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.
Acronym reference
The female sexual-medicine literature is acronym-dense. The full expansions used on this page:
| Acronym | Expansion |
|---|---|
| FSD | Female Sexual Dysfunction |
| HSDD | Hypoactive Sexual Desire Disorder |
| FSIAD | Female Sexual Interest / Arousal Disorder |
| GPPPD | Genito-Pelvic Pain / Penetration Disorder |
| PGAD | Persistent Genital Arousal Disorder |
| GSM | Genitourinary Syndrome of Menopause |
| DSM-5 | Diagnostic and Statistical Manual of Mental Disorders, 5th edition |
| ISSWSH | International Society for the Study of Women's Sexual Health |
| ICSM | International Consultation on Sexual Medicine |
| ACOG | American College of Obstetricians and Gynecologists |
| FSFI | Female Sexual Function Index (validated symptom-burden instrument) |
| FSDS | Female Sexual Distress Scale |
| SSE | Satisfying Sexual Event (the standard outcome metric across HSDD trials) |
| CBT | Cognitive Behavioral Therapy |
| PFPT | Pelvic Floor Physical Therapy |
| SERM | Selective Estrogen Receptor Modulator |
| DHEA | Dehydroepiandrosterone |
| SSRI / SNRI | Selective Serotonin / Serotonin-Norepinephrine Reuptake Inhibitor |
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 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 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 Disorder | Core features |
|---|---|
| Female Sexual Interest/Arousal Disorder (FSIAD) | Absent/reduced interest, thoughts/fantasies, initiation/responsiveness, excitement, or genital/nongenital sensations during activity |
| Female Orgasmic Disorder | Absent, 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 Dysfunction | Temporally 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 vs genital arousal), adds persistent genital arousal disorder (PGAD), and further expands orgasm-disorder subtypes by frequency, intensity, timing, and pleasure dimensions.[2] These frameworks overlap but are not interchangeable; distinguish pain, penetration difficulty, unwanted arousal and distress about low desire.
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] The Decreased Sexual Desire Screener (DSDS) is a brief HSDD screener; the SIDI-F-SR measures HSDD severity; PROMIS SexFS v2.0 includes genital discomfort domains; and PISQ-IR is designed for pelvic-floor-disorder populations and includes sexually inactive respondents. Scores support clinical assessment rather than independently establish a diagnosis. 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]
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/religious beliefs, inadequate sex education
ACOG 2019 evidence-graded recommendations
These grades summarize the 2019 bulletin. 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 (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 women younger than 65 years, including postmenopausal women (label expanded December 2025). Exclude desire loss primarily explained by another condition, relationship problems, or medication effects.[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] 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.[7] See the Flibanserin pharmacology page for the full prescribing framework.
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] In the 52-week open-label extension, 684 participants enrolled and 272 completed follow-up; reported sustained improvement and absence of new safety signals require interpretation in light of this attrition and the lack of a concurrent control,[10] and most prespecified age, weight, BMI and testosterone subgroups favored treatment, with exceptions; these analyses do not prove identical benefit in every subgroup.[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 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 US.[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] See the Female Testosterone for HSDD pharmacology page for the full prescribing and monitoring framework.
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; the review cannot rank those treatments head to head or establish effects in patients with sexual pain.
| Modality | Target disorder | Evidence level | Notes |
|---|---|---|---|
| CBT / mindfulness-based therapy | Desire, arousal, orgasm | Level B | May improve sexual function and distress; select according to the psychological and relational formulation.[15] |
| Couples therapy / sex therapy / PLISSIT | Desire, arousal, relational | Level B | Addresses partner and communication factors; integrate with treatment of contributing physical symptoms.[1] |
| Pelvic floor physical therapy | GPPPD | Level C | First-line for pain/penetration disorders[1] |
| Vaginal dilators | GPPPD / introital narrowing | Level C | Adjunct to PFPT[1] |
| Lubricants / moisturizers | Dyspareunia | Level C | OTC; adjunctive to all strategies[1] |
Treatment summary
Each pharmacologic row links to its dedicated pharmacology page for the full prescribing framework — dosing, contraindications, monitoring, and counseling details.
| Treatment | Indicated disorder | Route | Key data | Notable risks |
|---|---|---|---|---|
| Vaginal estrogen | Dyspareunia (GSM) | Vaginal | Level A; gold standard for postmenopausal dyspareunia[1] | Minimal systemic absorption at low doses |
| Ospemifene | Moderate-to-severe postmenopausal dyspareunia or vaginal dryness | Oral | FDA-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 |
| Vaginal DHEA (prasterone) | Moderate-to-severe postmenopausal dyspareunia | Vaginal | FDA-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 |
| Flibanserin | Acquired, generalized HSDD in women younger than 65 | Oral at bedtime | Modest average benefit; see label and dedicated page[7] | Alcohol timing/skip-dose rules; moderate/strong CYP3A4 inhibitors and hepatic impairment contraindicated |
| Bremelanotide | HSDD (premenopausal) | SC injection on demand | +0.35 FSFI desire over placebo (RECONNECT)[9] | Nausea 40%; flushing 21%; contraindicated with uncontrolled hypertension or known cardiovascular disease[18] |
| Transdermal testosterone | HSDD (postmenopausal) | Transdermal | +0.85 SSE/month (36 RCT meta-analysis)[13] | Androgen excess; no FDA approval in US; long-term safety unknown |
| CBT / mindfulness | Desire, arousal, orgasm | — | Significant FSFI improvement[15] | Discuss acceptability, access and possible emotional or physical discomfort |
| Pelvic floor PT | GPPPD | — | Level C consensus[1] | Discuss acceptability, access and possible emotional or physical discomfort |
See Also
Female sexual dysfunction context.
- Assessment Tools — Female Sexual Function — full validated-instrument catalog (FSFI / FSDS-R / DSDS / SIDI-F / PROMIS SexFS / PISQ-IR) with scoring details, psychometric data, and "which instrument when" practical-guidance block.
- Genitourinary Syndrome of Menopause — GSM as the most common biological substrate for dyspareunia and arousal disorder in postmenopausal women.
- Recurrent UTI — vaginal estrogen first-line for postmenopausal rUTI prevention.
- Chronic Pelvic Pain — GPPPD, vulvodynia, and pelvic-floor myofascial pain as overlapping diagnoses.
- Pelvic Floor Physical Therapy — first-line for GPPPD.
Pharmacology hubs — HSDD agents.
- Flibanserin (Addyi) — acquired, generalized HSDD in women younger than 65; bedtime dosing, alcohol precautions and CYP3A4 contraindications.
- 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.
- Vaginal & Topical Estrogen — formulations, systemic-absorption gradient, breast-cancer safety data.
- Vaginal DHEA (Prasterone) — dyspareunia indication, intracrinology and limitations of breast-cancer/aromatase-inhibitor safety evidence.
- Ospemifene — oral SERM; OAB / UUI off-label evidence; drug interactions.
- Preoperative Hormonal Priming — IMPROVE trial; local estrogen before pelvic-floor surgery.
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. ADDYI (flibanserin) tablets: US prescribing information. Revised December 2025. DailyMed label. Accessed September 11, 2026.
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
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.