Sexual dysfunction in women: causes and treatment options

Sexual dysfunction in women is a persistent disturbance in desire, arousal, orgasm, or comfort during sexual intercourse that lasts for at least several months and causes significant internal discomfort or relationship problems. Importantly, occasional unsuccessful sexual encounters or periodic decline in interest in sex are not generally considered a disorder in and of themselves. A disorder is considered when a woman experiences changes in her sex life and would like to return to a more satisfying level. [1]

According to current data, sexual symptoms of varying severity are reported by up to 40% of women, but clinically significant disorders with significant psychological distress occur in approximately 10-20%, depending on age and research methodology. The incidence of some disorders increases with age, but this does not mean that sexuality inevitably "ends" after a certain age. Health, relationships with a partner, and cultural attitudes are often decisive factors. [2]

Modern medicine views sexual dysfunctions through a biopsychosocial model. This means that sexual function is simultaneously influenced by biological factors (hormones, illnesses, medications), psychological factors (mood, anxiety, past trauma), and social factors (relationships, stress, culture, religious beliefs). Often, all these levels are intertwined, so it's rare for a sexual problem to have a single cause. [3]

The key criterion for diagnosis is the presence of subjective suffering or problems in the couple. A slight or infrequent desire for intimacy may be normal if the woman is satisfied with her life and body, and her partner accepts this without conflict. Conversely, even with a formally "normal" frequency of contact, a woman may suffer from pain, disgust, or internal pressure—in which case, help is needed. [4]

Sexual dysfunction in women significantly reduces quality of life: it increases anxiety and depression, lowers self-esteem, and can provoke conflicts and relationship breakdowns. Therefore, today, it is considered an important part of women's health, not a "whim" or a "mood issue." Seeking help from a specialist is a normal step, not a cause for shame. [5]

Table 1. Main groups of sexual disorders in women

Group of violations	Examples of states	Main manifestations	Comment
Disorders of desire and interest	Sexual interest and arousal disorder	Decreased or absent desire and fantasies	The criterion of subjective distress is important
Arousal disorders	Disorders of subjective and genital arousal	Difficulty "switching on" even with stimulation	May be associated with vaginal dryness and discomfort
Orgasmic disorders	Delayed orgasm, lack of orgasm	Prolonged arousal without discharge	Often associated with anxiety and relationship problems
Pain and penetrating disorders	Genitopelvic pain and penetrative disorder, dyspareunia	Pain, spasm, fear of penetration	Includes both purely painful and mixed psychophysiological disorders

Normal female sexuality and the normal range

Female sexuality is highly variable. Some women experience spontaneous desire that arises spontaneously, while others experience so-called responsive desire, where interest in intimacy arises through caresses, physical contact, and emotional closeness with a partner. Both are considered normal. What's more important is not how often a woman thinks about sex, but how satisfied she is with her sex life. [6]

Sexual response involves several interconnected components: interest and fantasies, arousal, physical changes (increased blood flow to the genitals, lubrication), potential orgasm, and a feeling of satisfaction after intercourse. However, not every encounter ends in orgasm, and this isn't always a problem. For many women, the primary sources of satisfaction are feelings of intimacy, acceptance, relaxation, and pleasant bodily sensations, not just the peak of orgasm. [7]

Sexual desire and satisfaction are affected by age, hormonal fluctuations, pregnancy, childbirth, breastfeeding, menopause, chronic illness, fatigue, and stress. A decrease in spontaneous desire due to a busy schedule, childcare, or a demanding job is often an adaptation rather than a sign of illness. It's important to distinguish a temporary decrease in interest due to stress from a persistent and distressing disorder. [8]

The role of culture and upbringing also must not be forgotten. Strict taboos on discussing sex, feelings of shame about one's own body, and negative experiences with partners can become long-lasting and complicate the development of healthy sexuality. Under such conditions, a woman may perceive normal arousal responses as "wrong" or dangerous, leading to internal conflict and avoidance of intimacy. [9]

Finally, the quality of the relationship is crucial. Trust, emotional intimacy, a sense of security and respect increase the likelihood of a satisfying sex life, while constant conflict, criticism, infidelity, and hidden aggression almost inevitably undermine desire and the ability to relax. Therefore, assessing sexual function always begins with understanding the context—the woman's life as a whole, not just her hormonal levels. [10]

Table 2. Factors influencing sexual desire and satisfaction

Group of factors	Examples	How does it affect	Possibility of correction
Biological	Hormonal changes, chronic diseases	Fatigue, pain, decreased arousal	Treatment of the underlying disease, hormone therapy
Psychological	Depression, anxiety, past trauma	Loss of interest, fear of intimacy	Psychotherapy, support
Social and cultural	Stress, financial problems, strict prohibitions	Difficulty relaxing, feeling ashamed	Dealing with stress, changing attitudes
Relationship with a partner	Conflicts, betrayal, criticism of appearance	Decreased trust and desire	Family and couples therapy
Lifestyle	Lack of sleep, fatigue, lack of rest	Fatigue, decreased libido	Sleep hygiene, rest planning

Classification and main types of sexual disorders in women

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, groups disorders of sexual desire and arousal in women into a single category: "Female Sexual Interest and Arousal Disorder." To qualify for this diagnosis, several features must be present (e.g., lack of fantasy, decreased interest in sex, poor response to stimulation), persist for at least six months, and cause significant distress to the woman. [11]

Orgasmic disorders are a separate group. In this case, a woman may experience sexual arousal, but orgasm either fails to occur, is noticeably delayed, or is perceived as insufficiently intense, and this is significant for her. It's important to distinguish this situation from cases where the lack of orgasm is not perceived as a problem: not every woman places orgasm at the center of her sexual life, and this doesn't make her "abnormal." [12]

Another major category is genito-pelvic pain and penetration disorder. This includes situations where attempted penetration is accompanied by severe pain, pelvic floor muscle spasm, and fear, making penetration difficult or impossible. This may involve a combination of physiological and psychological mechanisms: past trauma, infections, endometriosis, vulvodynia, as well as learned fear of pain and muscle tension. [13]

The International Classification of Diseases, Eleventh Revision, proposes a slightly different structure: some sexual dysfunctions (such as arousal and orgasmic disorders) remain in the sections devoted to sexual health, while a number of pain conditions, such as dyspareunia and vulvodynia, are transferred to the section on diseases of the genitourinary system. This reflects the understanding that some pain problems are closer to chronic pain syndromes than to purely sexual disorders. [14]

In practice, a single woman often experiences several forms of disorders simultaneously. For example, prolonged pain during intercourse can lead to decreased desire and avoidance of intimacy, while chronic lack of orgasm can lead to low self-esteem and increased anxiety. Therefore, it is important for the physician to look at the whole picture rather than trying to fit the patient into a single, narrow diagnosis. [15]

Table 3. Main types of sexual disorders in women

Category	Brief description	Typical complaints	Possible consequences
Interest and arousal disorder	Decreased sexual fantasies, interest, and response to stimuli	"I don't want sex," "it's hard to get going"	Conflicts in couples, decreased self-esteem
Orgasmic disorders	Absence, delay, or decrease in intensity of orgasm	"I can't finish," "it keeps dragging on without release."	Tension, avoidance of intimacy
Genitopelvic pain and penetrative disorder	Pain, spasm, fear when trying to penetrate	"It hurts when inserted," "my body contracts."	Avoiding penetrative sex
Mixed forms	A combination of several of the above violations	A complex set of complaints	Requires comprehensive assessment and treatment

Causes and risk factors of sexual disorders

Biological causes include endocrine disorders (hypoestrogenic conditions, decreased androgen levels, hyperprolactinemia, thyroid disease), chronic somatic diseases (cardiovascular, neurological, autoimmune, oncological), and any conditions causing chronic pain, weakness, or severe fatigue. All of these can reduce sexual desire, make arousal difficult, or increase discomfort during intercourse. [16]

Medications play a significant role. Sexual side effects are particularly common with antidepressants that affect the serotonin system, some antipsychotics, hypertension medications, hormonal contraceptives, and antiandrogen agents. Sometimes, changing the medication or adjusting the dosage is sufficient to gradually improve sexual function, but this should only be done in consultation with your doctor. [17]

Psychological factors—depression, anxiety disorders, post-traumatic stress disorder, and negative experiences of sexual violence—can significantly reduce sexual desire and the ability to trust a partner. Low self-esteem, body image issues, internal inhibitions, and shame about sexuality also often lead to a decreased interest in sex or to pain and cramping when attempting intimacy. [18]

The quality of the relationship is no less important. Conflicts, chronic resentment, lack of emotional intimacy, violence, infidelity, and financial stress rarely go unnoticed in a woman's sex life. Even with normal hormonal levels and no serious illnesses, a woman may stop wanting intimacy with a particular partner if she feels unaccepted, criticized, or unsafe. [19]

Finally, cultural and religious attitudes are significant. Strict prohibitions on masturbation, beliefs about the "sinfulness" of female pleasure, a lack of sex education, and widespread myths about what is normal (for example, the expectation of an obligatory orgasm with every intercourse) create the basis for anxiety and a sense of "failure." Under such conditions, even minor violations are perceived as catastrophic and increase distress. [20]

Table 4. Examples of conditions and medications that affect sexual function

Factor category	Examples	Possible effects	Comment
Endocrine disorders	Hypothyroidism, hyperprolactinemia, estrogen deficiency	Decreased desire, dryness, fatigue	Require targeted examination
Chronic diseases	Heart failure, diabetes, neurological diseases	Fatigue, pain, decreased arousal	Comprehensive management of the disease is important
Psychotropic drugs	Antidepressants, neuroleptics	Decreased libido, anorgasmia	There are possible options for correcting therapy.
Hormonal agents	Combined contraception, antiandrogens	Changes in free androgen levels	Decisions are made jointly with the doctor
Psychological factors	Depression, traumatic experience	Loss of interest, avoidance of intimacy	Psychotherapy indicated

How do sexual disorders manifest themselves and how are they diagnosed?

At a consultation, a woman typically complains not of a "sexual disorder," but of specific experiences: lack of desire, inability to "turn on," dryness and pain during intercourse, inability to achieve orgasm, and fear of intimacy. The doctor first asks how long the symptoms have been present, how persistent they are, in what situations they are more pronounced, and how they affect relationships and quality of life. Particular attention is paid to whether the woman is suffering or is simply fulfilling her partner's expectations. [21]

Modern recommendations emphasize the importance of gentle, respectful conversation. The couple's sexual history, history of violence, past trauma, and mental disorders are explored, as well as any specific areas that cause discomfort. Sometimes, this is the first time a woman has spoken openly about the sexual side of her relationship, so sensitivity and non-judgment are essential. Whenever possible, the partner's perspective is also considered, but only with the patient's consent. [22]

Standardized questionnaires are used to quantitatively assess sexual function and treatment progress, such as the Female Sexual Function Index, which assesses desire, arousal, lubrication, orgasm, satisfaction, and pain. These tools do not automatically provide a diagnosis, but they help structure the conversation and track changes during therapy. The individual context and the woman's subjective perception remain important. [23]

The physical examination includes a general examination, an assessment of signs of endocrine disorders, and a gynecological examination using gentle techniques and an explanation of each step. If pain is present, it is important to distinguish between superficial and deep pain, and to assess the condition of the vagina, vulva, and pelvic floor muscles. Additionally, smears may be performed for infections, including chlamydia and gonococcal infections, as well as tests for other diseases if indicated. [24]

Laboratory hormonal tests are not always indicated, according to current data. Estrogen, testosterone, prolactin, or thyroid hormone levels are measured if a corresponding pathology is suspected. It is emphasized that testosterone measurements must be performed using accurate methods, especially if androgen therapy is being considered. Excessive testing without clear indications increases costs and anxiety, but rarely provides benefit. [25]

Table 5. Key questions in the initial assessment of sexual dysfunction in women

Scope of assessment	Sample questions	Why is the question asked?
History of symptoms	When did the changes start and are they permanent?	Distinguish between a temporary decline and a persistent disorder
Relationship context	What is your relationship with your partner like? Are there any conflicts?	Assess the contribution of interpersonal factors
Mental state	Are there any signs of depression, anxiety, or traumatic experiences?	Understand the role of psychological causes
Physical symptoms	Is there pain, dryness, fatigue?	Identify somatic diseases and pain syndromes
Drug therapy	What medications are taken regularly?	Find possible medicinal causes

Modern approaches to the treatment of sexual disorders in women

Treatment always begins with clarifying the causes and expectations. The first step is sex education: explaining the normal range of response, the factors influencing desire, and debunking myths about "having to always want it" or "having to orgasm with every act." Already at this stage, some women report relief: the feeling of "failure" is reduced, and space for dialogue with their partner is created. Lifestyle, sleep, stress levels, substance use, and the need for adjustments are also discussed. [26]

Non-pharmacological approaches are central to the treatment of most sexual disorders. These include individual and couples sex therapy, cognitive-behavioral approaches aimed at changing negative beliefs, reducing anxiety, and teaching communication skills. For genito-pelvic pain and penetrative disorder, pelvic floor muscle relaxation exercises, breathing exercises, desensitization with vaginal dilators, and specialist-prescribed physical therapy are widely used. [27]

When interest and arousal are disturbed, relationship work plays an important role: restoring emotional intimacy, finding mutually enjoyable scenarios, expanding the repertoire of caresses, and reducing pressure on the outcome. Women are helped to better understand what stimuli trigger their desire and learn to share this with their partner. Sometimes, mindfulness techniques are prescribed, aimed at restoring sensitivity to bodily sensations rather than constantly evaluating themselves "from the outside." [28]

Pharmacotherapy is used selectively and always with due consideration of the evidence base and potential risks. For premenopausal women with severe sexual interest and arousal disorder not associated with other diseases or medications, flibanserin and bremelanotide are registered in some countries. These medications act on central neurotransmitter systems, the effect is moderate and not pronounced in everyone, and there are contraindications and restrictions for use. The decision to use them is made by a physician after a thorough assessment of the condition. [29]

Androgen therapy is a separate area. International clinical guidelines allow systemic administration of testosterone to postmenopausal women with confirmed hypoactive sexual desire, if other causes have been ruled out and non-pharmacological measures have been ineffective. However, it is strongly recommended to use low doses, strictly monitor hormone levels and side effects, and avoid medications with unpredictable dosages. Self-administration of "gel" or injectable testosterone without specialist supervision is dangerous. [30]

If sexual dysfunction is associated with the use of antidepressants or other psychotropic medications, options include changing the medication, reducing the dose, rescheduling the medication, and adding medications that can partially offset the negative impact on sexual function. These decisions are the responsibility of the psychiatrist or therapist managing the underlying condition. It is important not to discontinue vital medications on your own for the sake of "improving sex"—this could be more dangerous than the disorder itself. [31]

Table 6. Examples of treatment approaches for various sexual disorders

Type of disorder	Basic measures	Possible additional methods	Specialists
Disturbances of interest and arousal	Education, relationship work, lifestyle changes	Psychotherapy, flibanserin or bremelanotide as indicated	Gynecologist, sexologist, psychotherapist
Orgasmic disorders	Training in stimulation techniques, reducing anxiety	Cognitive behavioral therapy, sometimes pharmacotherapy	Sexologist, psychotherapist
Genitopelvic pain and penetrative disorder	Pain therapy, pelvic floor physiotherapy	Desensitization, working with trauma	Gynecologist, physiotherapist, psychotherapist
Drug-induced disorders	Discussion of drug change, dose adjustment	Addition of compensating agents according to indications	Psychiatrist, therapist, gynecologist

Prevention, the role of the partner, and when to see a doctor

Preventing sexual dysfunction begins with an open and honest attitude about one's own sexuality. The more access a woman has to reliable information and the opportunity to calmly discuss intimate matters, the lower the risk that natural fluctuations in desire will be perceived as a catastrophe. Basic knowledge about physiology, the impact of stress and illness on sexual function, and the idea that "my reactions may differ from others, and that's normal" are helpful. [32]

The role of a partner is difficult to overestimate. Support, respect for boundaries, a willingness to listen and discuss difficult topics without pressure or accusations help reduce anxiety and restore desire. It's important to move away from the "someone has a problem" mentality and toward a shared search for solutions: how to make intimate life more comfortable, what scenarios work for both, and what triggers tension. Sometimes, simply changing the intimacy scenario and reducing the "obligation" of penetration can provide significant relief. [33]

A doctor should be consulted if a sexual problem persists for at least several months, interferes with a woman's life, causes suffering or conflict, or if alarming symptoms appear: pain, spotting, burning sensation, a sudden, sharp decrease in desire alongside other signs of illness, persistent low mood, or feelings of worthlessness. If partner violence is present, safety is paramount. [34]

The best entry point is often a gynecologist or general practitioner, who will, if necessary, refer to a sexologist, psychotherapist, pelvic floor physiotherapist, or other specialists. For many women, it's important to know that sexual dysfunction is a recognized medical problem for which modern diagnostic and treatment approaches exist, and that seeking help is not considered a sign of "weakness" or "shame." [35]

In the long term, maintaining overall health, regular physical activity, adequate sleep, stress management, and paying attention to your mental state and relationship quality can help reduce the risk of developing sexual dysfunction and alleviate its course if it does occur. Sexual health is not separate from the rest of your life, so self-care in a broad sense is an important part of prevention. [36]

Table 7. Situations in which it is important to consult a doctor

Situation	Why is this important?	Who to contact
Pain or burning during intercourse	It may be a sign of infection or other disease.	Gynecologist
Sudden decrease in desire with other symptoms of illness	Endocrine or mental disorders are possible.	General practitioner, endocrinologist, psychiatrist
Persistent absence of orgasm with severe suffering	An assessment and selection of non-drug and drug treatments is required.	Sexologist, psychotherapist
Suspected side effects of medications	Changes in therapy may be possible	The doctor who prescribed the drug
The presence of violence or threats in the relationship	The issue of safety is more important than sexual function	Doctor, psychologist, support and protection services