Female Sexual Arousal Disorder

Female sexual arousal disorder is persistent or recurrent inability to attain or maintain adequate subjective sexual excitement or genital lubrication swelling response until completion of sexual activity, causing significant distress. Prevalence is 10 to 20 percent of women with distress (a higher proportion with low desire without distress). It may be lifelong or acquired, generalised or situational.

Current classification combines it with hypoactive desire as female sexual interest/arousal disorder. At least three of six features must be present for 6 months:

• Absent or reduced interest in sexual activity
• Absent or reduced sexual thoughts or fantasies
• No or reduced initiation, and unreceptive to partner's attempts
• Absent or reduced excitement or pleasure in 75 to 100 percent of encounters
• Absent or reduced responsive desire to internal or external cues
• Absent or reduced genital or non-genital sensations during sexual activity

Contributing factors:

• Oestrogen deficiency (menopause, lactation, hormonal contraception, oophorectomy)
• Vascular disease (diabetes, hypertension, atherosclerosis, smoking)
• Neurological disease (multiple sclerosis, spinal cord injury, diabetic neuropathy, pelvic surgery)
• Medications (selective serotonin reuptake inhibitors, antihypertensives such as beta blockers and thiazides, antipsychotics, antihistamines, opioids, combined oral contraceptives, anti-androgens)
• Depression and anxiety, chronic illness, relationship difficulty, past abuse or trauma, body image problems, stress, fatigue, and alcohol or substance use

• Reduced or absent subjective arousal (mental excitement), reduced vaginal lubrication, swelling of the labia and clitoris, and reduced genital sensation during sexual activity; sex is perceived as unpleasant or difficult, and desire declines secondarily.
• Dyspareunia from inadequate lubrication, and avoidance of intimacy.
• Distress, loss of self-esteem, relationship strain.
• Examination: vaginal atrophy (pale, dry, thin mucosa with loss of rugae, raised pH above 5), pelvic floor tension, clitoral atrophy or phimosis, lichen sclerosus, scarring, and neurological deficit (sacral sensation, bulbocavernosus reflex).
• Mental health: depression and anxiety are assessed; relationship dynamics and partner sexual function (erectile dysfunction, premature ejaculation) are explored.

• Diagnosis is clinical, from a sexual history in a private, non-judgemental setting: onset, situational versus generalised, relationship with desire, orgasm and pain, medications, medical history, mood, relationship quality, partner function, past abuse, and cultural beliefs. Validated tools: Female Sexual Function Index (a total score below 26.55 indicates dysfunction) and the Female Sexual Distress Scale (score 11 or above).
• Pelvic examination for atrophy, infection, pelvic masses, vulvar dermatoses, pelvic floor hypertonicity, and neurological function.
• Laboratory tests guided by the history: TSH, glucose or HbA1c, lipids, prolactin, serum FSH and oestradiol (menopausal status), testosterone (total and free; levels below 0.1 nmol/L may indicate androgen insufficiency in a postmenopausal woman with symptoms, but the correlation with symptoms is poor), and full blood count.
• Screening for depression (Patient Health Questionnaire-9) and abuse.
• Exclusion of medication effects through medication review.

Treatment is multimodal, biopsychosocial and individualised.

• Education: reassurance and information about normal sexual response, anatomy, and the contribution of context, emotional connection and stimulation. Advise adequate foreplay and sensate focus exercises, and use of vibrators and clitoral stimulation devices (including the clitoral vacuum device approved for female arousal disorder).
• Psychosexual therapy: cognitive behavioural therapy, mindfulness based therapy, sensate focus, and couple therapy. It is most effective for acquired and context related disorder. Treat depression, anxiety and trauma. Address relationship and partner dysfunction.
• Medication review and substitution: for antidepressant induced dysfunction, switch to bupropion (150 to 300 mg daily), add bupropion 150 mg daily, use mirtazapine, vortioxetine or agomelatine, reduce the dose, or try a drug holiday. Switch antihypertensive from beta blocker or thiazide to an angiotensin converting enzyme inhibitor or calcium channel blocker.
• Genitourinary syndrome of menopause or oestrogen deficiency: vaginal oestrogen (estradiol 10 microgram vaginal tablet daily for 2 weeks, then twice weekly; estriol 0.5 mg cream; conjugated oestrogen cream 0.5 g twice weekly), vaginal DHEA (prasterone 6.5 mg pessary nightly), or oral ospemifene 60 mg daily.
• Also use vaginal moisturisers (hyaluronic acid, used every 2 to 3 days) and water based or silicone lubricants during intercourse. Give systemic oestrogen therapy for vasomotor symptoms, with progestogen if the uterus is present.
• Testosterone: in postmenopausal women with distressing low desire and arousal, trial transdermal testosterone aiming for premenopausal levels (about 300 micrograms/day by a patch or 0.5 to 1 mL of 1 percent gel daily). Ensure adequate oestrogen replacement first.
• Measure testosterone at 6 weeks and 3 to 6 months, and stop if no benefit after 6 months. Monitor for acne, hirsutism and lipid changes. Unlicensed products are used with caution.
• Flibanserin 100 mg orally at bedtime for premenopausal women with generalised acquired low desire. Avoid alcohol and CYP3A4 inhibitors; risk of hypotension and syncope. Stop if no benefit at 8 weeks.
• Bremelanotide 1.75 mg subcutaneous injection at least 45 minutes before sex, no more than once in 24 hours and 8 times a month (nausea, flushing, transient blood pressure rise).
• Phosphodiesterase type 5 inhibitors (sildenafil 50 to 100 mg) have limited evidence in women, except in antidepressant induced arousal disorder.
• Pelvic floor physiotherapy for hypertonic pelvic floor or pain.
• Optimise diabetes, hypertension, and cardiovascular disease. Exercise and smoking cessation improve vascular function.
• Prognosis: improvement in most with full therapy. Refractory cases need specialist sexual medicine.