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Female Orgasmic Disorder

Practice Essentials

Female orgasmic disorder (FOD) involves difficulty in achieving orgasm, substantially decreased intensity of orgasm, or both.

Signs and symptoms

The medical history should address the following:

Chronic and acute medical conditions, including psychiatric conditions

Current and, when relevant, past medications, over-the-counter drugs, and supplements

Any patterns of substance abuse

Sexual complaints

Many patients are reluctant to volunteer sexual complaints. A good general strategy for gathering a sexual history might include the following steps:

First, explain the rationale for inquiring about sexual topics, while sympathizing with the patient reluctance to discuss intimate topics

Next, ask open-ended, general questions about the overall level of sexual interest and satisfaction

Gradually introduce the topic of sexual issues

As rapport improves, ask more specific, closed-ended questions that address the details of sexual activity Physical examination includes the following:

General examination

Cardiac, pelvic, and neurologic examinations to eliminate any coexisting medical conditions that might be contributing to the orgasmic dysfunction

Mental status examination (usually normal in primary FOD; mild, anxious, or depressed mood or affect should be investigated)

See Presentation for more detail.

Diagnosis

By definition, the diagnosis of FOD requires that the following criteria be met:

Another disorder does not account for the orgasmic dysfunction better than FOD does

The dysfunction is not exclusively due to a direct physiologic effect of a substance (eg, a drug of abuse or medication) or a general medical condition

Laboratory workup should include the following:

Complete blood count (CBC)

Chemistry panel

Hormone panel

Vitamin B-12 and folate levels

An informative hormone panel should include the following:

Thyroid test (thyroid-stimulating hormone [TSH] and free T4)

Estradiol

Follicle-stimulating hormone (FSH) and luteinizing hormone (LH

Prolactin

Testosterone (total and free) only in monitoring testosterone therapy

See Workup for more detail.

Management

In general, the initial goal of therapy for FOD is to enable the patient to reach orgasm as desired under any circumstance.

Psychotherapeutic interventions include the following:

Cognitive-behavioral therapy

Sensate focus therapy

Adjunctive approaches (eg, sex education, training in communication skills, and Kegel exercises)

Directed masturbation

Eros Clitoral Therapy Device

Couples or family therapy

Individual or couples sex therapy

As a rule, pharmacologic interventions for secondary anorgasmia should consider the underlying medical etiology, as follows:

Antidepressant-induced anorgasmia – Reduce the antidepressant dose, or switch to a different medication; alternatively, give bupropion

Anorgasmia related to substance abuse – Identify and treat the underlying abuse

Anorgasmia in postmenopausal women with decreased sexual desire – Consider testosterone plus estrogen or tibolone

At present, no medication has been specifically approved by the FDA. Agents that have been used, with mixed results, include the following:

Bupropion

Phosphodiesterase type 5 inhibitors (eg, sildenafil, tadalafil, and vardenafil)

Apomorphine

To date, no pharmacologic agents have been proved to demonstrate long-term beneficial effects on orgasmic function in women with FOD, beyond a placebo effect.

See Treatment and Medication for more detail.

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