What Is Female Sexual Dysfunction? Types, Symptoms and Treatment

Sexual problems are common, and most of them are not a disorder. In the PRESIDE study of more than 31,000 US women, 43% reported some sexual problem, but only about 12% said the problem also caused them significant distress (Shifren et al., 2008). That second group is what clinicians mean by female sexual dysfunction. The distinction matters: a change in your sex life is only a medical problem if it bothers you.

By the numbers

Sexual problems vs. sexual dysfunction (PRESIDE)

43%of US women reported some sexual problemSource: Shifren 2008

~12%said the problem also caused significant distressSource: Shifren 2008

What counts as female sexual dysfunction?

Clinicians generally diagnose FSD when a sexual problem:

• has lasted for several months or keeps coming back,
• causes you personal distress, and
• is not fully explained by another medical or mental health condition, a medication, substance use or serious relationship conflict.

The American College of Obstetricians and Gynecologists recommends that clinicians ask about sexual concerns as part of routine care, and that evaluation include a medical, sexual and psychosocial history plus a physical exam when there is pain (ACOG Practice Bulletin 213). In practice many women have to raise it themselves; our guide on how to talk to your doctor about low libido can help.

What are the four types of female sexual dysfunction?

Hypoactive sexual desire disorder (HSDD)

HSDD is the most common type. It describes persistently low desire that causes distress. Many women in long relationships have responsive desire, interest that builds after touch begins rather than before, and that is normal. HSDD is when desire doesn't show up in either way and you are unhappy about it (Clayton et al., 2018).

Female sexual arousal disorder

Arousal disorder is when you feel mentally interested but your body doesn't follow: lubrication, genital swelling and sensitivity are reduced or slow. It often overlaps with low estrogen after menopause, and with conditions that affect blood vessels or nerves.

Female orgasmic disorder

Orgasms that are markedly delayed, less intense or absent, despite enough arousal and stimulation, count as orgasmic disorder when they cause distress. SSRI and SNRI antidepressants are a frequent and under-recognized cause (Clayton et al., 2014).

Genito-pelvic pain/penetration disorder

This covers pain with sex, fear of pain, and involuntary tightening of the pelvic floor muscles that makes penetration difficult or impossible. After menopause the most common cause is genitourinary syndrome of menopause, which is very treatable (2020 GSM position statement). Pelvic floor tension is another frequent driver; see pelvic floor issues and sex.

Symptoms of female sexual dysfunction: a checklist

Consider talking to a clinician if, for several months, you notice any of the following and it bothers you:

• You rarely or never think about sex or want it, and miss that part of yourself.
• You avoid intimacy or make excuses to skip it.
• You feel interested but your body stays dry or unresponsive.
• You need much more stimulation than before, or genital sensation feels muted.
• Orgasm has become much harder, weaker or has stopped.
• Sex causes pain, burning, or a feeling of hitting a wall at the vaginal opening.
• You tense up or feel anxious before sex because you expect pain or disappointment.
• The change is causing distress for you or strain in your relationship.

What causes female sexual dysfunction?

FSD usually has more than one cause. A useful way to think about it is biological, psychological, relationship and cultural factors all feeding into one another (Parish et al., 2019).

Hormonal and life-stage changes

Falling estrogen in perimenopause and after menopause thins vaginal tissue and reduces lubrication; after childbirth and while breastfeeding, estrogen is also temporarily low. Surgical menopause, oral contraceptives and some cancer treatments also change hormone levels. Our guide to how hormones affect sexual desire explains each hormone's role, and low libido after menopause covers the midlife picture.

Medical conditions and medicines

Diabetes, heart and vascular disease, thyroid disorders, multiple sclerosis, pelvic surgery, cancer and chronic pain can all affect sexual response. Antidepressants (especially SSRIs and SNRIs), some blood pressure medicines, anti-seizure drugs, opioids and anti-androgens commonly lower desire, arousal or orgasm.

Psychological factors

Depression, anxiety, past trauma, body image concerns and chronic stress all press the brain's "brakes" on desire.

Relationship and lifestyle factors

Conflict, poor communication, a partner's sexual problems, exhaustion, poor sleep, alcohol and lack of privacy all matter. These factors are real causes, not excuses, and they respond to real treatment.

How is female sexual dysfunction treated?

Treatment matches the type and the causes. Most women do best with more than one step.

Addressing the basics

• Lubricants and vaginal moisturizers for dryness and friction.
• Medication review: a clinician may lower a dose, switch drugs or add a treatment. Do not stop a prescribed medicine on your own.
• Sleep, exercise and stress management, which affect desire and arousal directly.

Therapy

Sex therapy, couples therapy and cognitive behavioral therapy help with desire, orgasm and pain-related fear. Mindfulness-based programs have improved desire, arousal and sexual distress in trials (Brotto et al., 2008). Pelvic floor physical therapy is a core treatment for pain and muscle tension.

Hormonal treatments

Low-dose vaginal estrogen or vaginal DHEA treat pain and dryness from menopause. Systemic hormone therapy treats hot flashes and sleep disruption and can improve comfort. For postmenopausal women with HSDD, international guidance supports a trial of transdermal testosterone under supervision (Davis et al., 2019).

Prescription desire treatments

Two medicines are FDA-approved for HSDD: Addyi (flibanserin), a daily pill approved for women under 65, and Vyleesi (bremelanotide, or PT-141), an injection used before sex. In Vyleesi's phase 3 trials, desire improved and distress fell modestly compared with placebo, and nausea was the most common side effect (Kingsberg et al., 2019). Compare them in PT-141 vs. Addyi.

Clinicians may also consider compounded or off-label options. Amie's Blys is a compounded rapid-dissolve tablet with PT-141 (bremelanotide), oxytocin and tadalafil, taken 30–60 minutes before intimacy for low desire and arousal, and designed with women on antidepressants in mind. It is not FDA-approved, and the combination has not been studied in large trials. Because it contains tadalafil, it must never be used with nitrate medicines. A licensed clinician reviews your health history and medicines to decide whether it is appropriate.

Getting help