Female Sexual Dysfunction: Classification, Pathophysiology, and Management
Female Sexual Dysfunction: Classification, Pathophysiology, and Management
Female sexual dysfunction is a prevalent problem in the general community; however, it has not been studied as
extensively as male sexual dysfunction. Female sexual dysfunction is a common complication after most pelvic
surgeries. With the introduction of screening programs, most pelvic malignancies are detected at earlier stages
and in younger patients. Sexual dysfunction is a major quality-of-life issue in these young women. Hysterectomy
(simple or radical) is the most common type of pelvic surgery in women and is one of the most important causes of
female sexual dysfunction. Additionally, female sexual dysfunction is an important issue after urologic (radical
cystectomy) and colorectal surgeries (simple and radical proctocolectomy). Sexual dysfunction is a common prob-
lem among postmenopausal women. Modifications in the surgical technique (nerve sparing) are rapidly evolving in
the field of urology and colorectal surgery, which will be soon followed by modifications in the field of gynecologic
surgery. In this article we summarize the pathophysiology and classification of female sexual dysfunction, with
special emphasis on the relationship between female sexual dysfunction and pelvic surgeries. (Fertil Steril
2007;88:1273–84. 2007 by American Society for Reproductive Medicine.)
Key Words: Female sexual dysfunction, management of female sexual dysfunction, treatment of female sexual
dysfunction, nerve-sparing hysterectomy
Female sexual dysfunction (FSD) is a highly prevalent and rial in etiology and is associated with numerous medical and
often underestimated problem in the general community. Im- surgical diseases. It is a common complication of many pelvic
proved knowledge about the female pelvic anatomy and re- surgeries (gynecologic, urologic, and colorectal). Pelvic sur-
cent advances in female sexual physiology have helped to geries are important and often underestimated causes of sexual
classify FSD. Female sexual dysfunction is defined as a disor- dysfunction. Recently FSD has emerged as a major quality-
der of sexual desire, orgasm, arousal, and sexual pain that of-life issue in patients undergoing pelvic surgery, especially
results in significant personal distress. It is a multifactorial, after simple and radical hysterectomies for gynecologic malig-
age-related, progressive problem (1). nancies and radical cystectomies for bladder cancer. The sig-
nificant impact of FSD has led to modifications in surgical
The National Health Survey revealed that 43% of 1,749
technique. These modifications are rapidly evolving in the
women aged <60 years had some form of sexual dysfunction.
fields of urologic and colorectal surgeries and soon will be
Female sexual dysfunction is certainly not a problem limited
followed in gynecologic practice as well. No matter what
to young women. In fact, population census data from the
the cause, FSD can negatively affect a woman’s quality of life.
United States show that approximately 10 million American
women, approximately 3% of the total population, aged 50– In this article we discuss the classification and pathophys-
74 years self-reported some form of sexual dysfunction (2). A iology of FSD, with a special emphasis on the impact of pel-
recently conducted international survey including 4,507 vic surgeries and recent surgical technique modifications. We
women aged 18–59 years revealed that 34% of the partici- also outline the current status of medication in the treatment
pants had decreased sexual interest, and 19% did not consider of FSD.
sexual intercourse to be pleasurable (3).
Until recently FSD was considered to be psychological in DEFINITION AND CLASSIFICATION
nature. However, it is now recognized that FSD is multifacto- In 1966 Masters and Johnson reported that the normal female
sexual response cycle consists of four successive phases: ex-
Received September 10, 2007; accepted September 10, 2007.
citement, plateau, orgasm, and resolution. In 1979 Kaplan
Reprints requests: Rupesh Raina, M.D., Department of Internal Medicine
and Pediatrics, Case Western Reserve University (MHMC), Cleveland, modified this hypothesis by further dividing the excitement
Ohio 44109 (FAX: 216-778-1385; E-mail: [email protected]). phase into desire and arousal and eliminated the plateau
0015-0282/07/$32.00 Fertility and Sterility Vol. 88, No. 5, November 2007 1273
doi:10.1016/j.fertnstert.2007.09.012 Copyright ª2007 American Society for Reproductive Medicine, Published by Elsevier Inc.
phase. This three-dimensional model consisting of desire, can occur for a variety of reasons, including physical or sex-
arousal, and orgasm formed the basis for the Diagnostic ual abuse and childhood trauma.
and Statistical Manual of Mental Disorders, 4th edition
(DSM-IV) definitions of sexual dysfunction. Sexual arousal
is a state with specific feelings and physiologic changes, usu- Sexual Arousal Disorder
ally associated with sexual activity involving the genitals (4). Sexual arousal disorder is a persistent or recurring inability to
Basson et al. (5) later proposed a five-phase model focused on attain or maintain adequate sexual excitement, which leads to
intimacy. Intimacy and desire are essential for women to par- personal distress (1). Sexual arousal disorder may be experi-
ticipate in sexual activity. Once intimacy and sexual stimuli enced as a lack of subjective excitement, somatic responses,
lead women to arouse emotionally, sexual arousal and desire or genital lubrication/swelling. Decreased labial and clitoral
occur and culminate in emotional and physical satisfaction. sensation and engorgement and lack of vaginal smooth mus-
cle relaxation can also cause sexual arousal disorder. This
The Sexual Function Health Council of the American phenomenon is particularly important in patients who have
Foundation for Urologic Disease (AFUD) convened an inter- undergone pelvic surgeries. This may cause iatrogenic dam-
disciplinary consensus conference panel in 1998 that con- age to the pelvic nerves, leading to decreased arousal. Psy-
sisted of 19 experts in FSD selected from five countries. chological factors are among the other important causes of
The former DSM-IV classification was expanded by the sexual arousal disorder (9).
panel and now includes psychogenic and organic causes of
desire, arousal, orgasm, and sexual pain disorders. An essen-
tial element of this new diagnostic system is the personal dis- Orgasmic Disorders
tress criterion, meaning that a condition is considered Orgasmic disorder is either complete absence or recurrent
a disorder only if it creates distress for the woman experienc- difficulty in attaining orgasm after sufficient sexual stimula-
ing the condition (1). tion (1). Orgasmic disorders can be primary (a woman never
Clear definitions of sexual complaint, sexual dysfunction, has achieved orgasm) or secondary (a woman was able to
and sexual disorders are needed to estimate the prevalence of achieve orgasm previously but is no longer able to do so).
FSD, evaluate the etiology, and assess the potential interven- It is a prevalent problem among women who present to sex
tions, including therapy and pharmacologic treatments. Future therapy clinics. Anorgasmia is noticed in 24%–37% of
insight into the physiology of the sexual cycle might result in women presenting to sex therapy clinics for various reasons
modification of these definitions and classifications. As such, (10). Primary orgasmic disorder is usually due to emotional
the following definitions provide a basis for the remaining dis- trauma or sexual abuse. Hormonal deficiency, surgical
cussion in this article. Sexual complaint is the expression of trauma, or medications are the common causes for secondary
discontent or pain associated with sexual functioning. Sexual orgasmic disorder. Anorgasmia is also a common complaint
dysfunction is a disturbance in sexual functioning involving in women taking selective serotonin reuptake inhibitors. De-
one or multiple phases of the sexual response cycle or pain as- pending upon the dose and type of the drug, up to 50% of
sociated with sexual activity. Sexual disorder is sexual dys- women have been shown to suffer from a lack of orgasm (11).
function that meets DSM-IV criteria for a sexual disorder
and includes dysfunction and marked distress. Sexual Pain Disorders
Further defining sexual disorders, the 1999 AFUD Consen- There are two types of sexual pain disorders: vaginismus and
sus Panel Classification System (1) is as follows. dyspareunia (1). Vaginismus is defined as recurrent or persis-
tent involuntary spasm of vaginal musculature that interferes
with vaginal penetration. Dyspareunia is defined as recurrent
Sexual Desire Disorders or persistent genital pain associated with sexual intercourse.
Dyspareunia rates reported in the literature range from 14%
Hypoactive sexual desire disorder Hypoactive sexual desire
to 18% (12). Pain may also be induced by noncoital stimula-
disorder (HSDD) is a spectrum of diseases that cause per-
tion in certain disorders like genital herpes, endometriosis,
sonal distress owing to persistent or recurring deficiency (or
and vestibulitis. Psychological factors, such as fear, anxiety,
absence) of sexual fantasies and thoughts and a lack of recep-
and interpersonal conflict, are the cause of dyspareunia in
tivity to sexual activity (1). Medically induced menopause,
one third of cases (13). Disorders of the pelvic floor and post-
depression and its treatments, and endocrine disorders are
menopausal decreased vaginal lubrication can also cause
the most common causes that can disrupt the normal female
pain with sexual activity (14, 15). Dyspareunia is also seen
hormonal milieu, resulting in HSDD (6, 7). Long-term con-
in women with decreased vaginal lubrication. This is usually
flicting relationships have also been shown to adversely
seen in women with damage to the pelvic nerves as a com-
affect sexual desire (8).
plication of pelvic surgeries. Multiparous women are at in-
Sexual aversion disorder In this disorder women have a per- creased risk of pelvic floor disorders because of the
sistent or recurrent phobic aversion, leading to avoidance of muscular and vascular changes that occur during childbirth.
sexual contact and precipitating personal distress (1). It is Sexual dysfunction due to problems with vaginal lubrication
generally a psychological or emotionally based problem. It and sexual intercourse are commonly seen in older women.
1274 Raina et al. Female sexual dysfunction Vol. 88, No. 5, November 2007
PHYSIOLOGY AND PATHOPHYSIOLOGY OF FSD be intact for a woman to achieve orgasm and feel sexual de-
Female sexual dysfunction is a complex neurovascular phe- sire. The influence of SCI is strictly dependent on the degree
nomenon that is under the control of psychological, neurovas- and location of the injury (21). Complete upper motor neuron
cular, and hormonal factors. During sexual arousal, blood lesions that affect the sacral segments will have a negative
flow to the clitoris and the labia minora increases, leading to impact on psychogenic lubrication, whereas incomplete up-
engorgement of these organs, which in turn results in protru- per motor neuron lesions involving the sacral segments will
sion of the glans clitoris and eversion and engorgement of the allow both psychogenic and reflex vaginal lubrication (22,
labia minora. This increase in blood flow to the vagina and 23). It has been reported that women with SCI were less
uterus leads to increased secretion from the uterus and Bartho- likely to achieve orgasm than women without such an injury
lin’s glands, which lubricates the vagina. Additional lubrica- (21, 24). Sipski et al. (21) also reported that women with
tion comes from the transudation of plasma from engorged lower motor neuron lesions are less likely to achieve orgasm
vessels in the vaginal wall. Sexual dysfunction after pelvic than women with such lesions in any other area. Women with
surgeries may be due to interruption of the vascular supply SCI have been shown to take longer to achieve orgasm (21).
and neurologic innervation. Contraction of the pelvic floor Studies also have revealed that women’s sexual desire after
muscles (the pelvic diaphragm in particular) intensifies the or- an SCI falls significantly and that these patients are at an in-
gasm. However, a non-voluntary contraction commonly leads creased risk for hypoactive sexual desire after the injury (25,
to vaginismus. A complete understanding of the physiologic 26). These findings are further supported by studies reporting
and pathologic aspects of FSD is essential to develop any on women with multiple sclerosis. They reported a decrease
therapeutic strategies. Therefore, we will briefly review the in vaginal sensation, orgasmic capacity, and sexual desire
hormonal, neurologic, and vascular aspects of FSD. (27, 28).
TABLE 1
Sexual dysfunction after pelvic cancer surgeries.
Total Sexual
First author/year cases Type of F/U function
(reference) Study design (n) surgery (mo) (%) Definition
Radical
cystectomy
Bjerre/1997 (58) Retrospective N/A NSRC 54 18 Sexually active
(maintained coital
frequency)
Ileal conduit
NSRC þ 8 44
neobladder
Horenblas/ Retrospective 3 Neobladder 42 100 Normal vaginal
2001 (97) lubrication
Zippe/2004 (59) Retrospective 28 RC 24 48 Sexually active, IFSF
questionnaire
Rectal excision
Havenga/1996 (98) Retrospective 54 TME N/A 91 Achieve orgasm
Chatwin/2002 (99) Retrospective 11 LAR N/A 82 Sexually active
Pocard/ 2002 (66) Prospective 7 TME N/A 69 Sexually active
Hysterectomy (carcinoma of cervix, vagina, and ovary)
Dennerstein/ Retrospective 89 Hysterectomy/ N/A 37 Loss of desire
1997 (34) oophorectomy
Stewart/2001 (50) Retrospective 139 Hysterectomy/ 7.29 4.9 y 57 Decreased sexual
oophorectomy function
Note: F/U ¼ follow-up; NSRC ¼ nerve-sparing radical cystectomy; RC ¼ radical cystectomy; IFSI ¼ Index of Female
Sexual Function; TME ¼ total mesorectal excision; LAR ¼ low anterior resection.
Raina. Female sexual dysfunction. Fertil Steril 2007.
1276 Raina et al. Female sexual dysfunction Vol. 88, No. 5, November 2007
There is a growing interest among gynecologists regarding dent from the literature that sexual dysfunction is an impor-
the innervation of the cervix and upper vagina. This auto- tant and highly prevalent concern after cervical cancer
nomic innervation seems to play an essential role in orgasm. treatment, which should be an essential part of pretreatment
If the uterovaginal plexus are damaged during surgical re- informed consent.
moval of the cervix, it may interfere with lubrication and or-
gasm. This hypothesis was supported by a report from Kilkku FSD after treatment of other gynecologic malignancies Sexual
(42), who found that the frequency of orgasm was signifi- dysfunction is a common complication after ovarian cancer
cantly lower in women who underwent total hysterectomy management. Multimodality treatments include hysterec-
than in women who had a subtotal hysterectomy. However, tomy, oophorectomy, and adjuvant chemotherapy and are
further randomized controlled trials failed to support this the- commonly used in ovarian cancer management. The reported
ory (43). Further prospective research using validated ques- incidence rates are similar to those associated with cervical
tionnaires in women undergoing hysterectomy needs to be cancer management (49). In 2001 Stewart et al. (50) reported
carried out regarding this question. that 57% women who underwent ovarian cancer treatments
experienced a decrease in sexual function. Recently Carmack
It seems that simple hysterectomy does not adversely af- Taylor et al. (49) reported that of 232 ovarian cancer patients,
fect sexual function (44). This assumption needs to be con- only 50% were sexually active after treatment. Of these 50%
firmed in studies that feature validated questionnaires that patients, 47% reported no or little desire, 80% reported prob-
can stratify the different domains of sexual function, which lems with vaginal dryness, and 62% reported pain or discom-
include orgasm, desire and arousal, pain during intercourse, fort during penetration. The reasons for sexual inactivity
lubrication, and satisfaction. included lack of partner (44.1%), lack of interest (38.7%),
physical problems that made sex difficult (23.4%), and fa-
FSD after treatment of cervical cancer Quality-of-life issues tigue (10.8%). It is obvious from these studies that sexual
are becoming significant endpoints in gynecologic surgery dysfunction is a significant complication after ovarian cancer
patients. These issues have not been reported adequately in management. Sexual rehabilitation should be addressed in
the literature. The introduction of cervical screening pro- these patients and their partners. The published data on
grams (annual Papanicolaou smear evaluation) has led to sexual dysfunction rates after treatment of endometrial and
early detection of cervical cancer at a younger age. This vulval cancer are limited.
age migration can potentially make sexual function a major
postoperative issue in gynecologic surgery. Although reports There is a definitive increase in the awareness about the
of sexual function after gynecologic surgeries date back to impact of gynecologic cancer surgeries on FSD. The assess-
the 1980s, these studies did not use standard questionnaires ment and treatment of sexual function should become an im-
and definitions, which produced wide variations in the re- portant part of the standard care of women diagnosed and
ports. Surgical treatment of cervical cancer can lead to lack treated for gynecologic cancers.
of vaginal lubrication and loss of libido. Both of these com- The growing awareness about sexual dysfunction after pel-
plications can be further aggravated by bilateral oophorec- vic surgery will lead to the development of better surgical
tomy, especially after radical hysterectomy. Vaginal dryness techniques and better information on postoperative sexual
and short vaginal vault are the two most important causes dysfunction. The risk and benefits of any pelvic surgery in
of postoperative dyspareunia. terms of sexual dysfunction should be included in an accurate
In a population-based epidemiologic study in Sweden, consent process. In the future, sexual function will become
Bergmark et al. (45) reported that reduced sexual satisfaction a routine part of the informed consent process for gyneco-
and dyspareunia were the primary source of symptom- logic surgery.
induced distress after treatment of cervical cancer. Recent
Nerve-sparing hysterectomy: an evolving new
studies by Jensen et al. (46) demonstrated that patients treated
concept Recently there has been growing interest among gy-
with radical hysterectomy and radiotherapy had short-term
necologists regarding the role of nerve-sparing radical hyster-
sexual difficulties, such as dyspareunia and vaginal dryness,
ectomy for carcinoma of the cervix. Several cadaver studies
leading to decreased sexual satisfaction. However, some
outlined the detailed female pelvic anatomy and led to the
of these postoperative problems subsided 6 months after
modification of the hysterectomy procedure. In 1998 Hockel
surgery.
et al. (51) reported a detailed anatomic approach to nerve-
Sexual dysfunction is further aggravated by the use of ad- sparing hysterectomy in a cadaveric model using liposuc-
juvant radiotherapy. Multimodality treatments have been tion-assisted, nerve-sparing, extended radical hysterectomy.
more commonly used for cervical cancers (47). Radiotherapy They applied a similar technique in women with vaginal
as primary treatment or combined with surgery will more and cervical cancer and demonstrated that liposuction-assis-
commonly predispose women to sexual dysfunction than ted, nerve-sparing hysterectomy is feasible and safe. This
hysterectomy alone (47). A considerable percentage of pa- nerve-sparing technique later underwent several modifica-
tients who received intracavitary brachytherapy either failed tions (52). The oncologic safety of this surgery has yet to
to resume sexual activity within 1 year or stopped all sexual be proven in long-term studies. However, initial results
activity (48). Irrespective of the type of treatment, it is evi- showed a definite improvement in voiding dysfunction
1278 Raina et al. Female sexual dysfunction Vol. 88, No. 5, November 2007
decrease with age. Analysis of data from a national survey did using validated sexual health questionnaires and evaluating
not find any differences in the frequency of sexual activities all the components of female sexual dysfunction, as they
between men and women who were older than 60 years (69). are affected by different modes of delivery.
Many women experience a change in their sexual function
during the years immediately before and after menopause. EVALUATION OF FSD
This is primarily a result of a decrease in estrogen (E) and
Most women with FSD will present to a gynecologist for
T levels. As women age, they also experience decreased
evaluation, so it is essential for gynecologists to have a com-
blood flow to their genitals. Common complaints include
prehensive knowledge regarding the methodology of a com-
a loss of desire, diminished responsiveness, and low sexual
plete and systematic evaluation. A thorough clinical
arousal. Vaginal atrophy, which involves thinning, drying,
evaluation should be the cornerstone of this process, and it
and irritation of the vaginal lining, causes significant distress
should be followed by essential laboratory testing. Clinical
for the menopausal woman. In addition, the interplay of psy-
evaluation of FSD includes history (including medical disor-
chological, cultural, and interpersonal factors all contributes
ders, medications, and psychosexual assessment) and physi-
to the aging woman’s sexual experience.
cal examination (local examination for potential causes for
It is well known that sexual function decreases with age. It pain, including infectious diseases, tumors, polyps, and dis-
may be due to decrease in the libido because of decrease in eases such as endometriosis and pelvic inflammatory disor-
the E levels, increasing vaginal dryness, and decreased vascu- ders). Basic laboratory testing should be performed (serum
larity in the genital area. Evaluation of the exact cause of dys- chemistry, complete blood count, and lipid profiles) to iden-
function is difficult because the dysfunction is usually tify vascular risk factors such as hypercholesterolemia, dia-
multifactorial. betes, and renal failure. Thyroid function tests are used to
exclude hypothyroidism. Follicle-stimulating hormone, LH,
T, and E should be measured to gauge the functional integrity
SEXUAL DYSFUNCTION IN THE POSTPARTUM PERIOD of the hypothalamic–pituitary–gonadal axis.
The incidence of short-term postpartum sexual dysfunction
Medications such as antihypertensive agents (a-blockers,
varies from 22% to 86% (70). Even so, there are only a few
b-blockers, calcium channel blockers, and diuretics), chemo-
reports in the literature that were based on large, prospective
therapeutic agents, drugs that act on the central nervous sys-
trials. Approximately 4 million women give birth each year in
tem (antidepressants, anticonvulsants, antipsychotics, and
the United States. Irrespective of the type of delivery, short-
anticholinergics), and antiandrogens commonly cause FSD.
term postpartum sexual changes, such as dyspareunia and
loss of desire, are highly prevalent in postpartum women. Several self-reported questionnaires are available to assess
These problems are further compounded by increased family sexual dysfunction. However, most of them are not validated
burden and emotional problems. Glazener (71) reported that and do not assess all of the domains of female sexual function
53% of women have problems with sexual intercourse in the (e.g., arousal, desire, orgasm, and satisfaction). The Female
first 8 weeks after delivery. This study outlined the impor- Sexual Function Index is the most commonly used validated
tance of health education regarding sexual dysfunction in questionnaire. It is a 19-item questionnaire that assesses
the antenatal period. Johanson et al. (72) reported a significant female sexual function domains (75). There are two other
increase in dyspareunia after assisted vaginal delivery (for- validated questionnaires that are available: the 22-item Brief
ceps or vacuum) vs. spontaneous vaginal delivery or cesarean Sexual Function Index and the 31-item Sexual Function
section. There is a general consensus within the literature that Questionnaire (76).
assisted vaginal delivery is associated with increased risk of
It is not known whether advanced diagnostic investigations
sexual dysfunction in the postpartum period. However, there
such as vaginal plethysmography (which measures physical
is a major gap in the information regarding sexual function
changes in vaginal engorgement with each heart beat and pro-
after cesarean section. Most of the studies that have been per-
vides quantitative data on the extent of vaginal congestion)
formed on this topic are retrospective in nature, did not use
and duplex ultrasonography increase physician and patient
a validated questionnaire, and did not evaluate the various do-
understanding of the problem and the cost-effectiveness of
mains of sexual function. A recent large study utilizing a de-
the investigation.
tailed questionnaire reported that persistence of dyspareunia
for longer than 6 months occurred at a rate of 3.4% for the
spontaneous-without-injuries and cesarean section group, TREATMENT OPTIONS FOR FSD
10% for the episiotomy/leisure group, and 14% for the oper-
Numerous medications are available for the treatment of
ative vaginal deliveries group (73).
FSD, including hormones and various drugs. However, no
Perineal trauma and operative vaginal delivery are associ- single treatment has been established as a gold standard. Be-
ated with increasing severity and incidence of dyspareunia fore starting treatment, the patient should be evaluated thor-
(74). The higher rates of persistent dyspareunia with opera- oughly for all medical illnesses and drug history that may
tive vaginal delivery should be part of the antenatal counsel- produce sexual dysfunction. Estrogens, androgens, dopami-
ing process of patients. Further studies need to be conducted nergic agonists, nitric oxide donors, prostaglandins, and
TABLE 2
Results and outcomes of different treatment options for female sexual dysfunction.
Author/year Study Results and
(reference) design Treatment outcomes
Sherwin/1985 (19) Prospective, double-blind, Estrogen þ androgen vs. Energy level, appetite, and
crossover estrogen vs. placebo well-being were increased
in combination of androgen
compared with estrogen
alone or placebo
Sarrel/1998 (16) Prospective, randomized, Estrogen vs. estrogen þ Similar vasodilator effect in
parallel study androgen on blood flow each group
Lobo/2003 (100) Double-blind, Estrogen vs. estrogen þ Interest, desire, and
randomized, controlled testosterone frequency increase greater
in combination group than
with estrogen alone
Rioux/2000 (101) Open-label, randomized, Estrogen vaginal tablets Dryness, soreness, and
multicenter vs. estrogen cream irritation were relieved in
both groups. Estrogen
tablets have lesser
discontinuation rates than
cream
Ayton/1996 (102) Open-label, parallel, Estrogen cream vs. ring Vaginal rings are more
comparative, acceptable than vaginal
multicenter cream
Raina. Female sexual dysfunction. Fertil Steril 2007.
1280 Raina et al. Female sexual dysfunction Vol. 88, No. 5, November 2007
response. Several investigators assessed the role of PDE-5 in- managing women with sexual dysfunction. Female sexual
hibitors in women taking antidepressant medications and in arousal disorders can be effectively managed by psychother-
women with SCI. Sildenafil has been reported to increase apy. Psychotherapy in this group of women removes inhibi-
sexual function in patients taking selective serotonin reuptake tions and enhances interpersonal relations and motivation
inhibitors and patients with SCI (85, 86). Although initial re- levels (91). Vaginismus is one of the common female psycho-
ports have failed to find any significant improvement in sex- sexual problems. Behavioral therapy in women with vaginis-
ual arousal disorders, several investigators demonstrated its mus leads to improvements on parameters related to marital
usefulness in certain subsets of the population. The role of harmony and overall sexual functioning of the women (92).
sildenafil has yet to be confirmed in the general population Management of the partners with couples therapy helps cre-
presenting with FSD. ate changes at the deeper emotional levels and lead to better
intimacy levels (93). Behavioral therapy based on Master’s
Vardenafil is another PDE-5 inhibitor. The U.S. Food and
and Johnson’s theoretical model of communication leads to
Drug Administration (FDA) approved it in 2003 for the treat-
significant increase in assertiveness and intimacy in sexual
ment of erectile dysfunction in men. Tadalafil is another
relations for the couple (94–96).
PDE-5 inhibitor; phase II trials are currently under way to
evaluate its efficacy in FSD. Both vardenafil and tadalafil
are approved for the treatment of erectile dysfunction in SUMMARY
men. However, their role in FSD has not been studied.
Female sexual dysfunction is a multifactorial and complex
None of the oral PDE-5 inhibitors are approved by the
problem of the community. Recent advances in anatomic
FDA for treatment of FSD.
and physiologic details have led to increased insight into
Adrenoceptor antagonists Phentolamine and yohimbine are female sexual function, which formed the basis for an inter-
the two vasodilators (a-adrenoceptor antagonists) used to national consensus classification of FSD. Initial studies
treat FSD. They produce vasodilatation by relaxing smooth underestimated sexual dysfunction because of a lack of gen-
muscle. Phentolamine has been shown to increase self- eral consensus and validated questionnaires that can illustrate
reported lubrication and sexual arousal (87). Yohimbine different domains of female sexual function. Recently, with
failed to show any improvement in placebo-controlled trials the use of validated questionnaires and advances in the eval-
including patients with FSD induced by selective serotonin uation of sexual function in women, a more clear understand-
reuptake inhibitors (88). ing of the problem has emerged.
For years, the endpoints of cancer treatment were mainly
Other Medications concentrated on recurrence and survival. With increasing
Various other medications, such as dopamine receptor ago- availability of screening modalities, younger women are di-
nists (apomorphine), a-melanocyte-stimulating hormone, se- agnosed at earlier stages, making quality of life a major issue.
rotonin receptor antagonists (finasteride), selective E Sexual function has been one of the most important quality-
receptor modulators, and selective androgen receptor modu- of-life issues after pelvic cancer surgery. Recently, multimo-
lators are in phase II trials (89). dality treatments have become a standard treatment option
for many malignancies. These treatments, which include pel-
Tibolone is a synthetic steroid that has progestogenic and vic radiation after radical surgery, have further compounded
androgenic properties, as well as estrogenic effects. It has the problem of FSD.
been approved for treatment of FSD in Europe and Asia. Ti-
bolone increased sexual desire in women with FSD better The management of FSD should include psychological
than placebo (89). and medical evaluation. The medical management of FSD
is one of the rapidly developing fields of medicine. Currently,
hormonal supplement options are the mainstay of treatment.
Medical Devices The future of this field is interesting and encouraging. Gyne-
The Eros Clitoral Therapy Device is a handheld medical de- cologists will play a major role in the diagnosis and manage-
vice approved by the FDA for sexual arousal and orgasmic ment of FSD, irrespective of etiology. Further studies are
disorders in women. It seems to be beneficial in women essential for formulating effective treatment strategies.
with sexual arousal disorder (90).
InterStim therapy, which involves mild neurostimulation REFERENCES
of the sacral nerve, was originally designed for urinary incon- 1. Basson R, Berman J, Burnett A, Derogatis L, Ferguson D, Fourcroy J,
tinence and is currently under investigation for sexual arousal et al. Report of the international consensus development conference on
disorder (88). female sexual dysfunction: definitions and classifications. J Urol
2000;163:888–93.
2. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United
Behavioral Therapy States: prevalence and predictors. JAMA 1999;281:537–44.
3. Salonia A, Munarriz RM, Naspro R, Nappi RE, Briganti A,
Behavioral, cognitive, medical, and surgical therapeutic ap- Chionna R, et al. Women’s sexual dysfunction: a pathophysiological
proaches have to be combined in an integrated model for review. BJU Int 2004;93:1156–64.
1282 Raina et al. Female sexual dysfunction Vol. 88, No. 5, November 2007
52. Hoffman MS. Extent of radical hysterectomy: evolving emphasis. Gy- cohort study of primiparous women. Am J Obstet Gynecol 2001;184:
necol Oncol 2004;94:1–9. 881–8; discussion 888–90.
53. Stein JP, Skinner DG. Results with radical cystectomy for treating blad- 75. Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, et al.
der cancer: a ‘reference standard’ for high-grade, invasive bladder can- The Female Sexual Function Index (FSFI): a multidimensional self-
cer. BJU Int 2003;92:12–7. report instrument for the assessment of female sexual function. J Sex
54. Nordstrom GM, Nyman CR. Male and female sexual function and ac- Marital Ther 2000;26:191–208.
tivity following ileal conduit urinary diversion. Br J Urol 1992;70:33–9. 76. Mazer NA, Leiblum SR, Rosen RC. The brief index of sexual function-
55. Berman L, Berman J, Felder S, Pollets D, Chhabra S, Miles M, et al. ing for women (BISF-W): a new scoring algorithm and comparison of
Seeking help for sexual function complaints: what gynecologists need normative and surgically menopausal populations. Menopause 2000;7:
to know about the female patient’s experience. Fertil Steril 2003;79: 350–63.
572–6. 77. Fourcroy JL. Female sexual dysfunction: potential for pharmacother-
56. Stenzl A, Colleselli K, Poisel S, Feichtinger H, Pontasch H, apy. Drugs 2003;63:1445–57.
Bartsch G. Rationale and technique of nerve sparing radical cystec- 78. Burkman RT, Collins JA, Greene RA. Current perspectives on benefits
tomy before an orthotopic neobladder procedure in women. J Urol and risks of hormone replacement therapy. Am J Obstet Gynecol
1995;154:2044–9. 2001;185:S13–23.
57. Stenzl A, Colleselli K, Poisel S, Feichtinger H, Bartsch G. Anterior ex- 79. Cardozo L, Bachmann G, McClish D, Fonda D, Birgerson L. Meta-
enteration with subsequent ureteroileal urethrostomy in females. Anat- analysis of estrogen therapy in the management of urogenital atrophy
omy, risk of urethral recurrence, surgical technique, and results. Eur in postmenopausal women: second report of the Hormones and Urogen-
Urol 1998;33(Suppl 4):18–20. ital Therapy Committee. Obstet Gynecol 1998;92:722–7.
58. Bjerre BD, Johansen C, Steven K. A questionnaire study of sexological 80. Collins A, Landgren BM. Reproductive health, use of estrogen and ex-
problems following urinary diversion in the female patient. Scand J perience of symptoms in perimenopausal women: a population-based
Urol Nephrol 1997;31:155–60. study. Maturitas 1994;20:101–11.
59. Zippe CD, Raina R, Shah AD, Massanyi EZ, Agarwal A, Ulchaker J, 81. Basson R. Female sexual response: the role of drugs in the management
et al. Female sexual dysfunction after radical cystectomy: a new out- of sexual dysfunction. Obstet Gynecol 2001;98:350–3.
come measure. Urology 2004;63:1153–7. 82. Montgomery JC, Appleby L, Brincat M, Versi E, Tapp A, Fenwick PB,
60. Burkhard FC, Studer UE. Orthotopic bladder substitution. Curr Opin et al. Effect of oestrogen and testosterone implants on psychological
Urol 2000;10:343–9. disorders in the climacteric. Lancet 1987;1:297–9.
61. Kessler TM, Burkhard FC, Perimenis P, Danuser H, Thalmann GN, 83. Robinson D, Cardozo LD. The role of estrogens in female lower urinary
Hochreiter WW, et al. Attempted nerve sparing surgery and age have tract dysfunction. Urology 2003;62:45–51.
a significant effect on urinary continence and erectile function after rad- 84. Kaplan SA, Reis RB, Kohn IJ, Ikeguchi EF, Laor E, Te AE, et al. Safety
ical cystoprostatectomy and ileal orthotopic bladder substitution. J Urol and efficacy of sildenafil in postmenopausal women with sexual dys-
2004;172:1323–7. function. Urology 1999;53:481–6.
62. Schoenberg M, Hortopan S, Schlossberg L, Marshall FF. Anatomical 85. Berman JR, Berman LA, Lin H, Flaherty E, Lahey N, Goldstein I, et al.
anterior exenteration with urethral and vaginal preservation: illustrated Effect of sildenafil on subjective and physiologic parameters of the
surgical method. J Urol 1999;161:569–72. female sexual response in women with sexual arousal disorder. J Sex
63. Banerjee AK. Sexual dysfunction after surgery for rectal cancer. Lancet Marital Ther 2001;27:411–20.
1999;353:1900–2. 86. Sipski ML, Rosen RC, Alexander CJ, Hamer RM. Sildenafil effects on
64. Enker WE. Total mesorectal excision—the new golden standard of sur- sexual and cardiovascular responses in women with spinal cord injury.
gery for rectal cancer. Ann Med 1997;29:127–33. Urology 2000;55:812–5.
65. Enker WE, Havenga K, Polyak T, Thaler H, Cranor M. Abdominoper- 87. Rosen RC, Phillips NA, Gendrano NC 3rd, Ferguson DM. Oral phentol-
ineal resection via total mesorectal excision and autonomic nerve pres- amine and female sexual arousal disorder: a pilot study. J Sex Marital
ervation for low rectal cancer. World J Surg 1997;21:715–20. Ther 1999;25:137–44.
66. Pocard M, Zinzindohoue F, Haab F, Caplin S, Parc R, Tiret E. A pro- 88. Michelson D, Kociban K, Tamura R, Morrison MF. Mirtazapine, yo-
spective study of sexual and urinary function before and after total mes- himbine or olanzapine augmentation therapy for serotonin reuptake-
orectal excision with autonomic nerve preservation for rectal cancer. associated female sexual dysfunction: a randomized, placebo controlled
Surgery 2002;131:368–72. trial. J Psychiatr Res 2002;36:147–52.
67. Quah HM, Jayne DG, Eu KW, Seow-Choen F. Bladder and sexual dys- 89. Walsh KE, Berman JR. Sexual dysfunction in the older woman: an over-
function following laparoscopically assisted and conventional open view of the current understanding and management. Drugs Aging
mesorectal resection for cancer. Br J Surg 2002;89:1551–6. 2004;21:655–75.
68. Bretschneider JG, McCoy NL. Sexual interest and behavior in healthy 90. Wilson SK, Delk JR 2nd, Billups KL. Treating symptoms of female sex-
80- to 102-year-olds. Arch Sex Behav 1988;17:109–29. ual arousal disorder with the Eros-Clitoral Therapy Device. J Gend
69. Marsiglio W, Donnelly D. Sexual relations in later life: a national study Specif Med 2001;4:54–8.
of married persons. J Gerontol 1991;46:S338–44. 91. Leiblum S, Brown C, Wan J, Rawlinson L. Persistent sexual arousal
70. Hicks TL, Goodall SF, Quattrone EM, Lydon-Rochelle MT. Postpartum syndrome: a descriptive study. J Sex Med 2005;2:331–7.
sexual functioning and method of delivery: summary of the evidence. J 92. Kabakci E, Batur S. Who benefits from cognitive behavioral therapy for
Midwifery Womens Health 2004;49:430–6. vaginismus? J Sex Marital Ther 2003;29:277–88.
71. Glazener CM. Sexual function after childbirth: women’s experiences, 93. Gehring D. Couple therapy for low sexual desire: a systemic approach.
persistent morbidity and lack of professional recognition. Br J Obstet J Sex Marital Ther 2003;29:25–38.
Gynaecol 1997;104:330–5. 94. Marks IM. Review of behavioral psychotherapy, II: sexual disorders.
72. Johanson R, Wilkinson P, Bastible A, Ryan S, Murphy H, O’Brien S. Am J Psychiatry 1981;138:750–6.
Health after childbirth: a comparison of normal and assisted vaginal 95. Tullman GM, Gilner FH, Kolodny RC, Dornbush RL, Tullman GD. The
delivery. Midwifery 1993;9:161–8. pre- and post-therapy measurement of communication skills of couples
73. Buhling KJ, Schmidt S, Robinson JN, Klapp C, Siebert G, undergoing sex therapy at the Masters & Johnson Institute. Arch Sex
Dudenhausen JW. Rate of dyspareunia after delivery in primiparae ac- Behav 1981;10:95–109.
cording to mode of delivery. Eur J Obstet Gynecol Reprod Biol 96. Master WH, Johnson VE. Principles of the new sex therapy. Am J
2006;124:42–6. Psychiatry 1976;133:548–54.
74. Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual 97. Horenblas S, Meinhardt W, Ijzerman W, Moonen LF. Sexuality preserv-
functioning and its relationship to perineal trauma: a retrospective ing cystectomy and neobladder: initial results. J Urol 2001;166:837–40.
1284 Raina et al. Female sexual dysfunction Vol. 88, No. 5, November 2007