Causes of Female Sexual Dysfunction

Similar to its counterpart in the male, there are numerous causes of FSD (Table 5-1.3). In fact, any factors influencing normal physiology, or any step of the sexual response in women, may contribute to FSD. The etiologies can be grouped as being either psychogenic or organic in nature, although overlap often exists.

Psychogenic FSD may be noted as either a result of, or a causative factor for, depression. In fact, it behooves the physician to rule out a primary diagnosis of depression in any women presenting with symptoms of FSD, especially poor libido. Likewise, the temptation to assign a diagnosis of depression to a woman without at least screening for the presence of sexual dysfunction should be avoided. Other facets of psychogenic FSD may include interpersonal relationship issues, abuse, performance anxiety, and psychological distress. These psychological factors often accompany organic factors.

As in men, many women with sexual dysfunction will have an underlying or contributing organic etiology of their sexual dysfunction. Any factor, disease state, or medication affecting the vascular, hormonal, or neurologic

Table 5-1.3. Risk factors for female sexual dysfunction

Atherosclerosis

Radical pelvic surgery

Smoking

Colorectal surgery

Diabetes

Hysterectomy

Dyslipidemia

Neuropathies

Peripheral vascular disease

Genital atrophy

Hypertension

Dermatitis

Pelvic or perineal trauma

Clitoral adhesions

Arterial compression from cycling

Bartholin's gland cysts

Endocrinopathies

Episiotomy scars

Postmenopausal changes

Vestibulitis

Hypothyroidism, hyperthyroidism

Vulvar cancer

Low estrogen levels

Lichen sclerosis

Pituitary tumor, hyperprolactinemia

Liver and/or renal failure

Androgen insufficiency syndrome

Sexual abuse

Pudendal nerve injury

Psychological factors

Stroke, Alzheimer's, Parkinson's disease

Life stressors

Endocrinopathies

Interpersonal relationship issues

Pelvic/spinal cord injury

Medications

Multiple sclerosis

Table 5-1.4. Medications associated with female sexual dysfunction

Antidepressants

Beta-blockers

SSRI agents

Antihistamines

Antihypertensives

Sympathomimetic amines

Narcotics

Anticonvulsants

Diuretics

Metronidazole

Antiandrogens

Metoclopramide

H2 blockers

Marijuana

Anticholinergics

Calcium channel blockers

Psychotropics

Antiandrogens

Cocaine

Alkylating agents

Alcohol

Oral contraceptives

Lipid-lowering drugs

Sedatives

Nonsteroidal antiinflammatory drugs

Tamoxifen

Oncologic agents

Gonadotropin-releasing hormone agonists

Anxiolytics

Analgesics

components of the sexual response can cause FSD. Vascular causes of FSD include atherosclerosis, smoking, diabetes, dyslipidemia, peripheral vascular disease, hypertension, renal failure, and perineal or pelvic trauma, such as that seen with bicycle riding. Neurologic diseases associated with FSD may include stroke, multiple sclerosis, spinal cord injury,Alzheimer's disease, Parkinson's disease, pudendal nerve injury, and iatrogenic surgical changes during radical pelvic surgery, CRS, or hysterectomy. Hormonal or endocrinologic causes of FSD include hypogo-nadism, androgen insufficiency, menopausal changes and genital atrophy, hypothyroidism, hyperthyroidism, diabetes, low estrogen levels, pituitary tumor, and hyperpro-lactinemia.Various specific gynecologic causes of FSD have been identified. These include genital atrophy, vulvar dystrophy and cancer, dermatitis, clitoral phimosis and adhesions, Bartholin's duct cysts, episiotomy scars, vestibulitis, vulvar cancer, and lichen sclerosis.

Numerous medications may contribute to sexual dysfunction in women (Table 5-1.4). These include antihista-mines, sympathetics, anticonvulsants, metronidazole, antihypertensive agents, diuretics, beta-blocking agents, calcium channel blockers, antiandrogens, cancer drugs, anxiolytics, oral contraceptive agents, antidepressants, psy-chotropic agents, narcotics, alcohol, lipid-lowering agents, anti-estrogens, and gonadotropin-releasing hormone agents, to name a few.

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