Female sexual dysfunction in psychiatry

Bou Khalil writes an interesting viewpoint on the potential protective role of orgasm in promoting a positive mood in women. Like chocolate, it is not hard to believe that sex is good for a person’s state of mind. The approach Bou Khalil takes, explores the potential biological pathways between orgasm and positive mood, a relationship supported by epidemiological data (Davison et al., 2009). Female sexuality, including orgasm, is an important, complex area for psychiatrists to be aware of when considering the holistic care of female patients. Female sexual dysfunction (FSD), including anorgasmia and low libido, is extremely common in psychiatric patients. Both psychiatric illness and psychotropic medications can adversely affect female sexual function (Montejo et al., 2010). In excess of 50% of women who take selective serotonin reuptake inhibitors (SSRIs) experience impaired sexual function (Montejo et al., 2001). This is an important consideration for psychiatrists as FSD impairs quality of life and is associated with treatment discontinuation (Davis and Jane, 2011). Whilst SSRI-associated sexual dysfunction may remit with time (Haberfellner and Rittmannsberger, 2004), real-world rates of antidepressant medication discontinuation have been reported to be as high as 40% at 1 month (Olfson et al., 2006), meaning that women may not continue on SSRIs long enough for the FSD to subside.

FSD is of course multifactorial with psychological, social and biological contributors (Davis and Jane, 2011). The viewpoint presented in the current issue provides further potential explanations of the known relationship between FSD and reduced psychological well being. The suggested action of oxytocin in improving mood is intriguing, although still in an early phase of research. In clinical practice, other hormonal factors that contribute both to sexual function and mood should also be considered. For example, the hormonal changes associated with the menopausal transition are associated with an increased risk of depression in some women (Bromberger and Kravitz, 2011). Likewise, reduced libido is a common complaint among menopausal women. For improvement in mood and sexual symptoms, consideration of hormone therapy may be necessary, particularly in women whose mood or sexual symptoms have coincided with the onset of perimenopause. Androgen therapy in particular has proven to be helpful in women with FSD (Davis et al., 2008) and a trial being undertaken at the Monash University Women’s Health Research Program is investigating testosterone treatment for SSRI-induced FSD. The menopausal transition is not the only biological contributor to female sexual dysfunction. Other medical causes include urinary tract infections and pelvic disorders (Davis and Jane, 2011).

Whilst FSD is common in women with psychiatric disorders, and adversely impacts on their quality of life, women may not necessarily raise the topic themselves. Sensitive discussion of the issue is required as sexual abuse is not an uncommon cause of sexual difficulties (Davis and Jane, 2011). Social difficulties including relationship problems and financial strain also play a significant role in sexual dysfunction (Christensen et al., 2011).

Sexuality is viewed as important by most women in the community (Mulhall et al., 2008). For the optimal, long-term management of a woman’s mental health, it is important to address the impact of her ailments and treatments on her sexual health and relationships. If a woman is distressed by her symptoms, consideration of alternative psychotropic agents or referral to an appropriate specialist is warranted. Women with SSRI-induced FSD symptoms may improve over time, but sensitive discussion and understanding of her concerns must be part of the psychiatrist’s role.

See Viewpoint by Bou Khalil, 2012, 46(12): 1115–1117