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Female sexual dysfunction

What's new

The American Academy of Family Physicians (AAFP) has released a new evidence review on female sexual dysfunction. Screening is suggested during routine visits using open-ended questions, followed by thorough assessment when indicated. Mindfulness-based interventions and group cognitive behavioral therapy are suggested for sexual interest/arousal disorder and orgasmic disorders. Pelvic floor physical therapy is first-line treatment for genito-pelvic pain disorders. For genitourinary syndrome of menopause and associated dyspareunia, vaginal moisturizers and topical vaginal estrogen are recommended. Bupropion may be used as an adjunct for antidepressant-induced sexual dysfunction. .

Background

Overview

Definition
Female sexual dysfunction is a heterogeneous group of disorders characterized by persistent or recurrent difficulties in sexual desire, arousal, orgasm, or pain during sexual activity, causing significant personal distress or interpersonal difficulty.
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Pathophysiology
The pathophysiology of female sexual dysfunction is multifactorial, involving disruptions in neurovascular, hormonal, and psychological pathways that regulate sexual function. Hypoactive sexual desire may result from hormonal changes (low estrogen or androgens), neurotransmitter imbalances, or psychosocial stress. Arousal and orgasmic disorders may be associated with impaired genital blood flow, nerve dysfunction, or psychological inhibition. Sexual pain disorders, including genitopelvic pain/penetration disorder, may involve musculoskeletal dysfunction, hormonal atrophy, or anxiety-related pelvic floor hypertonicity.
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Epidemiology
Female sexual dysfunction is highly prevalent, affecting an estimated 40-50% of women at some point in their lives. About 12% experience symptoms that cause significant personal distress. Rates increase with age, with the highest prevalence observed during the perimenopausal and menopausal years, reaching 15% in women aged 45-64, compared to 10% in those aged 18-44 and 9% in those aged 65-85. Hypoactive sexual desire disorder is the most common subtype, followed by arousal and orgasmic difficulties. Cultural, demographic, and methodological differences contribute to variable prevalence estimates across studies.
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Risk factors
Female sexual dysfunction is influenced by a combination of biological, psychological, relational, and sociocultural factors. Risk factors include advancing age, menopause, hormonal changes, chronic medical conditions (such as diabetes, CVD, depression), medication use (such as SSRIs, chemotherapeutic agents, opioids, psychotropic drugs, antiepileptics, antihistamines, and antihypertensives), prior sexual trauma, relationship dissatisfaction, and poor body image.
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Disease course
Female sexual dysfunction may present as low libido, difficulty with arousal, delayed or absent orgasm, or pain with intercourse. Symptoms may be lifelong or acquired and can vary in severity and frequency over time. Menopausal transition, relationship changes, and chronic illness often influence symptom development.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of female sexual dysfunction are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2025), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2021), and the American College of Obstetricians and Gynecologists (ACOG 2019).
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Diagnostic investigations

Clinical assessment
As per AAFP 2025 guidelines:
Consider screening for female sexual dysfunction at routine visits using open-ended questions.
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Elicit a thorough sexual, obstetric, and gynecologic history, including the patient's associated level of distress, to best classify their sexual dysfunction.
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  • Laboratory tests

Medical management

Management of sexual arousal disorder, testosterone
As per AAFP 2025 guidelines:
Consider offering transdermal testosterone as a short-term treatment (up to 6 months) for disorders of sexual desire and arousal in postmenopausal patients.
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Recognize that transdermal testosterone patches at a dose of 300 mcg have been studied more extensively than other forms, but they are not commercially available. Monitor patients for signs of androgen excess.
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  • Management of sexual arousal disorder (other agents)

  • Management of hypoactive sexual desire disorder

  • Management of genito-pelvic pain/penetration disorder

  • Management of genitourinary syndrome of menopause (vaginal moisturizers and estrogen)

  • Management of genitourinary syndrome of menopause (systemic estrogen)

  • Management of genitourinary syndrome of menopause (ospemifene)

  • Management of genitourinary syndrome of menopause (vaginal laser)

  • Management of antidepressant-induced sexual dysfunction

Nonpharmacologic interventions

Psychological interventions: as per AAFP 2025 guidelines, consider offering mindfulness-based interventions and group cognitive behavior therapy for female sexual interest/arousal disorder and orgasmic disorders.
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  • Lubricants and moisturizers