Female sexual dysfunction: common, undercounted, and rarely one problem

How common sexual dysfunction is in women depends on one methodological choice: whether distress is required for the diagnosis. A 2025 cross-sectional study of 5,468 Australian women aged 40 to 69, published in The Lancet Obstetrics, Gynaecology & Women's Health, found that about one in four met criteria for a sexual dysfunction when distress was required, and another one in four had sexually related distress without an identified dysfunction [1]. Low desire was reported by 13.3 percent, impaired arousal by 13.1 percent, and poor sexual self-image by 12.8 percent [1]. Meta-analyses that pool questionnaire scores, most of them with no distress requirement, report higher figures: a 2026 meta-analysis of 23 studies and 11,892 postmenopausal women put sexual dysfunction at 61 percent [2]. Both numbers are informative. Roughly one in four midlife women has a sexual problem that bothers her; a majority of postmenopausal women score in the dysfunction range on a questionnaire.

Desire is not a lab value

Low desire is the problem women report most often. In PRESIDE, a 2008 US survey of 31,581 women, 38.7 percent reported low desire, 43.1 percent reported any sexual problem, and 22.2 percent reported distress about one [3]. It is also hard to pin to a single cause. The 2024 New England Journal of Medicine review by Davis frames the problem as multifactorial, with biological, psychological, and social contributors, and treats assessment as the first step [4]. In practice that assessment covers depression and its treatments (SSRIs and SNRIs are frequent contributors), relationship context, stress and sleep, pain with intercourse, and genitourinary syndrome of menopause, and each has its own treatment. Hypoactive sexual desire disorder, low desire with distress and no better explanation, affected about 10 percent of women in PRESIDE [3]. It is a diagnosis reached after the other causes are addressed, not before.

The tissue problem underneath many cases

Genitourinary syndrome of menopause is common. The 2020 Menopause Society position statement cites a range of 27 to 84 percent of postmenopausal women, depending on the survey, and calls the condition underdiagnosed and undertreated [5]. The symptoms are dryness, burning, pain with sex, urinary urgency, and recurrent urinary infections, driven by estrogen loss in genital tissue. Unlike hot flashes, it tends not to resolve on its own.

The 2025 AUA/SUFU/AUGS guideline (Kaufman et al.) gives a strong recommendation to offer low-dose vaginal estrogen for vulvovaginal dryness, irritation, and pain with sex, and a moderate recommendation to use it to reduce recurrent urinary tract infections [6]. The infection effect was first shown in a 1993 randomized trial of intravaginal estriol in 93 postmenopausal women, in which infections fell from 5.9 to 0.5 per patient-year [7]. A 2008 Cochrane review found that vaginal estrogen reduced recurrent infections in both placebo-controlled trials it identified, with the size of the effect depending on the product and duration (relative risks 0.25 and 0.64), while oral estrogen did not [8]. Vaginal DHEA and the oral drug ospemifene are alternatives [5, 6]. Energy-based treatments marketed for the same symptoms, principally vaginal laser, are not supported by the 2025 guideline [6]. In a 2021 sham-controlled trial of 85 women published in JAMA, fractional CO2 laser did no better than sham at 12 months on symptom severity, quality of life, or vaginal histology [9].

Pain deserves separate emphasis because it reorganizes everything downstream: a woman who expects pain loses desire, and desire-directed treatment fails until the pain is found and treated. The cause may be tissue change, infection, skin disease such as lichen sclerosus, or an overactive pelvic floor. In that last case the usual advice to do Kegels may not help, and the muscles need assessment by a pelvic floor physiotherapist before any exercise program is chosen [10].

Interpretation

The evidence supports a sequence: treat pain first, then tissue, then review medications and mood, and only then consider desire-specific therapy. In the Australian data, about half of midlife women reported poor sexual wellbeing [1], and the Davis review notes that fewer than half of women with sexual dysfunction seek medical help [4].

Sources

1. Wang, Islam, Bond, Skiba, Davis SR. Sexual dysfunction in women at midlife: a cross-sectional study of data from the Australian Women's Midlife Years study. The Lancet Obstetrics, Gynaecology & Women's Health, 2025. doi:10.1016/j.lanogw.2025.100024
2. Rodríguez-García M, Fagundo-Rivera J, Gómez-Salgado J, Partida-Márquez AL. Female sexual dysfunction in postmenopausal women: a systematic review and meta-analysis. Sexuality Research and Social Policy, 2026. doi:10.1007/s13178-026-01289-7
3. Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in United States women: prevalence and correlates. Obstetrics & Gynecology, 2008;112(5):970-978. PMID 18978095.
4. Davis SR. Sexual dysfunction in women. New England Journal of Medicine, 2024;391(8):736-745. doi:10.1056/NEJMcp2313307
5. Faubion SS, et al. The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause, 2020;27(9):976-992. doi:10.1097/GME.0000000000001609
6. Kaufman MR, Ackerman LA, Amin KA, et al. The AUA/SUFU/AUGS guideline on genitourinary syndrome of menopause. Journal of Urology, 2025;214(3):242-250. doi:10.1097/JU.0000000000004589
7. Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. New England Journal of Medicine, 1993;329(11):753-756. PMID 8350884.
8. Perrotta C, Aznar M, Mejia R, Albert X, Ng CW. Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database of Systematic Reviews, 2008;(2):CD005131. doi:10.1002/14651858.CD005131.pub2
9. Li FG, et al. Effect of fractional carbon dioxide laser vs sham treatment on symptom severity in women with postmenopausal vaginal symptoms: a randomized clinical trial. JAMA, 2021;326(14):1381-1389. doi:10.1001/jama.2021.14892
10. Padoa A, McLean L, Morin M, et al. The overactive pelvic floor (OPF) and sexual dysfunction. Part 2: evaluation and treatment of sexual dysfunction in OPF patients. Sexual Medicine, 2021;9(1):76-92.