Sexual interest/arousal disorder is characterized by absence of or a decrease in sexual interest, initiation of sexual activity, pleasure, thoughts, and fantasies; absence of responsive desire; and/or lack of subjective arousal or of physical genital response to sexual stimulation—nongenital, genital, or both.
(See also Overview of Female Sexual Function and Dysfunction.)
Women with sexual interest/arousal disorder have little or no interest in sex and do not respond subjectively or physically to sexual stimulation. The decrease in interest and ability to be sexually aroused is greater than what might be expected based on a woman’s age and the relationship duration. Lack of sexual interest and inability to be sexually aroused are considered a disorder only if they distress women and if interest is absent throughout the sexual experience.
Decreased sexual arousal can be categorized as subjective, genital, or combined. These categories are clinically based, distinguished in part by the woman’s response to genital and nongenital stimulation, as follows:
Subjective: Women do not feel aroused by any type of sexual genital or nongenital stimulation (eg, kissing, dancing, watching an erotic video, physical stimulation), despite the occurrence of physical genital response (eg, genital congestion).
Genital: Subjective arousal occurs in response to nongenital stimulation (eg, an erotic video) but not in response to genital stimulation. This disorder typically affects postmenopausal women. Vaginal lubrication and/or genital sexual sensitivity is reduced.
Combined: Subjective arousal in response to any type of sexual stimulation is absent or low, and women report absence of physical genital arousal (ie, they report the need of external lubricants and may state they know that swelling of the clitoris no longer occurs).
Etiology of Sexual Interest/Arousal Disorder
Common causes of sexual interest/arousal disorder are
Psychological factors (eg, depression, anxiety, low self-esteem, stress, anxiety, distractibility, lack of communication between partners, other relationship problems)
Unrewarding sexual experiences (eg, due to lack of sexual skills or poor communication of needs)
Physical factors (eg, disorders such as genitourinary syndrome of menopause and vulvar dystrophies, changes in sex hormone levels, certain medications, fatigue, debility)
Use of certain medications, such as selective serotonin reuptake inhibitors (SSRIs) particularly, some antiseizure medications, and beta-blockers, can reduce sexual interest, as can drinking excessive amounts of alcohol. Certain chronic disorders (eg, diabetes, multiple sclerosis) can damage autonomic or somatic nerves or their pathways, leading to decreased sensation in the genital area.
Fluctuations and changes in hormone levels (eg, at menopause, during pregnancy, postpartum, with the menstrual cycle) can also affect sexual interest. For example, the decrease in estrogen that occurs at menopause can cause genitourinary syndrome of menopause, which can cause dyspareunia and thus lessen sexual interest. Age-related reduction of testosterone can decrease the sex drive, as may hyperprolactinemia (which can also cause dyspareunia because estrogen levels are decreased).
Inadequate sexual stimulation or the wrong setting for sexual activity can also contribute to lack of sexual interest or arousal.
Diagnosis of Sexual Interest/Arousal Disorder
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria
Diagnosis of sexual interest/arousal disorder is clinical, based on DSM-5-TR criteria.
Criteria require an absence of or a significant decrease in ≥ 3 of the following:
Interest in sexual activity
Sexual or erotic fantasies or thoughts
Initiation of sexual activity and responsiveness to a partner's initiation
Excitement or pleasure during ≥ 75% of sexual activity
Interest or arousal in response to sexual internal or external erotic stimuli (eg, written, verbal, visual)
Genital or nongenital sensations during ≥ 75% of sexual activity
These symptoms must have been present for ≥ 6 months and cause significant distress for the woman.
The diagnosis is not made if a physical or another psychological cause (including relationship distress) could account for the symptoms.
A pelvic examination is done if penetration during sexual activity causes pain.
Treatment of Sexual Interest/Arousal Disorder
Education
Psychological therapies
Hormonal therapy
A multidisciplinary approach is best for management of sexual interest/arousal disorder. The multidisciplinary team may include sex counselors, pain specialists, psychotherapists, and physical therapists.
Education about sexual anatomy and function (eg, the need to stimulate other areas of the body before the clitoris, the requirement for emotional intimacy and trust) may help. Open, nonjudgmental communication between sex partners is essential.
Effective sexual stimuli may include nonphysical, physical nongenital, and nonpenetrative genital stimulation. Clinicians may recommend using more intensely erotic stimuli and fantasies, eliminating distractions (eg, a television in the bedroom), and taking measures to improve privacy and a sense of security.
For patient-specific psychological factors, psychological therapies (eg, cognitive-behavioral therapy) may be required, although simple awareness of the importance of psychological factors may be sufficient for women to change patterns of thinking and behavior. Mindfulness-based cognitive therapy (MBCT), typically used in small groups of women, can improve arousal, orgasm, and subsequent desire and motivation. Clinicians may refer women to a sex counselor or therapist or a psychotherapist.
Concomitant hormonal causes require targeted treatment—eg, topical estrogen for genitourinary syndrome of menopause
Estrogen therapy
estrogen because unopposed estrogen increases risk of endometrial cancer.
Doctors may recommend that postmenopausal women use forms of estrogen that are inserted into the vagina (eg, creams, tablets, in a ring) to manage symptoms of genitourinary syndrome of menopause. These forms of estrogen can maintain vaginal health but do not help with mood, vasomotor symptoms, or sleep disturbances.
Testosterone therapy
1). Testosterone treatment with and without concurrent estrogen resulted in improved sexual function in women with decreased sexual interest/arousal. The primary outcome was increased sexual desire, but arousal and orgasmic response also improved.
However, little is known about the long-term safety and efficacy of testosterone
The dose of transdermal testosterone
Currently, there are no data to suggest testosterone use in premenopausal women.
Oral or injected testosterone is not recommended.
Other therapies
Intravaginal prasterone (a preparation of dehydroepiandrosterone, or DHEA) may relieve vaginal dryness and dyspareunia due to genitourinary syndrome of menopause (2), which can interfere with sexual interest and arousal; prasterone may also improve genital sensitivity and orgasm. Systemic DHEA has been shown to be ineffective. No form of DHEA has been studied in premenopausal women.
Women with sexual interest/arousal disorder due to use of selective serotonin reuptake inhibitorsnorepinephrine-dopamine6).
Except in small pilot studies, there is scant evidence that devices such as vibrators or clitoral suction devices are effective in women with sexual interest/arousal and orgasmic disorder; however, some of these products are available over the counter and may be tried.
Treatment references
1. Achilli C, Pundir J, Ramanathan P, et al: Efficacy and safety of transdermal testosterone in postmenopausal women with hypoactive sexual desire disorder: A systematic review and meta-analysis. Fertil Steril 107:475–82, 2017. doi: 10.1016/j.fertnstert.2016.10.028
2. Labrie F, Archer DF, Koltun W, et al: Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause. Menopause 23 (3):243–256, 2016. doi: 10.1097/GME.0000000000000571
3. Jaspers L, Feys F, Bramer WM, et alJAMA Intern Med 176(4):453-462, 2016. doi: 10.1001/jamainternmed.2015.8565
4. Kingsberg SA, Clayton AH, Portman D, et al: Bremelanotide for the Treatment of Hypoactive Sexual Desire Disorder: Two Randomized Phase 3 Trials. Obstet Gynecol 134(5):899-908, 2019. doi:10.1097/AOG.0000000000003500
5. Clayton AH, Kingsberg SA, Portman D, et al: Safety Profile of Bremelanotide Across the Clinical Development Program. J Womens Health (Larchmt) 31(2):171-182, 2022. doi:10.1089/jwh.2021.0191
6. Nurberg HG, Hensley PL, Heiman JR, et alJAMA 300 (4):395–04, 2008. doi: 10.1001/jama.300.4.395
