Treating Female Sexual Dysfunction
A foundation for treating sexual concerns includes:
- Using the PLISSIT model for history-taking and therapy
- Facilitating patient and partner education
- Identifying and treating medical conditions that may contribute
- Considering medication and substance use (both current and past) as a possible causative role, and resolving appropriately
- Providing sexual counseling, coaching, and intensive sex therapy, when indicated
The following illustration provides an overview of interventions used in the treatment of patients with a female
sexual complaint or dysfunction.
NOTE: Click on one the treament methods for more information.
TREATMENT FOR FEMALE SEXUAL DYSFUNCTION MEETING DSM-IV-TR CRITERIA
Treatment of patients who meet the DSM-IV-TR criteria for female sexual dysfunction requires an individualized approach and may include a combination of counseling (office-based advice), cognitive-behavioral interventions, pharmacotherapy, and treatment of concomitant medical or psychiatric conditions.
Most front-line health care professionals enlist the help of a qualified specialist, including sexuality counselors and sex therapists, to care for patients with DSM-IV-TR sexual dysfunction (see “When and How to Refer”).
Pharmacologic treatments address physiologic needs, imbalances, or symptomatic complaints, and comprise only one part of the overall management of patients with female sexual disorders.
At the time of this writing, the only pharmacologic treatment approved by the U.S. Food and Drug Administration for the treatment of any female sexual disorder is conjugated equine estrogen (Premarin Vaginal Cream®) for the treatment of moderate to severe dyspareunia due to menopause.
TREATING HYPOACTIVE SEXUAL DESIRE DISORDER
Desire is a relatively complex concept that comprises 3 distinct but interrelated components.
- Drive: biologic component based on neuroendocrine mechanisms and evidenced by spontaneous sexual interest (i.e., feeling “horny”)
- Cognitive: reflects person’s expectations, beliefs, and values related to sex
- Motivation (emotional/interpersonal): willingness of a person to engage in sexual activity
Delineating the components of desire is essential because treatment approaches differ based on which component or components of desire are impaired. Treatment options include:
- Individual cognitive behavioral therapy and/or couples sex therapy
- Hormone therapy (e.g., exogenous testosterone replacement, DHEA-S)
- Centrally acting pharmacologic agents that may positively impact sexual functioning
TREATING SEXUAL AVERSION DISORDER
Sexual aversions may be general or very specific and can develop in response to any sexual stimulus, overt or covert.
- Aversion versus desire: aversion is a phobic avoidance and or revulsion of sexual activity whereas HSDD is about loss of desire and not an aversion to sex (although it may ultimately develop)
It is important to distinguish events that may have initiated aversion and current behavior that may reinforce the aversion response. Treatment is based on a graduated exposure paradigm.
- Behavioral therapy follows from the conceptualization
- Relaxation exercises with graded and patient-controlled reintroduction of sexual behavior (e.g., Yoga meditation, rhythmic breathing, music therapy, guided imagery)
- Pharmacotherapy (used to facilitate behavioral therapy)
TREATING FEMALE SEXUAL AROUSAL DISORDER
A thorough sexual history is essential in making an accurate diagnosis. Although not listed in the DSM IV-TR, many sexual medicine experts would suggest that arousal disorder is best understood by subtypes:
- Generalized: no subjective awareness of genital or overall arousal and no lubrication/vasocongestion or increased heart rate
- Missed arousal: genital engorgement present but no awareness
- Genital arousal: subjective excitement is present but no genital engorgement
There is significant overlap with arousal and orgasmic disorders, and distinguishing between the two may be difficult.
More randomized clinical trials are needed to evaluate the efficacy of treatment options for female sexual arousal disorder. Current options include:
- Self stimulation and masturbation, sensate focus exercises coupled with improving communication with partners— sexual accessories may be adjunctive aids as well as sexual education to understand genitor-pelvic anatomy and sexual response
- Medical intervention:
- Mechanical (EROS clitoral stimulator, vacuum device)
- Hormonal (systemic or local estrogen therapy for arousal disorder acquired after menopause)
- Pharmacologic (nitric oxide promoters)
- Over-the-counter-lubricants, feminine arousal oil (e.g., Zestra® Essential Arousal OilsTM), and/or long-acting
TREATING FEMALE ORGASMIC DISORDER
The etiology of orgasmic problems is likely multifactorial, including physiologic and psychosocial factors. Treatment options include:
- Cognitive-behavioral approaches that alter negative attitudes and reduce anxiety
- Permission-given by the clinician to:
- Become educated about sexual response including orgasmic response
- Practice and explore self-stimulation/masturbation in privacy
- Use fantasy, erotic literature, and/or self stimulators or vibrators to heighten arousal
- Practice sensate focus exercises
Dyspareunia is often viewed as a specific pain disorder with independent psychologic and biologic contributors with context-dependent etiologies. Physical examination may be required to rule out underlying anatomic pathology. Specific testing, including pelvic sonogram and vulvoscopy, may be useful in certain situations.
- Differential diagnosis: introital dyspareunia, vaginismus, vulvovaginal atrophy, inadequate lubrication, vulvodynia, deep dyspareunia, endometriosis, pelvic inflammatory disease
- Assess/consider concurrent psychologic or behavioral contributions via sexual history
Treatment options include treating the underlying physiologic or psychologic source of the pain:
- Anti-irritant hygiene program
- Vulvovaginal atrophy
- Topical/local estrogen preparations (tablets, creams, rings)
- Premarin® Vaginal Cream is FDA-approved to treat moderate-to-severe postmenopausal dyspareunia
- Burning pain (indicative of neuroproliferation)
- Low-dose tricyclic antidepressants (e.g., amitriptyline), SSRIs (e.g., duloxetine), or anticonvulsants (e.g., gabapentin)
- Pelvic floor myofascial pain and guarding of pelvic floor muscle
- Refer for manual pelvic floor muscle physical therapy (visit www.APTA.org for qualified and trained pelvic floor specialist/provider)
- Low-dose muscle relaxing agent (e.g., cyclobenzaprine, diazepam)
- Anxiety management and coping
- Refer for cognitive behavioral therapy
- Referral for couples sexual counseling/therapy to explore non-penetrating pleasuring techniques (as appropriate)
Vaginismus is persistent difficulty to allow vaginal entry of a penis, finger, or any object despite the express wish to do so.
Important considerations during assessment:
- Vaginismus may be limited to sexual activity and may not be seen during a pelvic examination
- Vaginismus may occur due to fear of pelvic examinations, but not impact sexual activity
Treatment is based on a combination of cognitive and behavioral psychotherapeutic approaches to desensitize the woman to her anxiety/panic and help achieve a sense of control over a sexual encounter or a pelvic examination, and an understanding that she is no longer in danger of experiencing pain. Treatment options may include:
- Cognitive behavioral therapy
- Pelvic floor physical therapy
- Relaxation training with systemic desensitization using graduated vaginal dilators to help gain control over and relax muscles and stretch the vagina
Sexuality counselors and sex therapists typically treat patients with desire, arousal, performance, and satisfaction
issues. They also counsel patients and their partners who have experienced sexual trauma or abuse, or those
who may be struggling with gender identity or sexual orientation issues, fetishes, sexual pain, or sexual
Qualified specialists, including sex therapists, offer a variety of interventions that may help a patient reconnect
emotionally and sexually with their partner(s). Some common strategies include:
- Helping patients develop realistic and appropriate expectations
- Identifying contextual catalysts for sexual activity and helping patients gain awareness of positive sexual cues/triggers
- Assigning sensate focus exercises that help individuals and couples desensitize to sexual activity that causes anxiety or avoidance and increase non-demanding pleasure
- Teaching the practice of mindfulness
- Exploring alternate forms of sexual expression
- Addressing sexual boredom
- Discussing the use of lubricants, moisturizers, dilators, vibrators, and sexual enhancers. For more information, click here.