24/09/2025
FEMALE SEXUAL DYSFUNCTION/ LOSS OF LIBIDO
INTRODUCTION
S*xual problems are common and can occur at any age. In the United States, approximately 40 percent of females have s*xual concerns and 12 percent report distressing s*xual problems
"S*xual dysfunction" is a term used to describe difficulties in libido (s*x drive), arousal, or**sm, or pain with s*x that are bothersome to an individual. S*xual dysfunction may be a lifelong problem or acquired later in life after a period of having no difficulties with s*x.
In general, females are most likely to be satisfied with their s*x lives if they are physically and psychologically healthy and have a good relationship with their partner. People who are not in a partnered relationship also may experience s*xual problems. Although a host of changes in hormones, blood vessels, the brain, and va**nal area can affect s*xuality, relationship difficulties and poor physical or psychological well-being contribute to many s*xual problems.
This article will discuss causes as well as treatments that are available to help with s*xual problems in females. S*xual problems in males are discussed separately.
SEXUAL PROBLEMS TERMINOLOGY
It is important to know the definitions of several terms used to describe the s*xual response to understand related s*xual problems.
Desire (libido) — Libido, or s*x drive, is the desire to have s*xual activity, and often involves s*xual thoughts, images, and wishes. Desire may occur spontaneously or after s*xual activity has started (in response to a partner, thoughts, events, or sensory cues; this is called "responsive desire"). Spontaneous desire is more common in new relationships while responsive desire is more typical of long-term relationships. A person can experience difficulties with either spontaneous or responsive desire.
Despite a focus on the importance of s*xual desire in the media, desire is not essential to have a satisfactory s*x life. In other words, a woman who does not frequently think about or initiate s*x does not necessarily have a problem.
Arousal (excitement) — Arousal is a sense of s*xual pleasure, often accompanied by an increase in blood flow to the ge****ls, increased lubrication, and an increased heart rate, blood pressure, and rate of breathing.
Or**sm — Or**sm is defined as a peaking of s*xual pleasure and release of s*xual tension, usually with contractions of the muscles in the ge***al area and reproductive organs. It is possible to experience s*xual pleasure without or**sm; absence of or**sm is a problem only if it bothers the person.
Although desire, arousal, and or**sm describe the typical s*xual response, the goal of s*xual activity is satisfaction, which may or may not involve all aspects of the s*xual response cycle (desire, arousal, or**sm).
Pain — Painful s*x is a common problem with many different causes. It often leads to other s*xual problems, including low libido.
RISK FACTORS FOR SEXUAL PROBLEMS
There are a number of risk factors that may contribute to s*xual problems in females. A risk factor is not necessarily the cause of a problem, but rather something that makes the problem more likely.
Personal well-being — Your sense of personal well-being is important to s*xual interest and activity. Diet and exercise habits can affect body image. Not feeling your best physically or emotionally may contribute to a decrease in s*xual interest or response.
Fatigue and stress — It is common to feel less interested in s*x and experience reduced s*xual pleasure when you are tired or under stress. Fatigue can result from an underlying medical problem, poor sleep, or simply not getting enough rest due to the demands of family, work, and other responsibilities.
Sociocultural factors — Lack of privacy and personal, religious, and cultural beliefs about s*x may contribute to s*xual problems.
Relationship issues — An emotionally healthy relationship with current and past s*xual partners is a critical factor in s*xual satisfaction. Stress in a relationship, conflict with your partner(s), and limited communication can negatively influence your s*xual desire and response. Current or past emotional, physical, or s*xual abuse or trauma often contribute to s*xual problems. In addition, it is normal for even healthy relationships to become less exciting s*xually over time.
Partner health or s*xual problems — S*xual dysfunction in a partner can affect your s*xual response. If you have a male partner, s*xual problems (including erectile dysfunction, diminished libido, and abnormal ej*******on) can occur at any time, but become more common with advancing age. In addition, females tend to live longer than males, resulting in fewer healthy, s*xually functional male partners over time. If you have a female partner, she can also experience s*xual problems that may impact your s*xual satisfaction.
Gynecologic issues
Childbirth — After childbirth, it is common to experience decreased s*xual desire. Contributing factors may include physical recovery and breastfeeding as well as fatigue and the demands of parenting. This can happen whether you gave birth va**nally or had a cesarean birth ("c-section"). Low estrogen levels after delivery and local injury to the ge***al area or abdominal wall at delivery may result in pain with s*xual activity. In most cases, these issues improve with time.
Menopause — Estrogen is a hormone produced by the ovaries. During the several years before menopause (when monthly periods stop), estrogen levels begin to fluctuate. After menopause, estrogen levels decline dramatically. This may contribute to changes in your libido and ability to become aroused. Hot flashes, night sweats, sleep disruption, and fatigue, which commonly occur with menopause, also may contribute to s*xual problems. There are treatments that can help with these symptoms.
In addition, many people experience discomfort or pain during s*x after menopause due to va**nal dryness, loss of normal secretions and lubrication, decreased elasticity, and narrowing of the va**na. Menopausal va**nal changes are generally more severe if in*******se (or other activities that involve va**nal pe*******on) is infrequent. Although hot flashes and most menopausal symptoms improve with time, va**nal dryness and resulting painful s*x generally worsen with time, if not treated.
Hysterectomy — In general, hysterectomy (removal of the uterus) does not cause s*xual dysfunction. Most studies actually show an improvement in s*xual function after hysterectomy, likely due to resolution of symptoms that interfere with s*x, such as heavy bleeding or pain. Removal of the cervix at the time of hysterectomy also has no negative effect on s*xuality. Removal of the ovaries at the time of hysterectomy, typically done to decrease the risk of ovarian cancer, reduces estrogen and androgen levels, which may impact s*xual function for some people.
Vaginal or pelvic pain — Vaginal or pelvic pain is a common cause of s*xual dysfunction. Pain during s*x may lead to fear of further pain, which can diminish lubrication and cause involuntary tightening of the pelvic muscles, resulting in further pain.
Pain may be caused by endometriosis, va**nal or pelvic surgery, infection, inflammation, or scar tissue. In people who have gone through menopause, a lack of estrogen often causes discomfort with in*******se and other forms of s*xual activity.
Bladder and pelvic support issues — Changes in the bladder or loss of pelvic support (pelvic organ prolapse) can lead to loss of urine or stool (incontinence) or sensations of va**nal pressure. Involuntary tightening of these muscles also can occur. These symptoms may interfere with s*xual desire and activity.
Medical issues — Almost any serious medical problem can impact s*xual desire and responsiveness. Problems such as heart disease, arthritis, and obesity can affect a person's physical ability to have pleasurable s*x.
People with cancer can experience discomfort, fatigue, and mood changes due to both the disease and its treatments, which often impact s*xual function. Changes in body image, especially after surgery involving the breasts, va**na, or pelvis, can also contribute to s*xual problems.
Other conditions, such as Parkinson disease, diabetes, or substance use disorders (involving alcohol, ma*****na, pain medications, or other drugs), can impair libido, arousal, and ability to experience or**sm.
Psychiatric or emotional problems may significantly impact s*xual function, either due to the disease itself or its treatment (see 'Medications' below). Depression is one of the most common causes of decreased libido and other s*xual disorders in females. Anxiety is another common cause of s*xual problems.
Medications — Both prescription and nonprescription medications can alter s*xual desire, arousal, or**sm, and pain. This may include:
●Many antidepressants (especially selective serotonin reuptake inhibitors)
●Some antipsychotic medications (used for psychiatric problems as well as sleep disorders and other conditions)
●Beta blockers (used to treat high blood pressure)
●Antiestrogens/aromatase inhibitors (used to treat breast cancer)
●Gonadotropin-releasing hormone agonists and antagonists (used to treat endometriosis or fibroids)
It is not clear if hormone-containing medications, such as birth control pills and menopausal hormone therapy, affect s*xual function. Studies have shown mixed results, with some studies showing that hormonal medications have no effect but others showing worsening or improvement of s*xual problems.
Surgery — Certain surgeries can affect a person's s*xual response. In particular, surgeries involving the breast, va**na, uterus, or ovaries can change how a person feels about their body, particularly if there is an underlying diagnosis such as cancer that led to the surgery.
Hysterectomy, with or without removal of the cervix, should not negatively impact s*xual function once healing is complete. However, some people experience s*xual problems after both ovaries are removed, possibly due to decreased estrogen and/or androgen levels. (See 'Hysterectomy' above.)
TREATMENT OF SEXUAL PROBLEMS
A number of treatments are available for females with s*xual problems. In many cases, a combination of treatments is most effective.
Managing stress, fatigue, and relationship issues — Strategies to reduce life stress, including exercise, yoga, massage, meditation, and other mind/body techniques, can result in a more satisfying s*x life. If possible, adjusting work schedules and obtaining help with childcare and household responsibilities can often improve quality of life and s*xual satisfaction. Prioritizing sleep and trying to find other ways to reduce fatigue may also improve s*xual interest.
Working with a professional counselor can help you to reduce stress and strengthen your relationships. S*x therapists are professionals with special expertise in helping individuals and couples address s*xual problems by providing information, improving communication, and giving instruction in specific exercises to improve intimacy and mutual pleasure.
Many couples have better s*x while on vacation, demonstrating the importance of reducing stress and fatigue to improve s*xual satisfaction. Couples who have more fun together outside of the bedroom typically are more satisfied with their s*x lives, so establishing a regular "date night" and increasing the frequency of time alone together can reduce s*xual problems. While this can be challenging to do given competing demands from work, family, and other priorities, it can help your s*x life to have time set aside for just you and your partner.
Counseling, books, and web sites about s*xuality help couples communicate better about their s*xual needs and differences, understand the causes of their difficulties, and provide treatment suggestions.
Novelty — Increasing novelty often sparks s*xual desire and enhances s*xual response. Try sensual massage, sharing a bath, experimenting with different s*xual positions or activities, using candles and music, or having s*x in the middle of the day or outside of the bedroom. Books, films, vi*****rs or other s*x toys, and lubricants can also add excitement. Vi*****rs are the most effective treatment for or**sm difficulties. They can be used with or without a partner.
Treating va**nal dryness — People with va**nal dryness that makes s*x uncomfortable may benefit from the use of a lubricant. These products are designed to reduce friction during s*xual activity and may result in greater comfort and pleasure. In addition, using a long-acting, nonhormonal va**nal moisturizer on a regular basis (several times weekly) reduces va**nal dryness. Both lubricants and moisturizers are available over-the-counter and do not require a prescription. It's best to use products without color, scents, or other additives in order to minimize va**nal irritation. People who have been through menopause generally will benefit from the use of low-dose va**nal estrogen therapy to treat va**nal dryness and painful s*x associated with menopause (brand names: Vagifem, Yuvafem, Estring, Estrace cream, Premarin cream). Treatment of va**nal dryness is discussed in detail in a separate topic. (See "Patient education: Vaginal dryness (Beyond the Basics)".)
Improving painful s*x — Many people who have pain with s*x have tight and tender muscles and connective tissue in the pelvis, lower belly, thighs, groin, and buttocks.
Pelvic floor physical therapy (PT) can significantly decrease discomfort associated with involuntary tightening of pelvic floor muscles. Physical therapists who perform this type of PT are specially trained in pelvic manipulation and rehabilitation.
Often, painful s*x is due to narrowing and shortening of the va**na after surgery or menopause, or involuntary tightening of the muscles of the pelvis and va**na, called "provoked pelvic floor hypertonus." This is best treated by purchasing a set of va**nal dilators and gently stretching the va**na over several months. A well-lubricated dilator of the appropriate size is placed into the va**na several times for approximately five minutes daily. The size of the dilator is gradually increased until in*******se is once again comfortable. These exercises are best guided by a gynecologist or pelvic floor physical therapist.
Adjusting medications with s*xual side effects — If you have s*xual side effects from a medication, speak with your health care provider about options for reducing the dose or finding an effective alternative medication.
Options for people who have side effects from an antidepressant medication include trying a reduced dose or change in type of antidepressant medication. Bupropion (brand name: Wellbutrin), nefazodone (brand name: Serzone), mirtazapine (brand name: Remeron), or duloxetine (brand name: Cymbalta) are antidepressant medications that have few or no s*xual side effects, and can sometimes be used in addition to or in place of your current medication. Talk to your health care provider before making any changes in your medications. Depression also is a common cause of s*xual problems, so it is important that the depression is managed effectively.
Carefully considering androgens — Androgens, such as testosterone, are s*x hormones that are produced in the te**es and adrenal glands in males and the ovaries and adrenal glands in females. In men, androgens are responsible for producing typical male characteristics, such as facial hair, as well as feelings of desire and arousal.
However, the role of androgens in female s*xuality is less clear. Androgen levels decline with aging, so anyone who has been through menopause has lower blood levels of androgens. Studies of postmenopausal females with low s*xual desire associated with distress and no other identifiable cause have shown that testosterone treatment may result in small but significant improvements in s*xual desire and response. Although studies of a testosterone patch showed benefit, studies of a similar dose of testosterone gel showed no benefit compared with a placebo gel. The high placebo response seen in studies of testosterone treatment for low s*xual desire in females demonstrates the importance of nonhormonal factors in s*xual function. No androgen products are approved for the treatment of females with s*xual dysfunction in the United States due to limited efficacy and the lack of data regarding long-term safety. (See 'Androgen side effects and risks' below.)
Testosterone — Testosterone products are sometimes used "off-label" to treat s*xual problems in females. These products include testosterone skin patches, gels, creams or ointments, pills, implants, and injections, often designed and government-approved for men. Testosterone doses provided by these formulations generally are much too high for females, increasing the likelihood of side effects. Testosterone products approved for males can be used at a much lower dose (approximately one-tenth) in females. Low doses of testosterone can be formulated in a topical cream or gel by a compounding pharmacist. Quality, efficacy, and safety of these products are generally untested. Testosterone is not recommended for females who have not yet been through menopause.
DHEA — DHEA (dehydroepiandrosterone), an androgen-like hormone made in the adrenal glands, is available as a nutritional supplement in the United States. Studies have shown that DHEA can improve s*xual interest and satisfaction in some females whose adrenal glands no longer function (adrenal insufficiency). (See "Patient education: Adrenal insufficiency (Beyond the Basics)".)
However, DHEA is not proven to be safe or effective in other situations, and it is not generally recommended. In addition, DHEA is produced as a nutritional supplement, so is not closely regulated by the government. The amount of hormone may vary from one pill or bottle to another and it is not possible to be certain that a product is free of potentially dangerous additives.
A nightly va**nal suppository containing a low dose of DHEA (brand name: Intrarosa) is approved by the US Food and Drug Administration for the treatment of painful s*x due to menopause. Improvements in s*xual function with va**nal DHEA are similar to those seen with the use of low-dose va**nal estrogen therapy in postmenopausal females.
Androgen side effects and risks — Testosterone treatment can cause bothersome side effects. Androgens can increase hair growth on the body and face and cause scalp hair loss, oily skin, acne, irreversible deepening of the voice, liver problems, and high cholesterol levels. In addition, because testosterone is converted to estrogen in a female's body, there may be an increased risk of breast cancer, coronary heart disease, leg and lung clots, and stroke. Females who take androgens should be monitored closely for side effects. They also must be aware that long-term safety is unknown.
If you are considering use of androgens (testosterone or DHEA), it's important to discuss the possible side effects and risks of this treatment with your health care provider.
Medications and devices — In the United States, two medications have been approved for treating low s*xual desire in premenopausal females with low desire for s*x that is causing them distress (called "hypoactive s*xual desire disorder"). Both must be prescribed by a health care provider. While they may slightly improve s*xual desire, there can be serious side effects.
In most cases, health care providers recommend trying other things to improve your relationship and s*x life before trying androgen therapy or either of these medications. Medication options include:
●Flibanserin (brand name: Addyi) – This medication comes in a pill that you take every day. Some people who take it have problems with fatigue, nausea, dizziness, or headaches. Alcohol, as well as certain other medications, can increase the risk of side effects. If you have one or two alcoholic drinks, you should wait at least two hours before taking flibanserin. If you have three or more drinks, you should not take flibanserin at all that day.
●Bremelanotide (brand name: Vyleesi) – This medication comes in the form of an injection that you give yourself approximately 45 minutes before you plan to have s*x. Side effects can include nausea, vomiting, or flushing (when your skin turns red and hot). Darkening of areas of skin can occur, including on the face, which may be permanent. A few people might have a rise in blood pressure. People with high blood pressure or heart problems cannot take bremelanotide.
Medications commonly used to treat erectile problems in males, including sildenafil (brand name: Vi**ra), tadalafil (brand name: Cialis), or vardenafil (brand name: Levitra), generally have not been shown to improve s*xual function in females more than would a placebo and are not usually recommended. The only females who may benefit from use of an erectile dysfunction medication are those who develop or**smic difficulties secondary to antidepressant medication, especially selective serotonin reuptake inhibitors.
Unproven treatments
Herbal therapies — Many people are interested in trying over-the-counter herbal supplements, which are advertised to increase s*xual desire and pleasure. More studies are needed to assess whether herbal therapies are safe and effective. Some herbal supplements may improve s*xual function, but no more than would a placebo. The production of herbs is not regulated by the government, and it is not always possible to know that an herbal product contains the type and quantity of ingredient that the label indicates, or that it is free of potentially dangerous additives. People who wish to use herbal therapies are urged to do so with caution.
Surgical and laser treatments — Surgery is very rarely necessary to make the va**na "better" for s*x. People born with abnormalities of the va**na, those who have had female ge***al cutting, and those with traumatic injuries from childbirth may benefit from surgical treatment performed by a surgeon with expertise in these procedures.
It's important to be wary of advertisements for "va**nal rejuvenation surgery." These procedures can be costly and uncomfortable, and may result in va**nal scarring and painful s*x, which can be permanent. They are unlikely to improve s*xual enjoyment.
The use of laser therapy to treat va**nal dryness and painful s*x after menopause is widely advertised; however, this is not generally recommended. Vaginal laser treatments are very expensive, not covered by health insurance, and may be no more effective than other therapies. Injuries and scarring may occur, resulting in increased pain with s*x. Studies of long-term safety and efficacy are lacking.
