Women with sexual interest/arousal disorder have little or no interest in sex and do not respond subjectively or physically to sexual stimulation. The decrease in interest and ability to be sexually aroused is greater than what might be expected based on a woman’s age and the relationship duration. Lack of sexual interest and inability to be sexually aroused are considered a disorder only if they distress women and if interest is absent throughout the sexual experience.
Decreased sexual arousal can be categorized as subjective, genital, or combined. These categories are clinically based, distinguished in part by the woman’s response to genital and nongenital stimulation, as follows:
Subjective: Women do not feel aroused by any type of sexual genital or nongenital stimulation (eg, kissing, dancing, watching an erotic video, physical stimulation), despite the occurrence of physical genital response (eg, genital congestion).
Genital: Subjective arousal occurs in response to nongenital stimulation (eg, an erotic video) but not in response to genital stimulation. This disorder typically affects postmenopausal women. Vaginal lubrication and/or genital sexual sensitivity is reduced.
Combined: Subjective arousal in response to any type of sexual stimulation is absent or low, and women report absence of physical genital arousal (ie, they report the need of external lubricants and may state they know that swelling of the clitoris no longer occurs).
Common causes of sexual interest/arousal disorder are
Psychologic factors (eg, depression, anxiety, low self-esteem, stress, anxiety, distractibility, lack of communication between partners, other relationship problems)
Unrewarding sexual experiences (eg, due to lack of sexual skills or poor communication of needs)
Physical factors (eg, disorders such as genitourinary syndrome of menopause and vulvar dystrophies, changes in sex hormone levels, certain drugs, fatigue, debility)
Use of certain drugs, such as selective serotonin reuptake inhibitors (SSRIs) particularly, some antiseizure drugs, and beta-blockers, can reduce sexual interest, as can drinking excessive amounts of alcohol. Certain chronic disorders (eg, diabetes, multiple sclerosis) can damage autonomic or somatic nerves or their pathways, leading to decreased sensation in the genital area.
Fluctuations and changes in hormone levels (eg, at menopause, during pregnancy, postpartum, with the menstrual cycle) can also affect sexual interest. For example, the decrease in estrogen that occurs at menopause can cause genitourinary syndrome of menopause, which can cause dyspareunia and thus lessen sexual interest. Age-related reduction of testosterone can decrease the sex drive, as may hyperprolactinemia (which can also cause dyspareunia because estrogen levels are decreased).
Inadequate sexual stimulation or the wrong setting for sexual activity can also contribute to lack of sexual interest or arousal.
Diagnosis of sexual interest/arousal disorder is clinical, based on DSM-5 criteria.
Criteria require an absence of or a significant decrease in ≥ 3 of the following:
Interest in sexual activity
Sexual or erotic fantasies or thoughts
Initiation of sexual activity and responsiveness to a partner's initiation
Excitement or pleasure during ≥ 75% of sexual activity
Interest or arousal in response to sexual internal or external erotic stimuli (eg, written, verbal, visual)
Genital or nongenital sensations during ≥ 75% of sexual activity
These symptoms must have been present for ≥ 6 months and cause significant distress for the woman.
The diagnosis is not made if a physical or another psychologic cause (including relationship distress) could account for the symptoms.
A pelvic examination is done if penetration during sexual activity causes pain.
A multidisciplinary approach is best for management of sexual interest/arousal disorder. The multidisciplinary team may include sex counselors, pain specialists, psychotherapists, and physical therapists.
Education about sexual anatomy and function (eg, the need to stimulate other areas of the body before the clitoris, the requirement for emotional intimacy and trust) may help. Open, nonjudgmental communication between sex partners is essential.
Effective sexual stimuli may include nonphysical, physical nongenital, and nonpenetrative genital stimulation. Clinicians may recommend using more intensely erotic stimuli and fantasies, eliminating distractions (eg, a television in the bedroom), and taking measures to improve privacy and a sense of security.
For patient-specific psychologic factors, psychologic therapies (eg, cognitive-behavioral therapy) may be required, although simple awareness of the importance of psychologic factors may be sufficient for women to change patterns of thinking and behavior. Mindfulness-based cognitive therapy (MBCT), typically used in small groups of women, can improve arousal, orgasm, and subsequent desire and motivation. Clinicians may refer women to a sex counselor or therapist or a psychotherapist.
Concomitant hormonal causes require targeted treatment—eg, topical estrogen for genitourinary syndrome of menopause or bromocriptine for hyperprolactinemia. Other disorders that may be contributing to symptoms (eg, stress urinary incontinence) should be treated.
Systemic estrogen is not indicated for treatment of sexual arousal/interest disorder. However, it may be used to treat menopausal symptoms; it may improve mood, help maintain skin and genital sexual sensitivity and vaginal lubrication, and decrease concomitant vasomotor symptoms (eg, hot flushes). These benefits may enhance sexual interest and arousal. Transdermal preparations of estrogen are usually preferred after menopause, but no studies identify which preparations are the most beneficial sexually. If women have a uterus, they are given progesterone in addition to estrogen because unopposed estrogen increases risk of endometrial cancer.
Doctors may recommend that postmenopausal women use forms of estrogen that are inserted into the vagina (eg, creams, tablets, in a ring) to manage symptoms of genitourinary syndrome of menopause. These forms of estrogen can maintain vaginal health but do not help with mood, vasomotor symptoms, or sleep disturbances.
Short-term use of transdermal testosterone can be effective in postmenopausal women with sexual interest/arousal disorder (1). Testosterone treatment with and without concurrent estrogen resulted in improved sexual function in women with decreased sexual interest/arousal. The primary outcome was increased sexual desire, but arousal and orgasmic response also improved.
However, little is known about the long-term safety and efficacy of testosterone therapy. If it is prescribed, full explanation of conflicting efficacy data and lack of long-term safety data is essential, as is close monitoring for adverse effects such as acne, hirsutism, and virilization. In addition, the patient should have normal lipids and liver test results before testosterone therapy is started. Shared decision-making is recommended.
The dose of transdermal testosterone is 300 mcg once a day. Testosterone levels should be measured at baseline and after 3 to 6 weeks; for premenopausal women, the goal is keeping the level at a normal age-adjusted value. If levels are above the normal range for premenopausal women, testosterone is stopped or the dose is decreased. Limiting treatment to the short term is recommended, and testosterone should be stopped if there is no response after 6 months of use. Mammography should be done at regular yearly interval to check for any changes in the breasts because of the possible effects of testosterone on breast tissue.
Currently, there are no data to suggest testosterone use in premenopausal women.
Oral or injected testosterone is not recommended.
Intravaginal prasterone (a preparation of dehydroepiandrosterone, or DHEA) may relieve vaginal dryness and dyspareunia due to genitourinary syndrome of menopause (2), which can interfere with sexual interest and arousal; prasterone may also improve genital sensitivity and orgasm. Systemic DHEA has been shown to be ineffective. No form of DHEA has been studied in premenopausal women.
Flibanserin, a serotonin-receptor agonist/antagonist, can be used in premenopausal women with female sexual interest/arousal disorder. However, a systematic review showed that the quality of evidence for its effectiveness and safety was low and that the effect was minimal (3). Flibanserin also has black box warnings stating that ingesting flibanserin and alcohol close together or use of flibanserin by patients who take a moderate or strong CYP3A4 inhibitor or who have hepatic impairment increases the risk of hypotension and syncope. Women taking antidepressants were excluded from studies of flibanserin; therefore, safety and efficacy in these women are unknown.
Women with sexual interest/arousal disorder due to use of selective serotonin reuptake inhibitors may benefit from the addition of bupropion (a norepinephrine-dopamine reuptake inhibitor). In general, studies of sildenafil (a phosphodiesterase type 5 inhibitor) have been inconsistent and mostly show sildenafil to be ineffective in women; only one small study showed a small reduction in adverse sexual effects in premenopausal women with SSRI-associated sexual dysfunction (4).
Except in small pilot studies, there is scant evidence that devices such as vibrators or clitoral suction devices are effective in women with sexual interest/arousal and orgasmic disorder; however, some of these products are available over the counter and may be tried.
1. Achilli C, Pundir J, Ramanathan P, et al: Efficacy and safety of transdermal testosterone in postmenopausal women with hypoactive sexual desire disorder: A systematic review and meta-analysis. Fertil Steril 107:475–82, 2017. doi: 10.1016/j.fertnstert.2016.10.028 Epub 2016 Dec 1
2. Labrie F, Archer DF, Koltun W, et al: Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause. Menopause 23 (3):243–256, 2016. doi: 10.1097/GME.0000000000000571
3. Jaspers L, Feys F, Bramer WM, et al: Efficacy and safety of flibanserin for the treatment of hypoactive sexual desire disorder in women: A systematic review and meta-analysis. JAMA Intern Med 176(4):453-462, 2016. doi: 10.1001/jamainternmed.2015.8565
4. Nurberg HG, Hensley PL, Heiman JR, et al: Sildenafil treatment of women with antidepressant-associated sexual dysfunction: A randomized controlled trial. JAMA 300 (4):395–04, 2008. doi: 10.1001/jama.300.4.395