Female Genital Arousal Disorder

Female sexual arousal disorders affect an individual’s mental or genital arousal response. Sometimes, a woman with a sexual arousal disorder may feel mentally turned on, but her body and genitals cannot respond to sexual stimulation. Other times, a woman’s body can respond to sexual stimulation, but she may have trouble feeling excited during sexual activity.

Not all psychological and medical organizations agree on how to classify female sexual arousal disorders. Some organizations classify sexual arousal disorders as being different from desire disorders, while others combine arousal and desire disorders into a single category. This is because women generally describe their own sexual arousal and sexual desire as being the same experience. While some parts of the brain regulating arousal and desire overlap, there are also unique and different areas of the brain and body that influence sexual arousal and desire. According to the International Society for the Study of Women’s Sexual Health (ISSWSH), sexual arousal and desire disorders have different clinical symptoms.

Under this grouping system, one type of female sexual arousal disorder is female genital arousal disorder (FGAD). FGAD is defined by the ISSWSH as the inability to develop or maintain adequate genital responses, including vulvovaginal lubrication, engorgement of the genitalia, and sensitivity of the genitalia, associated with sexual activity and which causes distress for a minimum of six months.

This means that women with FGAD do not have enough vaginal lubrication or sensitivity during sex, even when they have sufficient sexual stimulation. It is important to recognize that other conditions can also cause symptoms of FGAD but would not be considered FGAD.  These conditions include genitourinary syndrome of menopause (GSM), formerly known as vulvovaginal atrophy (the “shrinking” and thinning of vaginal tissues during menopause), inflammatory disorders, infections of the vulva/vagina, or sexual pain disorders like vestibulodynia or clitorodynia.

FGAD differs from female cognitive arousal disorder (FCAD) because women with FGAD may feel mentally turned on during sex but cannot get their genitals to respond, and women with FCAD may have good lubrication and sensitivity but no mental excitement. ISSWSH defines FCAD as difficulty or inability to attain or maintain adequate mental excitement associated with sexual activity as manifested by problems with feeling turned on, engaged, and/or mentally sexually aroused for a minimum of six months.

Sexual arousal disorders are called lifelong disorders if their symptoms have been present for a patient’s whole life. However, most sexual arousal disorders are acquired, meaning that a person develops symptoms later in life.  

Lots of sexual disorders can affect the lubrication and sensitivity of a woman’s genitals. However, a woman may have FGAD if she has these symptoms but does not have another condition which may cause these symptoms, such as an infection, inflammatory condition, sexual pain disorder, psychological distress, relationship issues, or significant thinning of her vaginal tissues. The most common FGAD symptoms are:

• Difficulty producing or maintaining natural lubrication during sex
• Lack of genital swelling during sex
• Lack of genital sensitivity during sex
• The feeling of having “dead” genitals
• Personal distress or relationship problems due to the condition

Sexual medicine experts believe that many things, whether physical, psychological, or social, can cause FGAD or make symptoms worse. A vascular injury (one related to blood vessels), neurological dysfunction (related to the nervous system), or a hormonal imbalance or deficiency can cause FGAD symptoms. This means that medical conditions that impact the body’s blood vessels, nervous system, or hormones can also affect genital arousal. Some examples of such conditions are cardiovascular disease, peripheral vascular disease, obesity, diabetes, thyroid disorders, multiple sclerosis (MS), spinal stenosis, pelvic surgeries (like a hysterectomy or prolapse repair), pelvic radiation therapy, and anorexia nervosa.

FGAD can also be impacted by psychological factors like anxiety or distraction, cultural factors like the belief that it is a sin to enjoy sex, and/or medications like birth control pills or antidepressants. Even things like the skill of the patient’s partner or the level of attraction she feels towards her partner can play a role in the body’s arousal response.

Lastly, aging can be associated with FGAD. As women age, their reproductive hormone levels decline, and this can affect the makeup and sensitivity of the genital tissues, as well as the amount of blood flow to the genital region.

An experienced sexual medicine provider can properly diagnose FGAD by obtaining a thorough patient history, doing a physical exam, and doing laboratory tests as necessary.

Perhaps the most important (and often overlooked) part of the diagnosis is the patient history. The patient history gives background information on the state of the disorder, and it can provide valuable information about the possible cause of the issue. This is why the provider should get a detailed description of symptoms from the patient, as well as the patient’s medical/surgical history, social history, and medication history before doing a physical exam or running any laboratory tests.

Then, the provider can perform a full physical exam including a visual inspection of the genitals, a measurement of vaginal pH, a pelvic floor assessment, a wet mount (test to detect infection of the vagina), and a pain evaluation in which the provider uses a cotton-tipped swab to gently touch the vulva and vestibule of the vagina to see if there are areas of pain or heightened symptoms. The physical exam can help rule out the possibility of other conditions that may be causing symptoms like atrophy of the vaginal tissues, infections, inflammatory disorders, vestibulodynia, or clitorodynia. The physical exam can also be helpful for determining if or when symptoms change throughout the process.

Based on the results of the physical exam, the health care provider may recommend follow-up laboratory tests such as:

• Thyroid and sex hormone testing to determine whether the symptoms are related to a hormonal imbalance.
• Vascular testing to establish if the cause of FGAD is related to vascular function.
• Quantitative sensory testing like hot and cold perception testing and/or biothesiometry (vibration testing) to see if FGAD might be caused by neurological factors.
• Vaginal blood flow testing measured by Doppler ultrasonography to determine if there is sufficient blood flow to the vagina.

Generally, a holistic approach is best when it comes to treating an arousal disorder of any kind. Every patient’s experience with FGAD is unique, and for each patient, a different combination of contributing factors has led to the onset of the disorder. Therefore, there is no “one-size-fits-all” treatment option, and treatment plans must be personalized for each patient to address the different underlying causes of FGAD in each case. 

Arousal disorders are often associated with vascular disease, cardiovascular disease, diabetes, and metabolic syndrome, so lifestyle changes such as getting enough sleep, maintaining a healthy diet, exercising regularly, and quitting smoking can all be beneficial in treating FGAD. Depending on the underlying cause of the condition, behavioral changes like adjusting medications (especially birth control pills or antidepressants), participating in sex therapy or cognitive behavioral therapy (CBT), or practicing mindfulness or yoga could also be helpful. For patients with pelvic pain or incontinence issues (leaking urine or stool), pelvic floor therapy is a possible treatment option.

FGAD patients might consider using vaginal moisturizers and lubricants, vibrators, or clitoral engorgement devices to help with their symptoms. If the FGAD symptoms are related to hormones, a medical provider might prescribe localized or systemic hormone treatment to the patient. Local hormonal creams have been shown to be highly effective in treating this sexual arousal disorder.

As with any sexual disorder, it is important to talk to your health care provider and other necessary medical specialists before pursuing treatment for your condition.  

Resources:

Brotto, L.A., Bitzer, J., Laan, E., Leiblum, S., & Luria, M. (2010). Women’s Sexual Desire and Arousal Disorders. The Journal of Sexual Medicine, 7(1), 586-614. https://www.jsm.jsexmed.org/article/S1743-6095(15)32866-6/fulltext.

Clinical Evaluation of Female Genital Arousal Disorder (FGAD) [Video]. (2019). Produced by the International Society for the Study of Women’s Sexual Health, presented by Lisa Larkin, MD.

Female Sexual Arousal Disorders: Prevalence, Physiology, Classification [Video]. (2019). Produced by the International Society for the Study of Women’s Sexual Health, presented by Leah S. Millheiser, MD.

Frank, J.E., Mistretta, P., & Will, J. (2008). Diagnosis and Treatment of Female Sexual Dysfunction. American Family Physician, 77(5), 635-642. https://www.aafp.org/afp/2008/0301/p635.html.

Giraldi, A., Rellini, A., Pfaus, J., & Laan, E. (2013). Female Sexual Arousal Disorders. The Journal of Sexual Medicine, 10(1), 58-73. https://www.jsm.jsexmed.org/article/S1743-6095(15)30116-8/fulltext.

Goldstein, I., Clayton, A.H., Goldstein, A.T., Kim, N.N., & Kingsberg, S.A. (2018). The International Society for the Study of Women’s Sexual Health Textbook of Female Sexual Function and Dysfunction Diagnosis and Treatment. Wiley Blackwell.

Management of Arousal Disorders [Video]. (2019). Produced by the International Society for the Study of Women’s Sexual Health, presented by Rachel Rubin, MD.

Mayo Clinic. (2020, December 17). Female Sexual Dysfunction. https://www.mayoclinic.org/diseases-conditions/female-sexual-dysfunction/symptoms-causes/syc-20372549.

Weiss, P., & Brody, S. (2009). Female Sexual Arousal Disorder with and without a Distress Criterion: Prevalence and Correlates in a Representative Czech Sample. The Journal of Sexual Medicine, 6(12), 3385-3394. https://www.jsm.jsexmed.org/article/S1743-6095(15)32351-1/fulltext.