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FEMALE SEXUAL HEALTH: A CLINICIAN’S GUIDE

CONFIDENTIAL

Anna Nash

PhD, PA-C

University of Utah Midlife Women’s Health

March 18, 2025

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WHY WOMEN’S SEXUAL HEALTH?

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CONFIDENTIAL

THE DOUBLE STANDARD

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BARRIERS TO CARE

Embarrassment
Cultural sensitivity
Previous dismissal
Safety
Judgement
Privacy
Language
Sexual and gender diversity

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ISSWSH

MONTH 00, YEAR

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ISSWSH is committed to leading our field in research, education, and advocacy, providing a multifaceted approach that decreases the gap between science, patient care, and the communities we serve.
Together, we will address the complexities of sexual health, push the boundaries of knowledge, and make a true and lasting impact on the lives of those we serve. We invite you to join us on our transformative journey as we move towards a future where sexual health is recognized as a fundamental right without any barriers for the entire humanity. (Sue Goldstein)

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DEFINING FEMALE SEXUAL DYSFUNCTION

Present for at least 6 months.
Causing distress
Meets 3/6 diagnostic criteria: lack of interest/fantasies, lack of initiation, reduced pleasure, low response to cues, reduced sensation

DSM-V DEFINITION-FEMALE SEXUAL INTEREST AND AROUSAL DISORDER (FSIAD)

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FSIAD SCREENING TOOLS

FEMALE SEXUAL FUNCTION INDEX

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FSFI-FEMALE SEXUAL FUNCTION INDEX

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DSDS

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COMMON CONCERNS

CONFIDENTIAL

1	Low libido
2	Arousal & orgasm disorders
3	Painful Intercourse
4	Desire discrepancy

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LOW LIBIDO�HSDD

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WHAT IS LIBIDO

“A complex construct influenced by biological, psychological and social factors determining an individual’s sexual interest and propensity for sexual activity.” Stephen Levine, 1987

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ISSWSH DEFINITION

Low libido = hypoactive sexual desire disorder

Lack of motivation for sexual activity as manifested by

decreased or absent spontaneous desire (sexual thoughts or fantasies)
decreased or absent responsive desire to erotic cues and stimulation or inability to maintain desire or interest through sexual activity

Loss of desire to initiate or participate in sexual activity, including behavioral responses such as avoidance of situations that could lead to sexual activity, that is not secondary to sexual pain disorders and is combined with clinically significant personal distress that includes frustration, grief, incompetence, loss, sadness, sorrow or worry. Parish et al, 2021

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BIOPSYCHOSOCIAL MODEL

CONFIDENTIAL

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BIOLOGY

CONFIDENTIAL

1	Medical conditions, HTN, DM, hormones, pregnancy, breast feeding, menopause
2	Medications: SSRI’s SNRI’s, BP meds, opioids, chemo drugs, OCP’s

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PSYCHOLOGY/MOOD

1	Anxiety/stress
2	Depression

3	Trauma/abuse/past experiences
4	Body image

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SOCIOCULTURAL

CONFIDENTIAL

1	Religious �messaging
2	Lack of sex education

3	Stigma
4	Cultural / family influences

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INTERPERSONAL

CONFIDENTIAL

1	Relationship stress
2	Lack of emotional intimacy
3	Infidelity/trust

4	Abuse/coercion
5	Hygiene/weight

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DESIRE DISCREPANCY

CONFIDENTIAL

1	High-desire partner
2	Lower-desire partner
3	Wide variability
4	Distress

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TYPES OF DESIRE

CONFIDENTIAL




	Spontaneous Desire- what we often think of as sexual desire. Sexual or non-sexual stimuli yield to desire. Responsive Desire- acquired through sexual engagement. Start neutral, but arousal develops in the process.

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THE ROLE OF SEX THERAPY

Sex therapists can be very helpful in helping patients unearth and resolve the underlying psychological or relational issues.

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CLINICAL ASSESSMENT

Assess meaning of libido
What did their libido look like before?
Duration of symptoms
Situational, cyclical, generalized
History of anxiety or depression

LOW LIBIDO

Medication list
Health problems
Painful intercourse
Isolated or in conjunction with FSAD
Stress management strategies

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TREATMENT OPTIONS FOR LOW LIBIDO

Treat underlying conditions
Consider medication changes
Menopausal hormone therapy
HSDD treatment options

-Flibanserin

-Bremelanotide

-Wellbutrin

Stress management
CBT
Testosterone therapy
Supplements- Maca root, Kava, Ashwaganda

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PAINFUL INTERCOURSE AND LIBIDO

CONFIDENTIAL


	“Dyspareunia has been associated with a more negative attitude toward sexuality, with more sexual function impairment and with lower levels of relationship adjustment.” Meana et al 1997 “Women with dyspareunia, not surprisingly, were found to have a lower frequency of intercourse and lower levels of desire and arousal, and to be less orgasmic with oral stimulation and intercourse.” Laumann, Paik and Rosen 1999

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DIFFERENTIAL DIAGNOSIS OF DYSPAREUNIA �

Vaginal dryness or atrophy
Hymenal conditions
Vulvodynia
Pelvic floor dysfunction
Prolapse
Uterine fibroids
endometriosis
Vaginal infections
Pudendal nerve pain
Dermatologic conditions

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SEXUAL PAIN ASSESSMENT

Acquired or primary
Situational or generalized
Location- deep or on entry
Type of pain
Contributing factors
Pain outside of sex
Menstrual periods
Health conditions

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PHYSICAL EXAM

External genitalia: discoloration, inflammation, lesions, pallor, friability, hymenal remnants
Cotton swab testing of the vestibule and vulva
Vaginal canal: pallor, absent rugae, dryness, abnormal discharge/odor, prolapse
Cervix: polyps, lesions, friability,
Bimanual: vaginismus, hypertonicity of the levator ani muscles, CMT, adnexal masses

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PELVIC FLOOR MUSCULATURE

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VULVAR ANATOMY

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VULVAR DERMATOLOGIC CONDITIONS

Contact dermatitis
Lichen sclerosus
Lichen simplex chronicus
Lichen planus

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VULVAR DERM IMAGES

Vullvovaginaldisorders.com

Contact dermatitis

Lichen sclerosus

Lichen simplex chronicus

Lichen planus

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COMMON VULVAR IRRITANTS

soap, bubble baths and salts, detergent, shampoo, conditioner
adult or baby wipes
panty liners and their adhesives
nylon underwear, chemically treated clothing
vaginal secretions, sweat, and urine

douches, yogurt
spermicides, lubricants
perfume, talcum powder, deodorants
alcohol and astringents
scented toilet paper
sensitivity to some fabrics.

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COMMON VULVAR ALLERGENS

benzocaine
neomycin
chlorhexidine (in K-Y Jelly)
imidazole antifungal
propylene glycol (a preservative used in many products)
fragrances
tea tree oil
latex (in condoms and diaphragms).

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VULVODYNIA

Unprovoked- arises spontaneously without reason
Provoked- comes from something that normally wouldn’t cause pain- i.e., touch or pressure
Localized- isolated to specific areas of the vulva- i.e., the vestibule

CHRONIC VULVAR PAIN WITHOUT IDENTIFIABLE CAUSE

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VESTIBULODYNIA ASSESSMENT

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GSM-GENITOURINARY SYNDROME OF MENOPAUSE

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TREATMENT OPTIONS FOR DYSPAREUNIA

Vagina dryness/atrophy (GSM)- lubricants, vaginal estrogen (ring, tablet, cream), E+T, vaginal DEAH, prasterone, dilators
Hymenotomy
Vulvodynia- medications, local anesthetics, nerve blocks, topical gabapentin, hormones (E/T), PT, CBT
Pelvic floor dysfunction- vaginal dilators, pelvic floor PT
Prolapse- refer to Urogyn for management.
Uterine fibroids- depending on the size and extent; observation, surgical options
Endometriosis management
Vaginal infections- appropriate treatment
Dermatologic conditions- appropriate management. Most will also benefit from vaginal estrogen

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FEMALE SEXUAL AROUSAL DISORDERS

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ISSWSH NOMENCLATURE

Female genital arousal disorder
Persistent genital arousal disorder
Female orgasm disorder
Female orgasmic illness syndrome

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FEMALE GENITAL AROUSAL DISORDER (FGAD)

The inability to maintain adequate genital response for ≥ 6 months, including

vulvovaginal lubrication
engorgement of genitals
sensitivity of the genitalia associated with sexual activity

Disorders related to

vascular injury or dysfunction and/or
neurologic injury or dysfunction

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FEMALE ORGASM DISORDER

Characterized by a persistent or recurrent distressing compromise of orgasm frequency, intensity, timing, and or pleasure associated with sexual activity for ≥ 6 months:

Frequency: orgasm occurs with decreased frequency (diminished frequency of orgasm) or is absent (anorgasmia)
Intensity: orgasm occurs with less intensity (muted orgasm)
Timing: orgasm occurs too late (delayed orgasm) or too soon (spontaneous or premature orgasm) than desired by the woman
Pleasure: orgasm occurs with absent or decreased pleasure (anhedonia orgasm, pleasure dissociative orgasm disorder)

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PHYSICAL EXAM

External genitalia: discoloration, inflammation, lesions, pallor, urethral caruncle, resorption/fusion of the labia clitoral hood retraction.

Speculum exam: pallor, absent rugae, dryness

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CLITORAL HOOD PHIMOSIS�

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TREATMENT OPTIONS FOR FGAD

Education

anatomy
literature

Psychotherapy

CBT, mindfulness, relationship

Tools

Eros therapy device, vibrator

Medication

MHT

off label: testosterone, sildenafil
Supplements: L-arginine, Yohimbine, Tribulus terresteris

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TESTOSTERONE THERAPY

Systemic

-1% testosterone 5 mg/gm. 1 gram applied to the lower leg once daily. Can use retail formulations or compounded cream.

Local

-0.1% testosterone 1 mg/gm. 1 gram applied to the clitoris 45 min before sexual activity. Compounded cream.

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RETAIL TESTOSTERONE THERAPY

Testim or Androgel transdermal gel 50 mg/gram

Request a 5 ml syringe to be provided. Have the patient squeeze the packet or tube into the syringe. Apply 0.5 ml to the lower leg once weekly

Vogelxo gel pump 12.5 mg/1.25 gram

One pump applied to the lower leg QOD to start. Can increase to daily if serum levels are appropriate

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RISKS AND BENEFITS OF TESTOSTERONE*

Acne
Deepening of the voice
Alopecia
Abnormal hair growth
Weight gain
Aggression/agitation
Clitoromegaly

* These side effects are rare when physiologic doses of testosterone are used

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TESTING LEVELS

Recommended testing includes baseline level, then 3 months, 9 months and yearly
Range of 15-70 ng/dl

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PSYCHOEDUCATION

Come As You Are- Emily Nagoski
Becoming Orgasmic- Julia Heiman, Joseph LoPiccolo, David Palladini
She Comes First- Ian kerner
Better Sex Through Mindfulness- Lori Brotto
Becoming Cliterate- Laurie Mintz
The Pleasure Prescription- Dee Hartman and Elizabeth Wood
OMG Yes- omgyes.com
Sensate focus- sexualhealthsolutions.com

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REFERENCES

Meana M, Binik YM, Khalife S, et al. Biopsychosocial profile of women with dyspareunia. Obstet Gynecol. 1997;90:583-9.
Laumann E, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;281:537-44 Published erratum appears in JAMA 1999;281:1174]
Parish SJ, Cottler-Casanova S, Clayton AH, McCabe MP, Coleman E, Reed GM. The Evolution of the Female Sexual Disorder/Dysfunction Definitions, Nomenclature, and Classifications: A Review of DSM, ICSM, ISSWSH, and ICD. Sex Med Rev. 2021 Jan;9(1):36-56. doi: 10.1016/j.sxmr.2020.05.001. Epub 2020 Aug 13. PMID: 32800563.
Caregiver Action Network, 2025 https://www.caregiveraction.org/caregiving-and-intimacy
Musbahi E, Kamp E, Ashraf M, DeGiovanni C. Menopause, skin and common dermatosis. Part 3: genital disorders. Clin Exp Dermatol. 2022 Dec; 47(12):2123-2129. doi: 10.1111/ced.15400. Epub 2022 Oct 26. PMID: 36103137; PMCID: PMC10092407
Davis, S. R. (2021). Use of testosterone in postmenopausal women. Endocrinology and Metabolism Clinics, 50(1), 113-124.
Carlson, Nguyen (2024) https://www.ncbi.nlm.nih.gov/books/NBK559297/.

8. Written by Debra Fulghum Bruce, PhD, Lorna Collier

Medically Reviewed by Zilpah Sheikh, MD on July 23, 2024

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REFERENCES

Krakowsky, Y., & Grober, E. D. (2018). A practical guide to female sexual
dysfunction: An evidence-based review for physicians in Canada. Canadian Urological Association journal = Journal de l'Association des urologues du Canada, 12(6), 211–216. https://doi.org/10.5489/cuaj.4907
NVA https://www.isswsh.org/images/PDF/NVA.Self-help.guide.pdf
https://vulvovaginaldisorders.org/