 90 days), E2
cream (100 micrograms E2/g of cream), or conjugated
estrogen cream (0.625 mg conjugated estrogens/g of
cream). For the E2 tablet and cream, a 2-week priming
period is recommended, with daily followed by twice-
weekly dosing. A randomized controlled trial evalu-
ated vaginal moisturizers, vaginal estrogen, and pla-
cebo and found no difference between the three arms
in reduction of vulvovaginal symptoms.55 However,
there is some critique of this study, because the vagi-
nal estrogen and moisturizer were dosed together and
generally the nonhormonal approach is trialed before
starting estrogen-based therapy. Additionally, the pla-
cebo gel may have had some therapeutic effect.
VOL. 136, NO. 1, JULY 2020
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Vaginal estrogen is thought to have minimal
systemic absorption and, thus, may be used in patients
with a history of hormone-sensitive cancers if non-
hormonal options are not effective, though this should
be discussed with the patient’s oncologist before initia-
tion.56,57 Topical aqueous lidocaine (4%, applied for
3 minutes before vaginal penetration) has been evalu-
ated in postmenopausal women with hormone-
sensitive breast cancer with good effect and serves as
another nonhormonal option for control of genitouri-
nary syndrome of menopause symptoms.58 Addition-
ally, vaginal estrogen is considered safe in women with
hereditary breast and ovarian cancer syndrome who
have undergone risk-reducing salpingo-oophorectomy
if nonhormonal options are not effective.
Intravaginal dehydroepiandrosterone (DHEA)
has been studied both in preclinical and clinical
settings on objective and subjective measures of
vulvovaginal atrophy. A randomized, double-blind,
placebo-controlled phase III trial evaluated vaginal
DHEA (0.50%, 6.5 mg) compared with placebo and
demonstrated improvement in both objective meas-
ures of vulvovaginal atrophy and decreased pain with
sexual activity with vaginal DHEA.59 The only noted
side effect was vaginal discharge, reported in 6% of
participants.59
Beyond vaginal therapy, ospemifene is a recently
FDA-approved selective estrogen receptor modulator
that is delivered orally (60 mg/d), functions as an
estrogen agonist in the vagina, and has been found to
be efficacious in treating vulvovaginal atrophy com-
pared with placebo.60 The most frequently noted side
effect was hot flushes at 6.6%.60 Given the agonistic
effects on the endometrium, the FDA currently rec-
ommends using an opposing progestin when giving
ospemifene if the patient still has a uterus, although
this has not been evaluated in randomized trials.27
Vulvar dermatoses can also cause genitopelvic
pain and penetration disorder. A complete review of
vulvar dermatoses is beyond the scope of this review,
but three conditions to be familiar with are lichen
sclerosis, lichen planus, and vulvodynia or vestibulitis.
Lichen sclerosis is an inflammatory process that
predominantly effects the labia, leading to discolor-
ation and agglutination of the vulvovaginal tissue.
Dyspareunia is often a later symptom, preceded by
pain and pruritis. Lichen sclerosis can lead to fissuring
and scarring, ultimately causing pain. Treatment with
potent topical steroids improves symptoms and
decreased progression of the disease.27,61 Lichen pla-
nus is another dermatosis caused by chronic irritation
that can lead to stenosis of the vagina and dyspareu-
nia. Patients will present with vulvar pain or pruritis
Wheeler and Guntupalli Female Sexual Dysfunction 183
and may have erythematous lesions or a reticular pat-
tern on examination. Treatment includes avoidance of
irritants and potent topical steroids. Finally, vulvody-
nia may be diagnosed if other vulvar etiologies are
ruled out. It is often a sensitivity or burning, fre-
quently noted at the vestibule or introitus, that can
be diagnosed with directed cotton swab palpation.
When localized to the vestibule, this may be consid-
ered vestibulitis. Vulvodynia and vestibulitis can be
treated with topical lidocaine ointment (5%) applied
before intercourse.27
Finally, a proper history, physical examination,
and indicated testing should be performed to evaluate
for other potential causes of genitopelvic pain and
penetration disorder, including endometriosis, leio-
myomas, prolapse, posttreatment scarring, new gyne-
cologic malignancy, and infectious processes. If all of
these causes are ruled out, the patient may be
diagnosed with and treated for genitopelvic pain and
penetration disorder. This often requires a multidisci-
plinary approach, with ob-gyns, psychologists, and
pelvic floor physical therapists. Pelvic floor physical
therapists may be able to assist with desensitization
techniques and dilator exercises.27
Substance- or Medication-Induced
Sexual Dysfunction
For substance- or medication-induced sexual dysfunc-
tion, cessation of the implicating agent should improve
sexual function if it is definitively the underlying
etiology. However, if a patient has a good response in
mood to an antidepressant that is also causing sexual
side effects, adjunctive therapy with sildenafil could be
considered because it has been shown to have benefit.43
A prospective, randomized, double-blind, placebo-con-
trolled clinical trial evaluated women who had improve-
ment of their depressive symptoms on serotonin re-
uptake inhibitors but continued sexual dysfunction.43
Forty-nine patients were randomized to sildenafil or pla-
cebo before sexual activity; a reduction in sexual side
effects was found in patients who received sildenafil.43
Given the mechanism and existing data, sildenafil may
play a role in treatment for patients with either
antidepressant–induced sexual dysfunction or specific
sexual arousal dysfunction.40Another option would be
discussing transition to bupropion, given generally
improved sexual functioning with this agent, though this
requires a transition of antidepressant.
CONCLUSIONS
Female sexual dysfunction is a multifaceted medical
problem that has a high prevalence. It is the respon-
sibility of ob-gyns to screen women for sexual
184 Wheeler and Guntupalli Female Sexual Dysfunction
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
dysfunction. If sexual dysfunction is identified and
confirmed to be distressing to the patient, a further
evaluation into the etiology and exacerbating factors
of the disorder is indicated. Psychotherapy is a cor-
nerstone for treatment of female sexual interest and
arousal and orgasmic disorders. In some scenarios,
pharmacologic interventions may be indicated for
female sexual interest and arousal disorder. When
considering genitopelvic pain and penetration disor-
der, determination of the underlying etiology is
paramount, followed by appropriate treatment. Refer-
ral to specialty centers as well as employing therapists
trained in the management of sexual dysfunction are
vital to the treatment of this spectrum of disorders.
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PEER REVIEW HISTORY
Received February 10, 2020. Received in revised form April 8,
2020. Accepted April 16, 2020. Peer reviews and author correspon-
dence are available at http://links.lww.com/AOG/B909.
CME FOR THE CLINICAL EXPERT SERIES
Learning Objectives for “Female Sexual Dysfunction:
Pharmacologic and Therapeutic Interventions”
After completing this learning experience, the involved learner
should be able to:
• Discuss the prevalence of female sexual dysfunction, including
female sexual interest and arousal disorder
•
Differentiate female orgasmic disorder, genitopelvic pain and penetration
disorder, and substance- and medication-induced sexual dysfunction
• Outline effective screening strategies for these disorders
• Institute appropriate and effective therapies for patients so affected
Instructions for Obtaining AMA PRA Category 1 Credits
Continuing Medical Education credit is provided through joint
providership with The American College of Obstetricians
and Gynecologists.
Obstetrics & Gynecology includes CME-certified content that is designed
to meet the educational needs of its readers. This article is certified for 2
186 Wheeler and Guntupalli Female Sexual Dysfunction
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
AMA PRA Category 1 Credits. This activity is available for credit
through July 31, 2023.
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nates this journal-based CME activity for a maximum of 2
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credit commensurate with the extent of their participation in the
activity.
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The American College of Obstetricians and Gynecologists desig-
nates this journal-based CME activity for a maximum of 2
Category 1 College Cognate Credits. The College has a reciprocity
agreement with the AMA that allows AMA PRA Category 1 Cred-
its to be equivalent to College Cognate Credits.
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committee members have signed a conflict of interest statement in
which they have disclosed any financial interests or other relation-
ships with industry relative to article topics. Such disclosures allow
the participant to evaluate better the objectivity of the information
presented in the articles.
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cology and complete the quiz, answering at least 70 percent of the
questions correctly. For more information on this CME educational
offering, visit the Lippincott CMEConnection portal at https://cme.
lww.com/browse/sources/196 to register and to complete the CME
activity online. ACOG Fellows will receive 50% off by using cou-
pon code, ONG50.
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available for credit through July 31, 2023. To receive proper
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that the information on their profile for the CME platform (where
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and day only) and 2) their ACOG ID. In addition, participants
should select that they are board-certified in obstetrics and
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Editorial Office, 202-314-2,317 or obgyn@greenjournal.org. For
queries related to the CME test online, please contact ceconnection@
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OBSTETRICS & GYNECOLOGY