Sexual interest/arousal disorder in women is lack of or decreased interest in sexual activity (low libido) and sexual thoughts and/or lack of response to sexual stimulation.
Many factors can impact a woman's interest in sex and ability to become sexually aroused, including relationship issues, menopause, medications, medical conditions, depression, anxiety, stress, and a history of sexual trauma.
Doctors diagnose sexual interest/arousal disorder based on a woman's description of the problem and specific criteria.
Improving the relationship and the setting for sexual activity and identifying what stimulates a woman sexually can help.
Medications or psychological therapies, particularly mindfulness-based cognitive therapy, may be recommended.
Changes in sexual desire or arousal are common throughout a woman's sexual life. However, a persistent (6 months or longer) decrease in or lack of sexual interest or arousal that is distressing to a woman is called sexual interest/arousal disorder.
Causes of Sexual Interest/Arousal Disorder
Female sexual interest/arousal disorder often has more than 1 cause. It is often influenced by a mix of physical, psychological, relationship, and social or cultural factors.
Physical (biological) factors: Ther physical causes of low sexual desire or arousal in women are not well understood, but some may include: hormonal changes (such as during menopause, pregnancy, or breastfeeding); certain medications (especially some antidepressants); medical conditions (such as hormone problems or nerve disorders). Levels of hormones like testosterone decrease with age, but research has not shown this to be linked directly to sexual desire or arousal in women. Physical illnesses can affect sexual desire or arousal indirectly, by causing fatigue, stress, or concerns about body image.
Certain chronic disorders (such as diabetes or multiple sclerosis) can damage nerves, reducing blood flow to and/or sensation in the genital area. Use of certain medications, including antidepressants (particularly selective serotonin reuptake inhibitors), opioids, some antiseizure medications, and beta-blockers, can reduce sexual desire, as can drinking excessive amounts of alcohol.
Many women experience a decrease in sexual interest after menopause due to the natural aging process or surgical removal of the ovaries (oophorectomy), chemotherapy, or radiation therapy. Estrogen and progesterone levels decrease significantly after menopause. Testosterone decreases gradually with age but does not change suddenly at menopause.
The decrease in estrogen that occurs at menopause can cause genitourinary syndrome of menopause (which causes symptoms affecting the vagina, vulva, and urinary tract). In this syndrome, the tissues of the vagina can become thin, dry, and have difficulty stretching. As a result, intercourse can be uncomfortable or painful. Women with this syndrome may also feel a compelling need to urinate (urinary urgency) and have frequent urinary tract infections. These symptoms make women less interested in sex.
However, overall, sexual interest/arousal disorder is as common among young healthy women as it is among older women. Still, changes in sex hormones sometimes cause lack of interest. For example, in young healthy women, sudden drops in levels of sex hormones, as may occur during the first few weeks after childbirth, may cause sexual interest to decrease.
Psychological factors: Mental health conditions such as depression or anxiety can make it harder to feel sexual desire or become aroused. Other thought and emotional patterns can also play a role, including “spectatoring” (feeling like you are watching yourself during sex rather than being engaged) or worrying about sexual performance. Sometimes, low desire develops because of another sexual problem, such as losing interest in sex due to pain during intercourse.
Relationship (interpersonal) factors: A woman’s relationship with a partner can strongly affect her sexual desire. Desire is often higher when there is emotional closeness, affection, and overall relationship satisfaction. On the other hand, issues such as ongoing conflict, lack of trust, infidelity, or a partner’s sexual function difficulties can reduce desire. Differences in how much each partner wants sex can also cause stress. Inadequate sexual stimulation can also contribute to decreased sexual interest or arousal. Many women experience “responsive desire,” meaning their interest in sex may increase in response to closeness, a partner’s initiation, or a romantic setting, rather than starting spontaneously.
Social and cultural factors: Cultural or religious beliefs about sexuality can influence how a woman feels about sex. These beliefs may lead to feelings of guilt, shame, or discomfort, which can reduce sexual desire and expression.
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Diagnosis of Sexual Interest/Arousal Disorder
A doctor's evaluation, based on standard psychiatric criteria
Doctors base the diagnosis of sexual interest/arousal disorder on a woman’s history and description of the problem and on standard psychiatric criteria. These criteria require a lack of or decrease in at least 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 almost all sexual activity
Interest or arousal in response to sexual stimuli—written, spoken, or visual
Physical sensations in the genital area or elsewhere during sexual activity
These symptoms must have been present for at least 6 months, must cause significant distress in the woman, and cannot be better explained by another mental health or general medical condition.
If a woman has pain during sex or other physical symptoms of the reproductive organs, a pelvic examination is done.
Treatment of Sexual Interest/Arousal Disorder
Behavioral measures
Psychological therapies
Medications
Care for women with sexual interest/arousal disorder is guided by addressing the emotional, interpersonal, and physical contributing factors. This is often managed by a team of several types of health care professionals (a multidisciplinary team). The multidisciplinary team may include primary care doctors or gynecologists, psychotherapists, sex therapists, and/or physical therapists.
A major focus of improving sexual desire or arousal is communication between sexual partners. It can be helpful for women to identify and tell their partner which things stimulate them and whether there is a sequence of sexual activities or a pace they prefer. Women may need to remind a partner that they want preparatory activities—which may involve touching or not—to get excited for sexual activity. For example, they may want to talk intimately, watch a romantic or erotic video, or dance. Women may want to kiss, hug, or cuddle. They may want more or different foreplay (their partner touching various parts of their body, the breasts or genitals) before moving to sexual intercourse or other sexual activity that involves penetration. Couples may experiment with different techniques or activities (including fantasy and sex toys) to find effective stimuli.
Measures recommended to treat sexual dysfunction in general can also help increase interest in sex. For example, eliminating distractions (such as a television in the bedroom) and taking measures to improve privacy and a sense of security can help. Doctors may recommend using intensely erotic stimuli (such as videos) and fantasizing.
If there is a medical or mental health issue that is negatively impacting sexual function, a doctor can recommend treatment. Other treatments depend on the cause. For example, if medications may be contributing, they are stopped if possible.
Psychological therapies, particularly mindfulness-based cognitive therapy, may benefit some women. Mindfulness involves focusing on what is happening in the moment. Mindfulness-based cognitive therapy, usually done in small groups, combines mindfulness and cognitive-behavioral therapy. It can help with arousal, orgasm, and the desire for sexual activity.
If a woman's body image or concept of herself as a sexual person are interfering with sexual function, or she has issues in her relationship or communication with a partner, doctors may suggest seeing a psychotherapist individually or as a couple or seeing a sex therapist.
Treatment of contributing factors
Because selective serotonin reuptake inhibitors (SSRIs, a type of antidepressant) may contribute to low sexual desire, a woman should speak with her doctor about the possibility of substituting another antidepressant that impairs sexual response less.
For postmenopausal women who are taking a full-body dose of estrogen and a progestogen, adding testosterone (given as a pill or cream applied to the skin), may help with sexual interest/arousal disorder. However, use of testosterone for this purpose is considered experimental, and women should discuss risks and benefits with their doctor. For women taking testosterone, doctors must regularly check for side effects such as acne, excess hair growth (hirsutism), and development of masculine characteristics (virilization).
If women have sexual pain, effective treatment of the pain may resolve issues with lack of sexual interest or arousal. This may be due to genitourinary syndrome of menopause, vulvodynia (chronic pain around the vulva), levator ani syndrome, pelvic infections, fibroids, endometriosis, or other causes.
Medications specifically for low sexual interest
There are several medication options that may help treat sexual interest/arousal disorder. In the United States, there are 2 medications available that are used to specifically treat this issue in premenopausal women. Flibanserin is a pill taken once daily; drinking alcohol must be avoided for at least 2 hours before taking it. Bremelanotide is an injection given under the skin 45 minutes before sexual activity.
Testosterone therapy
Some studies suggest that testosterone therapy may improve sexual desire in postmenopausal women, but this requires careful monitoring with blood tests to check for adverse effects and appropriate blood levels. High blood levels of testosterone in women can cause serious and sometimes permanent side effects, so certain forms (like injections or pellets) should be avoided. Little is known about the long-term effectiveness and safety of testosterone (taken by mouth or as a skin cream). Women should only be treated with testosterone by doctors with training and experience in female sexual dysfunction.
When taken for a short time, a pill that contains both testosterone and estrogen (usually also take with a progestogen) can be effective in postmenopausal women with sexual interest/arousal disorder. However, use of testosterone for this purpose is considered experimental and women should discuss risks and benefits with their doctor.
There are no prescription forms of testosterone alone manufactured for women in the United States. However, some doctors prescribe a skin cream or gel. Excessively high blood levels can be caused by testosterone pellets and injections, and can be associated with irreversible side effects.
If testosterone is prescribed, doctors explain the uncertainty of effectiveness and the risks of such therapy. They do blood tests to check liver function and measure lipid levels before testosterone is started. Testosterone is not prescribed if these test results indicate that a woman is at risk for liver problems or dyslipidemia (for example, too high a level of LDL, the "bad" cholesterol). Doctors schedule regular follow-up visits to check that levels are in the correct range and to check for side effects such as acne, excess facial or body hair growth, male pattern baldness, voice deepening, or enlargement of the clitoris.
Other therapies
Other medications are sometimes used to treat sexual interest/arousal disorder, but are supported by less research. Bupropion and buspirone may improve sexual desire in some women whose sexual problems are caused by certain antidepressants (SSRIs). Another medication that is sometimes used is trazodone; at low doses, it may improve sexual desire, but higher doses can sometimes cause side effects (such as drowsiness or dizziness).
Devices such as vibrators or clitoral suction stimulators may help with sexual arousal, but there is little evidence to support their effectiveness. Some of these products are available over the counter.
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