AFJOG

REVIEW INTRODUCTION The World Health Organization defines sexual health as a state of physical, mental and social wellbeing in relation to sexual health, and not merely the absence of disease. 1 Sexual health rests on being functional and unimpaired in the physical, psychological and relational aspects of sexual behaviour, and conversely, it is certain that these facets contributes to the state in which sexual function can eventually lead to dysfuntion. 2 Female sexual dysfunction (FSD) is a complex and often underdiagnosed condition that can significantly impact a woman’s quality of life. Until recently FSD was considered to be psychological in nature. However, it is now recognized that FSD is multifaceted, encompassing biological, psychological, relational and sociocultural factors. Biological factors such as vascular disease, diabetes mellitus, neurological conditions, and malignancies may impact sexual function directly or indirectly. 3,4 Ageing itself has been shown to be associated with a decrease in sexual responsiveness, sexual activity, and libido. 5 FSD is highly prevalent with overall prevalence rates as high as 43%. 6 Improved knowledge about female pelvic anatomy and advances in the understanding of female sexual physiology have helped to classify FSD. Female sexual dysfunction can be defined as a disorder of sexual desire, orgasm, arousal and sexual pain. 7 This article aims to provide a comprehensive overview of the approach to FSD, including its classification, investigations, management and the importance of addressing the issue in clinical practice CLASSIFICATION AND DEFINITIONS Sexual dysfunction refers to a problem that occurs during the sexual response cycle that prevents the individual from experiencing satisfaction from sexual activity. In 1966 Masters and Johnson reported that the normal female sexual response cycle consists of four successive phases: excitement, plateau, orgasm, and resolution. 8 In 1977 Helen Kaplan modified this hypothesis by further dividing the excitement phase into desire and arousal and eliminated the plateau phase. 9 This three-dimensional model consisting of desire, arousal, and orgasm formed the basis for the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) definitions of sexual dysfunction. The classification of FSD has evolved over time to reflect a better understanding of the underlying causes and manifestations of these disorders. The International Consensus Development Conference on Female Sexual Dysfunction (ICDC-FSD) in 2001 proposed a classification system that categorized FSD into four main disorders: sexual desire disorders, sexual arousal disorders, orgasmic disorders, and sexual pain disorders. 10 However, this classification system has been criticized for its arbitrary nature and imprecision. 11 More recent research has suggested a revised and expanded classification for FSD that incorporates both organic and psychogenic aetiologies. 12 The classification of FSD includes three main categories: female sexual interest/arousal disorder, female orgasmic disorder, and genito-pelvic pain/penetration disorder. FEMALE SEXUAL INTEREST/AROUSAL DISORDER The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), combines hypoactive sexual desire disorder and female sexual arousal disorder into a single disorder: female sexual interest/arousal disorder. But this is not based on sufficient evidence and for the purpose of this paper we will separate it into two separate disorders. Hypoactive Sexual Desire Disorder (HSSD) refers to the persistent or recurrent deficiency or absence of sexual or erotic thoughts or fantasies and desire for sexual activity. Whereas Female Sexual Arousal Disorder (FSAD) refers to the persistent or recurrent inability to attain or maintain arousal until completion of the sexual activity, an adequate subjective assessment of her genital response. 3,7 FEMALE ORGASMIC DISORDER Female orgasmic disorder is characterised by a delay, absence or reduced intensity of orgasm, despite adequate stimulation. It may involve difficulty reaching orgasm, a prolonged time to reach orgasm, or an inability to reach orgasm altogether. 3,7 GENITO-PELVIC PAIN/PENETRATION DISORDER (GPPD) GPPD involves the persistent or recurrent difficulties with vaginal penetration during intercourse or other forms of sexual activity. It may manifest as pain or discomfort during penetration, fear or anxiety about pain, or involuntary tightening of the pelvic floor muscles that interferes with penetration. 13 ASSESSMENT AND INVESTIGATIONS Accurate assessment of FSD is crucial for effective management. As with any medical condition a comprehensive assessment that include both physiological and psychological factors is crucial. There is a need for a thorough medical history, physical examination, and laboratory investigations to identify any underlying medical conditions or hormonal imbalances that might interfere with normal sexual function. Some chronic conditions such as vascular disease, diabetes mellitus, neurological disease and malignancies can directly or indirectly impact sexual function as seen in Table 1. 3,14 Further, commonly prescribed medications (Table 2) may adversely affect sexual functioning, including anti- estrogens such as aromatase inhibitors and combined hormonal contraceptives. 15 Dr Jireh Serfontein Clinical Head, MySexualHealth, Pretoria, South Africa CORRESPONDENCE: Jireh Serfontein| Email: jireh.serfontein@mysexualhealth.co.za An approach to Female Sexual Dysfunction African Journal of Obstetrics and Gynaecology | Volume 1 | Issue 2 | 2023 | 11