Female Sexual Dysfunction (FSD)

by Dr. Milton Lum

Female sexual dysfunction (FSD) refers to the various ways in which a woman is unable to participate in a sexual relationship as she would wish. It is not uncommon. The causes of FSD are usually both psychological and somatic, with each process impacting on the other.

Sidi H. and others, in their study on 'The Prevalence Of Sexual Dysfunction And Potential Risk Factors That May Impair Sexual Function In Malaysian Women' which was published in the Journal of Sexual Medicine in 2007, reported that the prevalence of FSD in the primary care population was 29.6%. The prevalence of low sexual arousal, lack of lubrication and sexual dissatisfaction were 60.9%, 50.4% and 52.2% respectively. The risk factors for FSD are older age, Malays, married longer (more than 14 years), having less sexual intercourse (less than 1 to 2 times a week), having more children, married to an older husband (aged over 42 years) and having a higher academic status.

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The American Medical Association reported a decade ago that sexual dysfunction affected about 43% of American women. Women under 20 and over 50 years experienced problems with arousal, orgasm, and satisfaction. However, the majority of FSD occurred after menopause, when hormone production drops and vascular conditions are more common.

It has been argued that FSD need to be viewed in context and not as an experience in isolation of other circumstances, and that it is necessary to measure both low sexual function and sexually related distress.

The lack or loss of sexual desire is one of the most common presenting problems but is often not easy to treat. The definition of lack or loss of desire is difficult. Whether it is abnormal or a variation of the normal state has been the subject of numerous debates. Whether desire is a thought or feeling is still unclear.

Causes of FSD

The causes of lack or loss of desire are not well understood. However, they can be divided into medical and psychological causes and medications. The human sexual response involves the sexual organs : genitals, breasts and the vascular, nervous and hormone (endocrine) systems. As such, any condition that affects the sexual organs and these systems can lead to a lack or loss of sexual desire.

Decreased blood flow to the pelvic organs can lead to a reduction in the sensitivity of the genital organs, especially the clitoris, and dryness thereby impairing arousal. This decrease can be due to aging, stress, diabetes and atherosclerosis.

Decreased levels of sex hormones, such as estrogen and testosterone, can affect sexual desire. The female hormone, oestrogen, is associated with sexual desire. Some women experience diminished sexual desire and impaired sensitivity following the menopause or hysterectomy as a result of reduced estrogen.

The male hormone, testosterone, plays an important role in a woman’s sexual development and functioning, including sensitivity of the breasts and clitoris. This hormone is produced in almost equal proportions by the ovaries and the adrenal glands, which are located on top of the kidneys. The production is reduced after the menopause, whether natural or surgical, or during chemotherapy for cancer.

Conditions and medications that cause an increase in the blood prolactin levels can also reduce sexual drive. The conditions include pituitary gland tumours, hypothyroidism, hypothalamic disease, liver cirrhosis, other liver disease and stress.

Other medical causes that may lead to lack or loss of desire include obstetric, gynaecological and urological causes of pain or discomfort on sexual intercourse; vaginal atrophy; urinary incontinence which can lead to embarrassment and avoidance; endocrine, neurological and psychiatric disorders; surgery involving the pelvic floor, bladder, abdomen, and genitals; spinal cord injury which can cause nerve damage and even paralysis; endocrine disorders; alcohol and substance abuse, including smoking.

Various medications can affect a woman’s sexual function and they include:

* Anti-androgens (cyproterone, gonadotrophin releasing hormone (GnRH) analogues)
* Anti-oestrogens and other hormones (contraceptives, tamoxifen)
* Anti-cancer drugs (methotrexate)
* Psychotrophic drugs (sedatives, hypnotics, narcotics, stimulants)

It is often difficult to separate medical from psychological causes. In considering psychological causes, it is important to remember that a woman has different and separate roles at different stages in life, as daughter, friend, worker, lover, housewife and mother. The woman's initial roles as daughter, worker and lover are usually not too onerous. However, as her responsibilities increase, the role of lover may decrease because of increasingly diverse claims on her time.

The lack or loss of desire can be due to inadequate genital stimulation. This is particularly so in healthy young women in which poor communication, inattention and lack of knowledge may lead to men not having sufficient know-how on how to stimulate a woman to arousal.


The management of lack or loss of desire is challenging as it requires an integrated approach involving the participation of the affected woman and her sexual partner. The history taking and physical examination seeks to evaluate any medical conditions that cause physical illness, medication intake and their treatment(s). Issues concerning sexual history and knowledge, psychological characteristics, relationship with and attraction to the sexual partner and life's changes are also assessed.

A distinction has to be made between disorders that are life-long and those that are acquired, as well as those that are situational and comprehensive. Medical causes have to be evaluated and treated adequately, for instance, good diabetic control with medicines or hormones in postmenopausal women.

Education plays an important role in the management. This involves an affected woman and her partner. Its content includes the physiology and psychology of sex and the need for good communication between the partners as well as its improvement. Many patients with this problem will be treated with cognitive behavioural approaches. Both the woman and her sexual partner will be asked to keep a diary of a typical week. There will be focus on the time which the couple have for each other alone as this is the time that sexual activity is more likely to take place. The couple will also have to explore their sexual knowledge and priorities.

This approach helps the patient and her partner to understand the problem better. As they realise their assumptions about their feelings, they will be helped to appreciate the differences in their sexuality and sexual needs. This encourages the acceptance of difference, which will contribute significantly to a solution of the problem.

The causes of the loss of sexual desire are medical, psychological and medication. The appropriate management of medical causes is essential. A change of medication will be considered when the problem is due to the side effects of medication. Those who have psychological problems are managed with cognitive behavioural approaches. An integrated approach is often needed as there is usually a combination of causes.

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