{"paper_id":"6f4c3b62-1738-4e8f-95b4-844df7c091e0","body_text":"Based on the model of the human sexual response cycle described by Masters and Johnson and H S Kaplan, Female Sexual Dysfunctions (FSD) can be classified into 4 groups based on the different components of the response cycle. 1 – 4\n\nPersistent or recurrent deficiency (or absence) of sexual fantasies/thoughts and/or desire for or receptivity to sexual activity, which  causes personal distress.\nPersistent or recurrent phobic aversion to and avoidance of sexual contact with a sexual partner,  which causes distress.\n\nPersistent or recurrent inability to attain or maintain sufficient sexual excitement  causing personal distress . It may be experienced as a lack of subjective excitement or genital (lubrication/ swelling) or other somatic responses.\n\nPersistent or recurrent difficulty, delay in or absence of attaining orgasm following sufficient sexual stimulation and arousal,  which causes personal distress.\n\nRecurrent or persistent genital pain associated with sexual intercourse,  which causes personal distress.\nRecurrent or persistent involuntary spasm of the musculature of the lower third of the vagina that interferes with vaginal penetration,  which causes personal distress.\nThere is an ongoing discussion regarding the available evidence to distinguish between desire and arousal and whether vaginismus and dyspareunia can be distinguished.\nIn the  Diagnostic and Statistical Manual of Mental Disorders (DSM-V) , desire and arousal disorders are combined into the category female sexual interest/arousal disorder.\nDyspareunia and vaginismus are combined into genito-pelvic pain/ penetration disorder. 5 , 6\n\nSexual health and sexual dysfunction are the result of a complex interaction of biological, psychological, interpersonal, and social factors. These factors interact with each other and can have a differential impact on the female sexual function, causing dysfunction. 7 - 9\n\nChronic diseases\n Cancer, cardiovascular, and metabolic psychiatric diseases Diseases can impact sexual health in the following ways: tissue damage of the organs involved in the sexual response damage to the neuromuscular and neurovascular system influencing the endocrine response impairment of the brain neurotransmitter responses\nCancer, cardiovascular, and metabolic psychiatric diseases\nDiseases can impact sexual health in the following ways:\ntissue damage of the organs involved in the sexual response\ndamage to the neuromuscular and neurovascular system\ninfluencing the endocrine response\nimpairment of the brain neurotransmitter responses\nEndocrine changes\n Postpartum\n Low estrogen, prolactin contributing to low desire, and painful intercourse Menopause\n Estrogen fluctuation, low estrogen, and testosterone insufficiency Contributing to low desire and arousal difficulties Diabetes Vascular changes in the genital organs of men and women can contribute to arousal problem (erectile dysfunction and arousal disorder in women)\nPostpartum\n Low estrogen, prolactin contributing to low desire, and painful intercourse\nLow estrogen, prolactin contributing to low desire, and painful intercourse\nMenopause\n Estrogen fluctuation, low estrogen, and testosterone insufficiency Contributing to low desire and arousal difficulties\nEstrogen fluctuation, low estrogen, and testosterone insufficiency\nContributing to low desire and arousal difficulties\nDiabetes\nVascular changes in the genital organs of men and women can contribute to arousal problem (erectile dysfunction and arousal disorder in women)\nMedications and recreational drugs\n Drugs influencing the peripheral response, such as antihypertensives Antidepressants having an impact on serotonin central action contributing to low desire Antihormones having an impact on the genital organs and on the brain regulation of the sexual response\nDrugs influencing the peripheral response, such as antihypertensives\nAntidepressants having an impact on serotonin central action contributing to low desire\nAntihormones having an impact on the genital organs and on the brain regulation of the sexual response\n\nImmediate factors\n Sexual anxiety (not knowing what will happen, lack of knowledge) Performance anxiety Fear of getting hurt\nSexual anxiety (not knowing what will happen, lack of knowledge)\nPerformance anxiety\nFear of getting hurt\nPersonality traits\n Lack of self esteem Body image problem\nLack of self esteem\nBody image problem\nBiographic factors\n Early neglect Sexual abuse Later traumatic experiences Separation, humiliation Sexual violence Lack of sexual education\nEarly neglect\nSexual abuse\nLater traumatic experiences\nSeparation, humiliation\nSexual violence\nLack of sexual education\n\nSexual dysfunction partner\n Erectile dysfunction Premature ejaculation\nErectile dysfunction\nPremature ejaculation\nConflicts\n Jealousy and mistrust Differences in needs Imbalance of giving and taking Inability to compromise and forgive\nJealousy and mistrust\nDifferences in needs\nImbalance of giving and taking\nInability to compromise and forgive\nRoutine\n Loss of tension Loss of seduction and fantasy\nLoss of tension\nLoss of seduction and fantasy\nLack of communication\n Avoiding to talk about feelings Fear of hurting the partner Hidden stories Third-party involvement Internet pornography\nAvoiding to talk about feelings\nFear of hurting the partner\nHidden stories\nThird-party involvement\nInternet pornography\n\nGeneral living conditions\nSocial distress\nSociocultural norms\n\nOwing to the frequently complex pathogenesis, treatment strategies also need to follow a biopsychosocial and, frequently, multidisciplinary approach.\nThe first step is always basic counseling. 10\n\nBasic counseling has several components, which have proven therapeutic effects.\nEmotional relief\nGive the patient, the opportunity to talk about his/her own sexuality\nListen actively\nPatient feels accepted and understood\nEducation and empowerment\nInform about the reality of human sexuality\nPut the variety of personal experiences into perspective\nFrequency of problems\nDifferences between female and male sexuality\nDispel myths about male and female sexuality represented in social media about normal sexuality with different new norms and false information about “good sex.”\n“It rocks you and makes you feel like in heaven.”\nSex is not penis in vagina, the usual program, but there is a large variety of sexual expression and preferences\nThe pleasure of nongenital sex\nThe use of sex toys is not pornographic\nHaving sexual problems means that love has died\nThe second step is establishing a treatment plan based on the understanding of the contributing factors (see above).\n\nExamples\n Treatment of endometriosis in sexual pain disorder\n Surgical and drug treatment Adaptation of drug treatment in cancer patients\n Aromatase inhibitors Change of antihypertensives\n Antihypertensive without negative impact on peripheral vascular function Change of antidepressants\n Change from tricyclics to Selective Serotonin Reuptake Inhibitors Endocrine treatment\n Estrogen: The large majority of studies show positive effects of estrogen therapy on different aspects of female sexual function and sexual satisfaction, including desire, arousal, and treatment of sexual pain due to vulvovaginal atrophy. Testosterone and tibolone: Androgens play a role in sexual desire, arousal, orgasm, and satisfaction. PDE-5 inhibitors for erectile dysfunction in men; arousal difficulties in diabetic women Antibiotics for infections causing painful ejaculation in men Dapoxetine for premature ejaculation Centrally acting drugs like flibanserin for low desire in women\nTreatment of endometriosis in sexual pain disorder\n Surgical and drug treatment\nSurgical and drug treatment\nAdaptation of drug treatment in cancer patients\n Aromatase inhibitors\nAromatase inhibitors\nChange of antihypertensives\n Antihypertensive without negative impact on peripheral vascular function\nAntihypertensive without negative impact on peripheral vascular function\nChange of antidepressants\n Change from tricyclics to Selective Serotonin Reuptake Inhibitors\nChange from tricyclics to Selective Serotonin Reuptake Inhibitors\nEndocrine treatment\n Estrogen: The large majority of studies show positive effects of estrogen therapy on different aspects of female sexual function and sexual satisfaction, including desire, arousal, and treatment of sexual pain due to vulvovaginal atrophy. Testosterone and tibolone: Androgens play a role in sexual desire, arousal, orgasm, and satisfaction.\nEstrogen: The large majority of studies show positive effects of estrogen therapy on different aspects of female sexual function and sexual satisfaction, including desire, arousal, and treatment of sexual pain due to vulvovaginal atrophy.\nTestosterone and tibolone: Androgens play a role in sexual desire, arousal, orgasm, and satisfaction.\nPDE-5 inhibitors for erectile dysfunction in men; arousal difficulties in diabetic women\nAntibiotics for infections causing painful ejaculation in men\nDapoxetine for premature ejaculation\nCentrally acting drugs like flibanserin for low desire in women\n\nExamples\n Body awareness methods for orgasmic and arousal difficulties related to insecurity, lack of knowledge about one’s own body\n Masturbation exercises Therapy sexocorporelle Physiotherapy for sexual pain disorders related to pelvic floor dysfunction Cognitive behavioral interventions for dysfunctions related to the following:\n irrational beliefs and thoughts leading to negative emotions by becoming aware of these patterns and actively changing perspectives and way of thinking distress and performance anxiety by learning relaxation and coping techniques Psychodynamic focal therapy for dysfunctions related to feelings of guilt, shame, and internal conflicts between sexual needs and sexual norms:\n making them aware of this dynamics and helping the patient to find a solution based on integration of both parts of his or her personality Mindfulness\nBody awareness methods for orgasmic and arousal difficulties related to insecurity, lack of knowledge about one’s own body\n Masturbation exercises Therapy sexocorporelle\nMasturbation exercises\nTherapy sexocorporelle\nPhysiotherapy for sexual pain disorders related to pelvic floor dysfunction\nCognitive behavioral interventions for dysfunctions related to the following:\n irrational beliefs and thoughts leading to negative emotions by becoming aware of these patterns and actively changing perspectives and way of thinking distress and performance anxiety by learning relaxation and coping techniques\nirrational beliefs and thoughts leading to negative emotions by becoming aware of these patterns and actively changing perspectives and way of thinking\ndistress and performance anxiety by learning relaxation and coping techniques\nPsychodynamic focal therapy for dysfunctions related to feelings of guilt, shame, and internal conflicts between sexual needs and sexual norms:\n making them aware of this dynamics and helping the patient to find a solution based on integration of both parts of his or her personality\nmaking them aware of this dynamics and helping the patient to find a solution based on integration of both parts of his or her personality\nMindfulness\nMindfulness can be defined as a state of present-moment, nonjudgmental awareness\n Regulation of attention to keep it focused on the immediate experience. Approaching one’s experience with curiosity, openness, and acceptance. The here and now should be observed and experienced with all senses, thoughts and feelings should be perceived without judgment but with an open mind. Thus, every sexual experience is unique.\nRegulation of attention to keep it focused on the immediate experience.\nApproaching one’s experience with curiosity, openness, and acceptance.\nThe here and now should be observed and experienced with all senses, thoughts and feelings should be perceived without judgment but with an open mind. Thus, every sexual experience is unique.\n\nExamples\n Communication training for dysfunctions based on dysfunctional communication\n Listening to each other (facts, emotions, relationship messages, etc.) How to communicate yes and no How to communicate without hurting each other How to give feedback How to negotiate Sensate focus (Masters and Johnson)\n Masters and Johnsons developed a therapeutic concept, which combined different elements of body awareness, focal psychotherapy, and systemic therapy into one approach. The concept supports couples in “relearning the sexual encounter” by dividing the intercourse into different phases, which allow both partners to observe and communicate about their physical and emotional reactions, thus creating the conditions of an enjoyable sexual encounter without being under the pressure of success.\nCommunication training for dysfunctions based on dysfunctional communication\n Listening to each other (facts, emotions, relationship messages, etc.) How to communicate yes and no How to communicate without hurting each other How to give feedback How to negotiate\nListening to each other (facts, emotions, relationship messages, etc.)\nHow to communicate yes and no\nHow to communicate without hurting each other\nHow to give feedback\nHow to negotiate\nSensate focus (Masters and Johnson)\n Masters and Johnsons developed a therapeutic concept, which combined different elements of body awareness, focal psychotherapy, and systemic therapy into one approach. The concept supports couples in “relearning the sexual encounter” by dividing the intercourse into different phases, which allow both partners to observe and communicate about their physical and emotional reactions, thus creating the conditions of an enjoyable sexual encounter without being under the pressure of success.\nMasters and Johnsons developed a therapeutic concept, which combined different elements of body awareness, focal psychotherapy, and systemic therapy into one approach.\nThe concept supports couples in “relearning the sexual encounter” by dividing the intercourse into different phases, which allow both partners to observe and communicate about their physical and emotional reactions, thus creating the conditions of an enjoyable sexual encounter without being under the pressure of success.\n\nEstrogens, androgens, and tibolone\nHormone therapy in women with sex hormone deficiency, for example, during menopausal transition or in those women showing signs of Androgen Insufficiency\nAddressing co-morbid depression\nDepression is a frequent comorbidity and needs treatment eventually by adjustment of dosages or types of psychotropic drugs\nIndividual\nBuilding on previous positive experiences and models of satisfying sexuality\nAddressing negative experiences\nHelping patients to find out what they really want in their sexual life\nCouple therapy\nSensate focus (see above)\n\nHormonal therapy (see therapies above)\nLocal estrogen therapy to improve vaginal tissue and vaginal blood flow\nBlood vessel dilators\nPDE-5 inhibitors have proven to be effective in women with diabetes\nClitoral therapy device\nA Food and Drug Administration approved device such as a vibrator\nPhysiotherapy of the pelvic floor\nLifestyle changes\nPhysical activities\nBody awareness methods (see above)\n\nMedical therapy\nOptimize hormones\nAdjustment of orgasm-inhibiting medications\nPhysiotherapy of the pelvic floor\nPsychosexual therapy\nBody awareness methods\n\nMedical treatment\nSpecific treatment for underlying disease\nSuperficial dyspareunia (e.g., vulvovaginal infections and dermatologic diseases)\nDeep dyspareunia (e.g., endometriosis, adhesions, and irritable bowel syndrome)\nNormalize vaginal tropism and pH (by local hormonal treatment)\nUse of moisturizers\nPhysiotherapy of pelvic floor\nCombined with imagination and relaxation techniques\nPsychosexual single and couple therapy\nMindfulness\nSensate focus\nCommunication training to improve understanding of adequate stimulation\nAnalgesic therapy\nSystemic: NSARs, antidepressants, and anticonvulsants (neuropathic pain)\nLocal: Cortisone and injection of anesthetics\nSurgical interventions (vestibulectomy)","source_license":"CC-BY-4.0","license_restricted":false}