Female Sexual Dysfunction

Low-dose vaginal estrogen therapy is the preferred hormonal treatment for female sexual dysfunction that is due to genitourinary syndrome of menopause.

Low-dose systemic hormone therapy, with estrogen alone or in combination with progestin, can be recommended as an alternative to low-dose vaginal estrogen in women experiencing dyspareunia related to genitourinary syndrome of menopause as well as vasomotor symptoms.

Ospemifene can be recommended as an alternative to vaginal estrogen for the management of dyspareunia caused by genitourinary syndrome of menopause.

Systemic DHEA is not effective and, therefore, is not recommended for use in the treatment of women with sexual interest/arousal disorders.

Psychologic interventions, including sexual skills training, cognitive–behavioral therapy (with or without pharmacotherapy), mindfulness-based therapy, and couples therapy, are recommended as part of female sexual dysfunction treatment.

A physical examination should be performed to diagnose female sexual dysfunction related to genitourinary syndrome of menopause before starting vaginal or systemic hormone therapy.

Short-term use of transdermal testosterone can be considered as a treatment option for postmenopausal women with sexual interest and arousal disorders who have been appropriately counseled about the potential risks and unknown long-term effects.

Evidence is insufficient to recommend for or against testosterone for the treatment of sexual interest and arousal disorders in premenopausal women.

Intravaginal prasterone, low-dose vaginal estrogen, and ospemifene can be used in postmenopausal women for the treatment of moderate-to-severe dyspareunia that is due to genitourinary syndrome of menopause.

Estrogen or SERM therapy is not recommended for the treatment of female sexual dysfunction that is not due to a hypoestrogenic state.

Vaginal carbon dioxide (CO₂) fractional laser for treatment of dyspareunia that is due to genitourinary syndrome of menopause should not be used outside of a research setting.

Flibanserin can be considered as a treatment option for hypoactive sexual desire disorder in premenopausal women without depression who are appropriately counseled about the risks of alcohol use during treatment.

Obstetrician–gynecologists should initiate a clinical discussion of sexual function during routine care visits to identify issues that may require further exploration and to help destigmatize discussion of sexual function for patients.

The initial evaluation of a patient with female sexual dysfunction symptoms may require an extended visit and should include a comprehensive history and physical examination to evaluate possible gynecologic etiologies.

Laboratory testing typically is not necessary in the initial evaluation of female sexual dysfunction unless an undiagnosed medical etiology is suspected.

If transdermal testosterone therapy is used in postmenopausal women with sexual interest and arousal disorders, a 3–6-month trial is recommended with assessment of testosterone levels at baseline and after 3–6 weeks of initial use to ensure levels remain within the normal range for reproductive-aged women. Transdermal testosterone therapy should be discontinued at 6 months in patients who do not show a response. If ongoing therapy is used, followup clinical evaluation and testosterone measurement every 6 months are recommended to assess for androgen excess. The long-term safety and efficacy of transdermal testosterone have not been studied.

Pelvic floor physical therapy is recommended for the treatment of genito–pelvic pain and penetration disorders to restore muscle function and decrease pain.

Lubricants, topical anesthesia, and moisturizers may help reduce or alleviate dyspareunia.