Distressing Sexual Function at Midlife

Female sexual dysfunction (FSD) is characterized as chronic sexual symptoms that manifest with personal distress in the domains of desire, arousal, orgasm, and pain. Extensive epidemiologic evidence estimates that almost 50% of perimenopausal and postmenopausal women experience FSD. Screening for FSD is not readily conducted and patient-physician discussion of sexuality is limited by the lack of physician training on the topic and by the patient-held belief that sexual issues are not medical in nature. The purpose of this commentary is to provide clinicians with a framework to approach the discussion of FSD, to clinically identify FSD through patient symptoms and physical signs, and to manage FSD in perimenopausal and postmenopausal patients with the available U.S. Food and Drug Administration-approved and off-label treatments. Particular attention will be paid to FSD with common midlife onset including vulvovaginal atrophy, vulvodynia, and hypoactive sexual desire disorder. Although evaluating FSD can be a challenge, triaging symptoms by addressing pain before desire and arousal will improve patient outcomes and greatly simplify FSD management.