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Female Sexual Dysfunction

Female sexual dysfunction (FSD) affects approximately 43% of American women, with 12% experiencing distress significant enough to meet criteria for a sexual disorder; distress peaks at ~15% among women aged 45–64 years.[1] ACOG recommends that obstetrician-gynecologists initiate clinical discussion of sexual function during routine care visits to identify issues and destigmatize the topic.[1] For urogynecologists and pelvic reconstructive surgeons, FSD intersects with daily practice — dyspareunia and genito-pelvic pain drive surgical referrals, vaginal estrogen is a perioperative adjunct, and many patients undergoing prolapse or incontinence repair have overlapping sexual concerns that require evaluation and counseling.

Prevalence and epidemiology​

FSD is highly prevalent, with an estimated overall prevalence of 39–50% for sexual symptoms and ~12–20% for clinically distressing dysfunction.[2][3][4] A 2024 NEJM review highlighted that low desire progressively increases with age, but sexually associated distress concurrently declines, so that the peak in hypoactive sexual desire dysfunction emerges during midlife.[5] In a large Australian community-based study, 27.4% of women aged 18–24 and 58.9% of women aged 45–49 had low desire, but distressing dysfunction peaked in the middle-age groups.[5]

Arousal dysfunction affects approximately 3–9% of women aged 18–44 and 5–7.5% of women aged 45–64.[5] Among young women (18–39 years), 20.6% have at least one FSD, with sexual self-image dysfunction (11.1%) the most prevalent subtype. Psychotropic medication use was significantly associated with all FSD subtypes in this population.[4]

DSM-5 classification​

The DSM-5 identifies four types of female sexual dysfunction.[1][6] All diagnoses require ≥6 months duration (except substance-induced), clinically significant personal distress, and exclusion of another mental disorder, relationship distress, or medical condition as primary explanation.

DSM-5 DisorderCore features
Female Sexual Interest/Arousal Disorder (FSIAD)Absent/reduced interest, thoughts/fantasies, initiation/responsiveness, excitement, or genital/nongenital sensations during activity
Female Orgasmic DisorderAbsent, delayed, infrequent, or markedly reduced intensity of orgasm
Genito-pelvic Pain/Penetration Disorder (GPPPD)Difficulty with penetration, vulvovaginal/pelvic pain, fear/anxiety about pain, or pelvic floor muscle tensing; combines former diagnoses of vaginismus and dyspareunia
Substance/Medication-Induced Sexual DysfunctionTemporally linked to a substance or medication

The ISSWSH/ICSM classification separates desire from arousal (cognitive vs. genital arousal), adds persistent genital arousal disorder (PGAD), and further expands orgasm disorder subtypes by frequency, intensity, timing, and pleasure dimensions.[2] Pain disorders are classified identically between the two systems.

Evaluation​

The initial evaluation may require an extended visit and should include a comprehensive history and physical examination.[1] A detailed sexual history should cover:

  • Sexual and gender identity
  • Symptom nature, duration, and onset (acquired vs. lifelong; generalized vs. situational)
  • Personal distress level
  • Partner factors and relationship quality
  • History of abuse or trauma
  • Genito-pelvic activities and injuries
  • Sleep quality and body image concerns

Validated instruments: Female Sexual Function Index (FSFI) and Female Sexual Distress Scale (FSDS) are useful adjuncts for quantifying symptom burden and tracking treatment response.[1]

Laboratory testing is typically not necessary unless an undiagnosed medical etiology is suspected.[1]

Risk factors and contributing conditions​

FSD is multifactorial, requiring a biopsychosocial framework:[2][5]

  • Biological: menopause/hypoestrogenism (GSM), diabetes, cardiovascular disease, neurologic conditions, pelvic floor dysfunction, endometriosis, chronic pain, surgical history (hysterectomy, oophorectomy)
  • Medications: SSRIs/SNRIs, antipsychotics, hormonal contraceptives, antiepileptics, opioids, antihypertensives
  • Psychological: depression, anxiety, history of sexual trauma, body image concerns, stress
  • Relational: partner sexual dysfunction, relationship conflict, communication barriers
  • Sociocultural: cultural/religious beliefs, inadequate sex education

ACOG evidence-graded recommendations​

Level A (good and consistent evidence)[1]​

  • Low-dose vaginal estrogen is the preferred hormonal treatment for FSD due to GSM
  • Low-dose systemic hormone therapy (estrogen ± progestin) is an alternative for women with both dyspareunia from GSM and vasomotor symptoms
  • Ospemifene is an alternative to vaginal estrogen for dyspareunia caused by GSM
  • Systemic DHEA is not effective and is not recommended for sexual interest/arousal disorders

Level B (limited or inconsistent evidence)[1]​

  • Psychological interventions (CBT, mindfulness-based therapy, couples therapy, sexual skills training) are recommended as part of treatment
  • Short-term transdermal testosterone can be considered for postmenopausal women with sexual interest/arousal disorders after appropriate counseling about risks and unknown long-term effects
  • Flibanserin can be considered for HSDD in premenopausal women without depression, with counseling about alcohol-related risks
  • Intravaginal prasterone, low-dose vaginal estrogen, and ospemifene can all be used for moderate-to-severe dyspareunia from GSM
  • Sildenafil should not be used for female interest/arousal disorders outside clinical trials
  • Vaginal CO₂ laser should not be used outside a research setting

Level C (consensus/expert opinion)[1]​

  • Pelvic floor physical therapy is recommended for genito-pelvic pain/penetration disorders
  • Lubricants, topical anesthesia, and moisturizers may help reduce dyspareunia
  • If transdermal testosterone is used, a 3–6 month trial is recommended with baseline and follow-up testosterone levels to confirm levels remain in the normal premenopausal range; discontinue at 6 months if no response

Pharmacologic treatments​

Flibanserin (Addyi)​

FDA-approved for acquired, generalized HSDD in premenopausal women only.[7] Mechanism: modulates serotonin, dopamine, and norepinephrine pathways (5-HT1A agonist / 5-HT2A antagonist). Efficacy is modest: a meta-analysis of 8 trials (5,914 participants) showed an increase of ~0.5 satisfying sexual events (SSEs) per month over placebo, with significant side effects including dizziness, somnolence, nausea, and fatigue.[5] Alcohol must be avoided within 2 hours of dosing due to risk of hypotension and syncope; contraindicated with strong CYP3A4 inhibitors or hepatic impairment.[2]

Bremelanotide (Vyleesi)​

FDA-approved for acquired, generalized HSDD in premenopausal women.[8] Mechanism: melanocortin-4 receptor agonist administered subcutaneously (1.75 mg) as needed ~45 minutes before anticipated sexual activity. The RECONNECT phase 3 trials (n = 1,267) demonstrated statistically significant improvements in desire (FSFI-desire domain increase of 0.35 over placebo, p<0.001) and reductions in distress.[9] The most common adverse effects are nausea (40%), flushing (21%), and headache (12%).[10] The 52-week open-label extension showed sustained improvements with no new safety signals,[10] and efficacy was consistent across age, weight, BMI, and baseline testosterone subgroups.[11]

Transdermal testosterone​

The only evidence-based indication for testosterone in women is postmenopausal HSDD, per the 2019 Global Consensus Position Statement.[12] A meta-analysis of 36 RCTs (8,480 participants) showed testosterone significantly increased SSEs by ~0.85/month, with improvements in desire, arousal, orgasm, pleasure, and reduced distress.[13]

No FDA-approved female testosterone formulation exists in the United States. A transdermal 1% testosterone cream is approved in Australia.[5] When prescribed off-label, a fractionated dose of a regulator-approved male formulation is preferred over compounded preparations, with regular monitoring of serum testosterone and clinical assessment for androgen excess.[5][12] More than 2 million testosterone prescriptions are written annually for women in the U.S.[5] Oral testosterone adversely affects HDL and LDL cholesterol; transdermal routes are preferred.[5][13] Side effects include acne, increased facial/body hair, and weight gain; long-term safety data are lacking.[12] A 2025 review confirmed that two clinical guidelines now provide expert guidance on testosterone treatment and monitoring for HSDD in women.[14]

Non-pharmacologic treatments​

A 2025 systematic review and meta-analysis confirmed that mindfulness-based CBT significantly improved total FSFI scores and subscales of desire, arousal, and orgasm, and that all three modalities — CBT, flibanserin, and bremelanotide — reduced distress.[15] No studies have yet directly compared CBT to pharmacotherapy.

ModalityTarget disorderEvidence levelNotes
CBT / mindfulness-based therapyDesire, arousal, orgasmLevel BSignificant FSFI improvement; first-line for psychogenic disorders[15]
Couples therapy / sex therapyDesire, arousal, relationalLevel BAddresses partner and communication factors[1]
Pelvic floor physical therapyGPPPDLevel CFirst-line for pain/penetration disorders[1]
Vaginal dilatorsGPPPD / introital narrowingLevel CAdjunct to PFPT[1]
Lubricants / moisturizersDyspareuniaLevel COTC; adjunctive to all strategies[1]

Treatment summary​

TreatmentIndicated disorderRouteKey dataNotable risks
Vaginal estrogenDyspareunia (GSM)VaginalLevel A; gold standard for postmenopausal dyspareunia[1]Minimal systemic absorption at low doses
OspemifeneDyspareunia (GSM); OABOralLevel A/B; SERM with vaginal agonist + breast antagonist activity[1]Fluconazole interaction (2.7× AUC); take with food
Vaginal DHEA (prasterone)Dyspareunia (GSM); FSIADVaginalLevel B; improves all 6 FSFI domains[1]No systemic E2 elevation (AI-user safe)
FlibanserinHSDD (premenopausal)Oral+0.5 SSE/month over placebo[5]Alcohol contraindication; CYP3A4 interactions
BremelanotideHSDD (premenopausal)SC injection+0.35 FSFI desire over placebo (RECONNECT)[9]Nausea 40%; flushing 21%
Transdermal testosteroneHSDD (postmenopausal)Transdermal+0.85 SSE/month (36 RCT meta-analysis)[13]Androgen excess; no FDA approval in US
CBT / mindfulnessDesire, arousal, orgasm—Significant FSFI improvement[15]None
Pelvic floor PTGPPPD—Level C consensus[1]None

Cross-references​

References​

1. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology. "Female Sexual Dysfunction: ACOG Practice Bulletin Clinical Management Guidelines, Number 213." Obstet Gynecol. 2019;134(1):e1–e18. doi:10.1097/AOG.0000000000003324

2. Dalrymple SN, Hoeg L, Thacker H. "Female Sexual Dysfunction: Common Questions and Answers." Am Fam Physician. 2025;111(5):433–442.

3. Vechiu C, Zimmermann M, Aubuchon-Endsley N, et al. "Female Sexual Dysfunction in Primary Care: A Systematic Review and Meta-Analysis of Prevalence." J Womens Health. 2025. doi:10.1177/15409996251410095

4. Zheng J, Skiba MA, Bell RJ, Islam RM, Davis SR. "The Prevalence of Sexual Dysfunctions and Sexually Related Distress in Young Women: A Cross-Sectional Survey." Fertil Steril. 2020;113(2):426–434. doi:10.1016/j.fertnstert.2019.09.027

5. Davis SR. "Sexual Dysfunction in Women." N Engl J Med. 2024;391(8):736–745. doi:10.1056/NEJMcp2313307

6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). American Psychiatric Association; 2022.

7. U.S. Food and Drug Administration. FDA Orange Book: Approved Drug Products with Therapeutic Equivalence Evaluations. https://www.accessdata.fda.gov/scripts/cder/ob/

8. Dhillon S, Keam SJ. "Bremelanotide: First Approval." Drugs. 2019;79(14):1599–1606. doi:10.1007/s40265-019-01187-w

9. Kingsberg SA, Clayton AH, Portman D, et al. "Bremelanotide for the Treatment of Hypoactive Sexual Desire Disorder: Two Randomized Phase 3 Trials." Obstet Gynecol. 2019;134(5):899–908. doi:10.1097/AOG.0000000000003500

10. Simon JA, Kingsberg SA, Portman D, et al. "Long-Term Safety and Efficacy of Bremelanotide for Hypoactive Sexual Desire Disorder." Obstet Gynecol. 2019;134(5):909–917. doi:10.1097/AOG.0000000000003514

11. Simon JA, Kingsberg SA, Portman D, et al. "Prespecified and Integrated Subgroup Analyses From the RECONNECT Phase 3 Studies of Bremelanotide." J Womens Health. 2022;31(3):391–400. doi:10.1089/jwh.2021.0225

12. Davis SR, Baber R, Panay N, et al. "Global Consensus Position Statement on the Use of Testosterone Therapy for Women." J Clin Endocrinol Metab. 2019;104(10):4660–4666. doi:10.1210/jc.2019-01603

13. Islam RM, Bell RJ, Green S, Page MJ, Davis SR. "Safety and Efficacy of Testosterone for Women: A Systematic Review and Meta-Analysis of Randomised Controlled Trial Data." Lancet Diabetes Endocrinol. 2019;7(10):754–766. doi:10.1016/S2213-8587(19)30189-5

14. Kling JM. "Testosterone for the Treatment of Hypoactive Sexual Desire Disorder in Perimenopausal and Postmenopausal Women." Obstet Gynecol. 2025. doi:10.1097/AOG.0000000000006015

15. Toledo RG, Winkelman WD, Reyes-Gonzalez D, et al. "Female Sexual Desire, Arousal, and Orgasmic Dysfunctions: A Systematic Review and Meta-Analysis of Treatment Options." J Minim Invasive Gynecol. 2025. doi:10.1016/j.jmig.2025.06.004