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Female Sexual Dysfunction

In a national survey of 31,581 U.S. women aged 18 and older, the age-adjusted prevalence of any sexual problem was 43.1%; 12.0% reported both a sexual problem and sexually related personal distress, a combined measure found in 10.8% at ages 18–44, 14.8% at 45–64, and 8.9% at 65–85.[1][36] ACOG recommends that obstetrician-gynecologists initiate clinical discussion of sexual function during routine care visits to identify issues and destigmatize the topic.[1] Dyspareunia, genito-pelvic pain, and sexual concerns warrant evaluation in prolapse and incontinence care; vaginal estrogen treats GSM symptoms.[1][40]

Acronym reference​

AcronymExpansion
FSDFemale Sexual Dysfunction
HSDDHypoactive Sexual Desire Disorder
FSIADFemale Sexual Interest / Arousal Disorder
GPPPDGenito-Pelvic Pain / Penetration Disorder
PGADPersistent Genital Arousal Disorder
GSMGenitourinary Syndrome of Menopause
DSM-5Diagnostic and Statistical Manual of Mental Disorders, 5th edition
ISSWSHInternational Society for the Study of Women's Sexual Health
ICSMInternational Consultation on Sexual Medicine
ACOGAmerican College of Obstetricians and Gynecologists
FSFIFemale Sexual Function Index (validated symptom-burden instrument)
FSDSFemale Sexual Distress Scale
SSESatisfying Sexual Event (the standard outcome metric across HSDD trials)
CBTCognitive Behavioral Therapy
PFPTPelvic Floor Physical Therapy
SERMSelective Estrogen Receptor Modulator
DHEADehydroepiandrosterone
SSRI / SNRISelective Serotonin / Serotonin-Norepinephrine Reuptake Inhibitor

Prevalence and epidemiology​

FSD is highly prevalent. A primary-care meta-analysis estimated overall prevalence at 39%.[3] In a community survey of Australian women aged 18–39, 50.2% had sexually related personal distress and 20.6% had at least one FSD, defined as low function in a domain plus distress.[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 disorder (HSDD) 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 hypoactive sexual desire dysfunction peaked during midlife.[5]

Unspecified arousal dysfunction has been reported in population-based studies in approximately 3–9% of women aged 18–44 and 5–7.5% of women aged 45–64.[5] In a community survey of Australian women aged 18–39 years, 20.6% had at least one FSD, with sexual self-image dysfunction (11.1%) the most prevalent subtype.[4] 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] DSM-5 diagnoses generally require symptoms for at least six months (except substance/medication-induced dysfunction), clinically significant personal distress, and exclusion of a nonsexual mental disorder, medical condition, severe relationship distress, or another significant life stressor as a better explanation.[1]

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 International Society for the Study of Women's Sexual Health / International Consultation on Sexual Medicine (ISSWSH / ICSM) classification separates desire from arousal (cognitive versus genital arousal), adds persistent genital arousal disorder (PGAD) (see PGAD/GPD), and further expands orgasm-disorder subtypes by frequency, intensity, timing, and pleasure dimensions.[2]

Evaluation​

The initial evaluation may require an extended visit and should include a comprehensive history and physical examination.[1] Before prolapse repair, document baseline sexual activity and dyspareunia for counseling about postoperative sexual outcomes.[42] A detailed sexual history should cover:

  • Sexual and gender identity
  • Symptom nature, duration, and onset (acquired versus lifelong; generalized versus 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. ACOG describes the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale (FSDS) as research tools that may be useful clinical adjuncts.[1] The Decreased Sexual Desire Screener (DSDS) is a brief HSDD screener;[25] the SIDI-F measures HSDD severity;[26] PROMIS SexFS v2.0 includes genital discomfort domains;[27] and PISQ-IR is designed for pelvic-floor-disorder populations and includes sexually inactive respondents.[28] For the full instrument catalog with comparison table, scoring details, psychometric data, and a "which instrument when" practical-guidance block see Assessment Tools — Female Sexual Function.

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

Physical examination. A structured, outside-in genital exam complements the history and gives a documented baseline before treatment starts: pubic hair pattern; labia majora for skin or lichenoid changes and postmenopausal flattening from labial fat-pad loss; labia minora for resorption or fusion (GSM findings).[29][34] Record oral-contraceptive use, breastfeeding, and breast-cancer endocrine therapy in the history as possible contributors to genital dryness or vulvar pain.[29][32][35] Retract the clitoral hood to visualize the glans corona; incomplete visualization suggests adhesions or phimosis, which may coexist with lichen sclerosus, and light cotton-swab contact can localize glans pain or hypersensitivity.[19][29] Inspect the urethral meatus for telescoping, caruncles, or polyps and the vestibule for erythema. Map vestibular and periurethral-gland tenderness systematically with a cotton swab after separating the labia, distinguishing it from pain in surrounding vulvar skin; palpate the urethra, bladder neck, and bladder separately to localize pain.[19][29][31] Vestibular tenderness prompts assessment for GSM, infection, dermatoses, provoked vestibulodynia, and pelvic-floor hypertonicity.[32][35] Hormonal factors and neuroproliferation are potential associated factors of vulvodynia.[32] Inspect the vagina with a speculum, rotating it 90° to visualize the anterior and posterior walls.[33] After prior midurethral sling surgery, inspect for vaginal mesh exposure and scarring and localize focal tenderness.[41] Palpate the pelvic floor circumferentially with one digit, including the levator ani, to assess tenderness or hypertonicity.[31][35]

Risk factors and contributing conditions​

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

  • Biological: menopause / hypoestrogenism (genitourinary syndrome of menopause, 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 or religious beliefs, inadequate sex education

ACOG 2019 evidence-graded recommendations​

These grades summarize the 2019 ACOG bulletin. The 2025 AUA/SUFU/AUGS GSM guideline recommends offering local low-dose vaginal estrogen for dyspareunia , offering vaginal DHEA , and permits ospemifene .[29] The 2025 AUA/SUFU/AUGS GSM guideline says evidence does not support CO₂ laser for GSM-related dryness, discomfort, dysuria, or dyspareunia , while clinicians may consider it for those symptoms in patients who are not candidates for, or prefer alternatives to, FDA-approved treatments, with disclosure that use outside trials is experimental .[29] For subsequent FDA labeling changes, including flibanserin eligibility, use the current prescribing information summarized below.

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 (cognitive behavioral therapy [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 [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 in postmenopausal women with sexual interest or arousal disorders, ACOG recommends a 3–6-month trial with testosterone measured at baseline and after 3–6 weeks to confirm levels remain in the normal premenopausal range. During continued therapy, reassess clinical response and testosterone every six months; discontinue at six months without response.[1]

Pharmacologic treatments​

Flibanserin (Addyi)​

FDA-approved for acquired, generalized HSDD in women younger than 65 years, including postmenopausal women (label expanded December 2025).[7] Exclude desire loss primarily explained by another condition, relationship problems, or medication effects.[7] Flibanserin has 5-HT1A agonist and 5-HT2A antagonist activity in vitro; its therapeutic mechanism in HSDD is unknown.[7] Efficacy is modest: a meta-analysis of 8 trials (5,914 participants) showed an increase of about 0.5 satisfying sexual events (SSEs) per month over placebo, with significant side effects including dizziness, somnolence, nausea, and fatigue.[5] For alcohol safety, wait at least 2 hours after 1–2 standard drinks before the bedtime dose; skip the dose after 3 or more drinks. After taking it, avoid alcohol until the next day. Moderate or strong CYP3A4 inhibitors and hepatic impairment are contraindications; discontinue flibanserin after eight weeks without symptom improvement.[7] See the Flibanserin pharmacology page for the full prescribing framework.

Bremelanotide (Vyleesi)​

FDA-approved for acquired, generalized HSDD in premenopausal women.[8] Bremelanotide activates multiple melanocortin receptors, especially MC1R and MC4R at therapeutic doses; its mechanism for improving HSDD is unknown. Administer 1.75 mg subcutaneously at least 45 minutes before anticipated activity; do not administer more than one dose within 24 hours, and more than eight doses per month is not recommended.[18] The 24-week RECONNECT phase 3 trials randomized 1,267 women; in the modified intention-to-treat efficacy population (n = 1,202), the integrated placebo-adjusted FSFI-desire domain change was 0.35 (p < 0.001), with a reduction in distress.[9] Among the 684 women who entered the 52-week open-label extension, the most common drug-related treatment-emergent adverse events were nausea (40%), flushing (21%), and headache (12%).[10] In the 52-week open-label extension, 684 enrolled and 272 completed follow-up; sustained improvement and no new safety signals were reported, with interpretation limited by attrition and no concurrent control.[10] Most prespecified age, weight, BMI and testosterone subgroups favored treatment, with exceptions.[11] See the Bremelanotide pharmacology page for the full prescribing framework.

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 women) found that, in eight studies of postmenopausal women measuring satisfying sexual events over four weeks, testosterone increased events by a pooled 0.82 versus placebo or another comparator (95% CI 0.50–1.15); desire, arousal, orgasm, pleasure, and distress outcomes in postmenopausal women also favored testosterone.[13]

No FDA-approved female testosterone formulation exists in the United States.[5] 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 US.[5] Oral testosterone raised LDL cholesterol and lowered HDL cholesterol in the meta-analysis, whereas non-oral routes did not.[13] Transdermal routes are preferred.[5] Acne and increased facial or body hair have been reported with physiologic-dose testosterone, and the meta-analysis also found weight gain.[12][13] ACOG warns that voice deepening and clitoral enlargement may occur and may be irreversible; long-term safety data are lacking.[1] A 2025 review confirmed that two clinical guidelines now provide expert guidance on testosterone treatment and monitoring for HSDD in women.[14] See the Female Testosterone for HSDD pharmacology page for the full prescribing and monitoring framework.

Medication-induced sexual dysfunction (SSRI/SNRI)​

In an eight-week open-label randomized trial with 50 married women completing follow-up, the group assigned Thursday–Friday drug holidays from SSRIs other than fluoxetine reported improved FSFI sexual-function scores.[37] Gradual antidepressant dose reduction remains another option; coordinate either change with the prescriber and monitor for recurrence of depression or anxiety and discontinuation symptoms, particularly with venlafaxine or desvenlafaxine.[38][39] In a four-week placebo-controlled trial of 42 SSRI-treated patients with sexual dysfunction, adjunctive bupropion SR improved self-reported desire and sexual-activity frequency versus placebo; differences in overall sexual function and orgasm were not statistically significant.[20] In a 10-week open-label study, 18 depressed minority women with low desire and poor SSRI tolerability or efficacy reported improvements in desire, arousal, and orgasm after switching to bupropion SR.[21] In an eight-week randomized trial of 98 women, most premenopausal, with remitted depression and SRI-associated sexual dysfunction, sildenafil improved clinician-rated global sexual function versus placebo (primary endpoint; mean between-group improvement 0.8; p = .001), while the Sexual Function Questionnaire orgasm domain also improved (secondary endpoint; mean between-group improvement 2.1; p = .01).[22]

Non-pharmacologic treatments​

A 2025 systematic review included 36 studies (26 randomized and 10 single-arm), excluded sexual pain conditions, and found 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 included study directly compared CBT with pharmacotherapy.

ModalityTarget disorderEvidence levelNotes
CBT / mindfulness-based therapyDesire, arousal, orgasmLevel BMay improve sexual function and distress; select according to the psychological and relational formulation.[15]
Couples therapy / sex therapyDesire, arousal, relationalLevel BAddresses partner and communication factors; integrate with treatment of contributing physical symptoms.[1]
Pelvic floor physical therapyGPPPDACOG Level CRecommended for genito-pelvic pain/penetration disorder.[1] When high-tone pelvic-floor dysfunction contributes, use relaxation-focused therapy; strengthening can exacerbate symptoms.[43]
Vaginal dilatorsGPPPD / introital narrowingNot gradedSelf-dilation for vaginismus, trigger points, or stenosis after radiation or other injury; data on optimal use are scant[1]
Lubricants / moisturizersDyspareunia; GSM-related drynessACOG 2019 Level C for dyspareunia; AUA/SUFU/AUGS 2025 Moderate Recommendation, Grade C for GSMOTC options may alleviate dyspareunia.[1] For GSM-related dryness or dyspareunia, the 2025 guideline recommends use alone or with other therapies.[29]
Clitoral vacuum-suction deviceGenital arousal disorderEros authorization; separate Fiera physiology dataThe prescription Eros clitoral therapy device received FDA marketing authorization in 2000; its vacuum pump applies gentle suction over the clitoris to increase blood flow.[23] A separate single-visit Fiera thermography study enrolled women without sexual dysfunction.[24]

Treatment summary​

Each pharmacologic row links to its dedicated pharmacology page for the full prescribing framework: dosing, contraindications, monitoring, and counseling details.

TreatmentIndicated disorderRouteKey dataNotable risks
Vaginal estrogenDyspareunia (GSM)VaginalACOG 2019 Level A: preferred hormonal treatment for dyspareunia due to GSM.[1] AUA/SUFU/AUGS 2025: offer local low-dose vaginal estrogen for dyspareunia .[29]Minimal systemic absorption at low doses
OspemifeneModerate-to-severe postmenopausal dyspareunia or vaginal drynessOralFDA-approved GSM indications; OAB is not an approved indication[16]Endometrial and cardiovascular boxed warnings; thromboembolic contraindications; US labeling advises against use with known, suspected or previous breast cancer; if feasible, discontinue at least 4–6 weeks before surgery associated with increased thromboembolism risk or during prolonged immobilization.[16]
Vaginal DHEA (prasterone)Moderate-to-severe postmenopausal dyspareuniaVaginalFDA-approved dyspareunia indication[17]Estrogen is a metabolite; label warns about current/past breast cancer and notes this population was not studied. Do not assume safety with aromatase inhibitors
FlibanserinAcquired, generalized HSDD in women younger than 65Oral at bedtimeModest average benefit; see label and dedicated page[7]Alcohol timing/skip-dose rules; moderate/strong CYP3A4 inhibitors and hepatic impairment contraindicated
BremelanotideHSDD (premenopausal)SC injection on demand+0.35 FSFI desire over placebo (RECONNECT)[9]; no significant between-group difference in the change in satisfying sexual events[18]Nausea 40%; flushing 20%; contraindicated with uncontrolled hypertension or known cardiovascular disease[18]
Transdermal testosteroneHSDD (postmenopausal)Transdermal+0.85 satisfying sexual events per 4 weeks versus placebo/comparator (eight-study pooled estimate)[13]Androgen excess; no FDA approval in US; long-term safety unknown
CBT / mindfulnessDesire, arousal, orgasm—Significant FSFI improvement[15]Discuss acceptability, access and possible emotional or physical discomfort
Pelvic floor PTGPPPD—Level C consensus[1]Discuss acceptability, access and possible emotional or physical discomfort

See Also​

Female sexual dysfunction context.

Pharmacology hubs (HSDD agents).

  • Flibanserin (Addyi): acquired, generalized HSDD in women younger than 65; bedtime dosing, alcohol precautions and CYP3A4 contraindications.[7]
  • Bremelanotide (Vyleesi): premenopausal HSDD on-demand SC; RECONNECT phase 3; contraindicated with uncontrolled hypertension or known cardiovascular disease.
  • Female Testosterone for HSDD: postmenopausal off-label transdermal; 2019 Global Consensus; Islam 2019 Lancet Diabetes Endocrinol meta.

Pharmacology hubs (GSM and dyspareunia agents).

Podcasts​

Urology’s Role in Advancing Female Sexual Health
BackTable OBGYN, Ep. 44 (2024) · Kelly Casperson, Suzette Sutherland
backtable.com

References​

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2. Dalrymple SN, Hoeg L, Thacker H. "Female Sexual Dysfunction: Common Questions and Answers." Am Fam Physician. 2025;111(5):433–442. PMID 40378324

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

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16. OSPHENA (ospemifene) tablets: US prescribing information. DailyMed label. Accessed September 11, 2026.

17. INTRAROSA (prasterone) vaginal inserts: US prescribing information. DailyMed label. Accessed September 11, 2026.

18. VYLEESI (bremelanotide) injection: US prescribing information. DailyMed label. Accessed September 11, 2026.

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