Classifying dysfunction. Disorders of female sexual function are divided into 4 areas, described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (Table 1). They are:
- disorders of libido, which are central in origin, i.e., they originate in the brain and central nervous system;
- disorders of arousal, which are presumably peripheral/physical (frequently caused by vascular disease and diabetes limiting the vascular supply to the genitalia, or by estrogen deficiency);
- an inability to achieve orgasm; and
- pain disorders.
This division, while not necessarily inaccurate, overlooks the complexity of female sexuality. In women, the libido is better described as a striving for emotional closeness and intimacy rather than simply the sexual drive. Women have fewer spontaneous sexual thoughts and fantasies throughout the biological life span than men and are often unaware of or inattentive to signs of their own physical arousal.5-8 Environmental signals such as romance, a feeling of being cherished, and emotional closeness are more likely to call their attention to physical sensations.
A new model. Trying to assess female sexual complaints using only a biological model is unlikely to be successful. The social environment, hormones, drugs, physical abnormalities, and women’s deep psychological issues all have an impact on their sexual encounters. Thus, I find a biopsychosocial model more useful for assessing complaints. I typically explore 4 areas: physical, psychological, relational, and situational. Using these categories of inquiry, I am able to address the complexities of my patients’ complaints and assess each component of sexual dysfunction in the DSM-IV classification.
Disorders of libido or desire. A lack of desire for sex is the most common sexual complaint and the most difficult to assess quickly. It is typically further classified as either hypoactive sexual desire disorder (HSDD) or sexual aversion disorder (SAD). The first is a deficiency or lack of sexual fantasies or thoughts and/or the desire for sexual activity, while SAD is a phobic aversion to and avoidance of sexual contact with a partner.9 HSDD may be caused by psychological or emotional factors or be secondary to endocrine disorders or other medical problems. In contrast, SAD is usually psychological or emotional in origin, frequently deriving from physical or sexual abuse or childhood trauma.
Often the problem may be related to differing expectations between partners regarding the frequency of their desire for sexual contact. Some people are very happy with weekly or monthly sex, while others think 3 times a day is not enough! And despite media hype to the contrary, decreased interest in sexual activity is rarely caused by a hormonal imbalance. Although testosterone levels decline with age, natural menopause does not trigger a dramatic alteration in them. At menopause, estrogen levels decline much more rapidly than ovarian androgen production, decreasing sex hormone binding globulin (SHBG) and effectively increasing free testosterone levels. However, during the perimenopausal anovulatory time frame, as well as with oral estrogen therapy, SHBG is increased, which may reduce free testosterone levels and contribute to a noticeable and rapid decrease in sexual desire in some circumstances.
Premenopausal women may note decreased libido when taking oral contraceptives (OCs) or other medications that suppress ovarian androgen production. However, in these women, the adrenals remain a source of androgen, which may explain why decreased libido is not a universal complaint in this population. Chronic anxiety, stress (both physical and emotional), depression, chronic pain, and longstanding insomnia all deplete the adrenals and are associated with a decrease in libido. Androgen replacement is rarely successful in these patients.
I usually begin my evaluation by asking the patient if she has experienced discomfort with sexual activity. If she reports that sex has become painful when it wasn’t in the past, a careful physiologic assessment is indicated. I look for genital atrophy, tearing, and vaginismus when evaluating patients with decreased sexual desire.
Relational and situational factors are extremely important in evaluating complaints of diminished libido. Many women are exhausted by their roles as mother, daughter, spouse, and productive member of the workforce. Thus, an assessment of the patient’s social situation is critical. Professional counseling may be required to help women learn to limit their commitments and accept the need for “downtime.”
Management strategies for patients with diminished libido incorporate correction of any vulvar and vaginal atrophy, counseling to improve communication between the patient and her partner, and the identification and treatment of any underlying psychiatric problems. The addition of testosterone may be useful for patients on OCs or oral hormone replacement therapy (HRT) and women with surgical menopause or menopause secondary to chemotherapy.9 In other patients with low libido, the benefit of testosterone is less clear. I prefer compounded 1% or 2% testosterone in PLA cream or petrolatum (depending on whether the patient prefers a cream or an ointment). Patients should apply 1/8 teaspoon to thin skin daily. The ointment may be smoothed directly on the genitalia for added lubrication and rapid improvement in atrophic symptoms. Women who are survivors of domestic and/or sexual abuse will require psychotherapy by a trained counselor.