Female Sexual Dysfunction Differential Diagnoses

Updated: Oct 18, 2020
  • Author: Brett Worly, MD, MBA, FACOG; Chief Editor: Christine Isaacs, MD  more...
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Diagnostic Considerations

Although female sexual dysfunction (FSD) is categorized by symptoms, sexual problems often overlap, with one problem contributing to another.  That is, a woman complaining of decreased desire may have low desire because sex is painful.  A woman with inadequate arousal may experience insertional pain due to a lack of lubrication. A woman with a male partner who experiences erectile dysfunction or premature ejaculation may not receive adequate stimulation with insertional intercourse. While patients may have multiple sexual complaints, it is helpful to take a good history that identifies which problem came first. Sometimes in assessment, one problem is more pronounced than the others, or some patients may be bothered by one problem more than the others, so that is often the place to start. [4, 16]

Most FSD diagnoses are made based on history alone, and laboratory evaluation is rarely helpful. A fraction of patients with desire complaints may have underlying thyroid dysfunction, so a thyroid-stimulating hormone (TSH) screen may be helpful. [17] Serum testing for estrogen and androgens is rarely necessary. Occasionally testing of gonadotropins or estrogen may be helpful in women for whom the diagnosis of menopause is in doubt, for example following hysterectomy. Salivary testing of hormones is not a reliable, accurate method to assess a patient’s sexual problems or design a treatment plan. [11]

For patients with complaints related to desire and arousal, relationship problems are a common etiology, as patients with a “good” relationship for years or decades often experience a decrease in sexual frequency or diminished sexual reaction as novelty and excitement wane. It is important to differentiate between a true disorder and the normal changes over time that mark the evolution of a romantic relationship, which may not be a cause of distress. [16]

Patients with Female Orgasmic Disorder may experience decreased intensity in orgasm, or marked delay, marked infrequency of, or absence of orgasm. This problem may be related to inadequate stimulation necessary to get to orgasm, particularly with insertional intercourse, and a specific history of sexual positions tried, types of stimulation used (manual, oral, vibrator), and duration may prove helpful. [1, 16, 11]  

Differential Diagnoses

  • Female Orgasmic Dysfunction

    - Lack of Education

    - Lack of Stimulation

    - Arousal Disorder

    - Medication (eg, SSRIs)

    - Neuropathy

    - Sexual Pain

    - Lack of Sexual Desire

    - Relationship Issues

  • Female Sexual Interest/ Arousal Disorder

    - Relationship issues

    - Depression and other Psychiatric Disorders

    - Medications (Psychiatric, antihypertensive, opioid medications)

    - Thyroid disorder

    - Survivor of Physical, Sexual, Emotional, or Mental Abuse

    - Sexual Pain

    - Possible Sex Hormone Deficiency

    - Vascular Disease

    - Prior Pelvic Surgery

  • Genitopelvic Pain/ Penetration Disorder

    - Vulvovaginal Atrophy

    - Endometriosis

    - Survivor of Physical, Sexual, Emotional, or Mental Abuse

    - Gastrointestinal Etiologies (Irritable bowel syndrome, Irritable bowel disease, chronic constipation)

    - Genitourinary Causes (Painful bladder syndrome)

    - Vulvar Skin Disorders (Vulvar intraepithelial neoplasia, vulvar atrophy, lichen sclerosis, condyloma)

    - Fibromyalgia/ Musculoskeletal Trigger Point

    - Vulvodynia

    - Vaginismus

    - Vestibulodynia

    - Vulvitis/ Vaginitis

    - Adenomyosis

    - Uterine Leiomyomas

    - Pelvic Inflammatory Disease

    - Pelvic Adhesive Disease

    - Ovarian Remnant Syndrome

    - Ovarian Masses

    - Diabetic Neuropathy