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Female sexual arousal disorder (FSAD) is a disorder characterized by a persistent or recurrent inability to attain sexual arousal or to maintain arousal until the completion of a sexual activity. The diagnosis can also refer to an inadequate lubrication-swelling response normally present during arousal and sexual activity. The condition should be distinguished from a general loss of interest in sexual activity and from other sexual dysfunctions, such as the orgasmic disorder (anorgasmia) and hypoactive sexual desire disorder, which is characterized as a lack or absence of sexual fantasies and desire for sexual activity for some period of time.
Causes of Female Sexual Arousal Disorder
Contrary to popular belief, the disorder is not always caused by a lack of sexual arousal. Possible causes of the disorder include psychological and emotional factors, such as depression, anger, and stress; relationship factors, such as conflict or lack of trust; medical factors, such as depleted hormones, reduced regional blood flow, and nerve damage; and drug use. The lack of sexual arousal may be due to a general lack of sexual desire or due to a lack of sexual desire for the current partner (i.e., situational). A person may always have had no or low sexual desire or the lack of desire may have been acquired during the person’s life.
Illnesses that may result in loss of sexual desire
- Gynecological disorders causing pain on sexual intercourse
- Obstetric disorders causing pain on sexual intercourse
- Urological disorders causing pain on sexual intercourse
- Alcohol and substance misuse
- Stress and chronic anxiety
- Endocrine disorders
- Neurological disorders
- Psychiatric disorders
- Depression
- Fatigue
Common psychotropic classes causing sexual dysfunction
TRICYCLIC ANTIDEPRESSANTS |
|---|
| Adapted from Crenshaw TL, Goldberg JP. Sexual Pharmacology: Drugs That Affect Sexual Functioning. New York, NY: W. W. Norton & Company, 1996. |
| Mechanism of action (general) |
|
| Mechanism of action (sexual) |
| Positive Increased adrenergic α1 activity Decreased cortisol |
| Negative Decreased β–adrenergic activity Decreased cholinergic activity Decreased histamine Decreased oxytocin Increased prolactin Increased serotonin |
| Direct sexual side effects* |
| Desire disorders Dyspareunia Erection difficulties |
| Orgasm disorders Orgasmic inhibition Anorgasmia Spontaneous orgasm |
| Ejaculation disorders Retarded ejaculation Ejaculation without orgasm Anesthetic ejaculation |
| MONOAMINE OXIDASE INHIBITORS |
| Mechanism of action (general) |
|
| Mechanism of action (sexual) |
| Positive Increased adrenergic α1 activity Decreased monoamine oxidase |
| Negative Decreased β-adrenergic activity Decreased cholinergic activity Increased prolactin Increased serotonin Decreased testosterone |
| Direct sexual side effects* |
| Desire disorders Erection difficulties |
| Orgasm disorders Orgasmic inhibition Decreased number |
| Ejaculation disorders Retarded, inhibited premature ejaculation diminished |
| SELECTIVE SEROTONIN REUPTAKE INHIBITORS |
| Mechanism of action (general) |
|
| Mechanism of action (sexual) |
| Negative Increased cortisol Increased opioids Increased prolactin Increased serotonin (5-HT) |
| Direct sexual side effects |
| Desire disorders Hyposexuality Hypersexuality |
| Orgasm disorders Orgasmic inhibition Anorgasmia Spontaneous orgasm |
| Ejaculation disorders Retarded ejaculation Ejaculatory inhibition |
| Erection disorders Inability/difficulty obtaining an erection Decreased quality of erection Decreased or absent nocturnal/morning erections |
| ANTIPSYCHOTICS |
| Mechanism of action (general) |
|
| Mechanism of action (sexual) |
| Negative Decreased adrenergic ·1 activity Decreased cholinergic activity Decreased dopamine Increased prolactin Decreased testosterone Decreased LHRH pulsatile activity |
| Direct sexual side effects |
| Desire disorders Hyposexuality Hypersexuality (rare) |
| Orgasm disorders Orgasmic inhibition Anorgasmia The diminished number of orgasms |
| Ejaculation disorders Retarded ejaculation Ejaculatory inhibition Decreased ejaculatory volume Anesthetic ejaculation Orgasm without ejaculation Dyspareunia |
| Erection disorders Inability/difficulty obtaining an erection Decreased quality of erection Priapism |
* Desipramine appears to have the least amount of sexual side effects of the TCAs
Symptoms of Female Sexual Arousal Disorder
- Decreased sexual desire. You may begin to lose interest in sex. While this can be due to lack of arousal, it may also be a symptom of stress and anxiety from having FSIAD.
- Few thoughts related to sex. You may rarely think about sex.
- Less initiation of sexual activity. You may not initiate sex and may be unreceptive to a partner’s attempts to initiate sex.
- Decreased sexual excitement or pleasure during sex. Sexual stimulation or other things that used to turn you on no longer do.
- Reduced arousal from internal or external sexual cues. You may no longer be aroused by cues like psychological intimacy, reading about enjoyable sex, or recalling an erotic fantasy.
- Lack of genital or nongenital sensations during sex. When having sex, you might not feel much in your genital area or other erogenous zones.
Diagnosis of Female Sexual Arousal Disorder
DSM-5
The DSM-5 lists the diagnostic criteria as including a minimum of three of the following:[rx]
- Little interest in sex
- Few thoughts related to sex
- Decreased start and rejecting of sex
- Little pleasure during sex most of the time
- Decreased interest in sex even when exposed to erotic stimuli
- Little genital sensations during sex most of the time
DSM-IV
The DSM-IV (American Psychiatric Association 1994) diagnostic criteria were:
persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement,[rx]
- the disturbance causes marked distress or interpersonal difficulty, and
- the sexual dysfunction is not better accounted for by another Axis I disorder (except another sexual dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
Marita P. McCabe noted:
Difficulties arise with this definition in terms of what constitutes an adequate lubrication-swelling response. There is no “gold standard” regarding the length of time it should take to become aroused or the level of arousal that should be achieved. These responses may vary from one woman to another and are dependent on a range of factors, which include her general mood when sexual stimulation commences and her partner’s skill in stimulating her. There may also be differences in physiological and subjective levels of arousal, with some women reporting no feelings of sexual arousal despite evidence of vaginal vasocongestion and others reporting arousal in the absence of such evidence. The expectations and past experiences of clinicians and clients may also lead them to classify the same symptoms as female sexual arousal disorder in one woman but not in another.[rx]
Subtypes
There are several subtypes of female sexual arousal disorders. They may indicate onset: lifelong (since birth) or acquired. They may be based on context: they may occur in all situations (generalized) or be situation-specific (situational). For example, the disorder may occur with a spouse but not with a different partner.
The length of time the disorder has existed and the extent to which it is partner- or situation-specific, as opposed to occurring in all situations, may be the result of different causative factors and may influence the treatment for the disorder. It may be due to psychological factors or a combination of factors.
Treatment of Female Sexual Arousal Disorder
The FDA has approved flibanserin[rx] and bremelanotide[rx] for low sexual libido in women.
Depending on the cause of the disorder, hormone therapy or a blood-flow enhancing medication, like Viagra, may be appropriate.
Bremelanotide (formerly PT-141) is being studied in clinical tests to increase sexual desire in women. In 2014, Palatin, the company developing the drug, announced the beginning of Phase 3 clinical trial to determine its effectiveness.[rx]
Pharmacotherapy
Multiple hormones have been studied for the treatment of sexual desire disorders. For example, androgen replacement has been studied as a possible treatment for HSDD. “In patients with induced or spontaneous hypogonadism, either pathological withdrawal and re-introduction or exogenous androgens affect the frequency of sexual fantasies, arousal, desire, spontaneous erections during sleep and in the morning, ejaculation, sexual activities with and without a partner, and orgasms through coitus and masturbation.”[rx]
Unfortunately, the evidence for the efficacy of testosterone in eugonadal men is conflicting. Some studies show no benefit,[rx] whereas other studies do show some benefit. For example, a study by O’Carroll and Bancroft showed that testosterone injections did have efficacy for sexual interest, but unfortunately this did not translate into an improvement in their sexual relationships.[rx]
One theory for the lack of efficacy in eugonadal men is that it is more difficult to manipulate endogenous androgen levels with administration of exogenous androgens due to efficient homeostatic hormone mechanisms.[rx]
Androgen supplementation is available in many forms, including oral, sublingual, cream, and dermal patches. Side effects of testosterone supplementation in women include weight gain, clitoral enlargement, facial hair, hypercholesterolemia,[rx] changes in long-term breast cancer risk and cardiovascular factors.[rx] Side effects in men of androgen supplementation include hypertension and prostatic enlargement.[rx] The benefit of androgen therapy in women is also not clear.[rx] Although studies using supraphysiologic levels of androgens have shown increased sex libido, there is the risk of masculinization from chronic use.[rx]
Testosterone therapy has shown to improve sexual function in postmenopausal women in multiple ways, including increased desire, fantasy, sexual acts, orgasm, pleasure, and satisfaction of sexual acts.[rx] Roughly half of all testosterone production in women is from the ovaries.
Estrogen replacement in postmenopausal women can improve clitoral and vaginal sensitivity, increase libido, and decrease vaginal dryness and pain during intercourse. Estrogen is available in several forms, including oral tablets, dermal patches, vaginal rings, and creams. Testosterone supplementation has demonstrated increased libido, increased vaginal and clitoral sensitivity, increased vaginal lubrication, and heightened sexual arousal.[rx]
Dehydroepiandrosterone-sulfate (DHEA-S), a testosterone precursor, has also been studied for the treatment of sexual desire disorders. Low physiologic levels of DHEA-S have been found in women presenting with HSDD.[rx] Increased libido was observed in women with adrenal insufficiency who were given DHEA-S.[rx] women with breast cancer reported increased libido while receiving tamoxifen, which increases gonadotropin-releasing hormone levels and therefore testosterone concentrations.[rx]
Some medications can be used to increase desire due to their receptor profiles. For example, amphetamine and methylphenidate can increase sexual desire by increasing dopamine release. Bupropion, norepinephrine, and dopamine reuptake inhibitor has been shown to increase libido.[rx]
A study by Segraves, et al.,[rx] showed that bupropion treatment in premenopausal women increased desire, but not to a statistically significant level compared to placebo. But, the bupropion SR group did show a statistically significant difference in other measures of sexual function: increased pleasure and arousal, and frequency of orgasms. Multiple herbal remedies, such as yohimbine and ginseng root, are purported to increase desire, but this has not been confirmed in studies.[rx]
Ten myths about sex
- In general, a man should not be seen to express certain emotions
- In sex, as elsewhere, it is a performance that counts
- An erection is essential for a satisfying sexual experience
- All physical contact must lead to sex
- Sex equals intercourse
- Good sex must follow a linear progression of increasing excitement and terminate in orgasm
- Sex should be natural and spontaneous
- On the whole, the man must take charge of and orchestrate sex
- A man wants and is always ready for sex
- We no longer believe the above myths
*Adapted from Zilbergeld B. Men and sex: a guide to sexual fulfillment. London: Harper Collins, 1995
References
