Female sexual dysfunction — what the literature supports beyond Vyleesi, across desire, arousal, orgasm, and pain

Female sexual dysfunction (FSD) resists single-drug framing more than almost any other domain in adult medicine. The DSM-5 collapses what previous editions treated as separate disorders — hypoactive sexual desire disorder, female sexual arousal disorder — into a unified diagnosis (female sexual interest/arousal disorder, FSIAD) while preserving female orgasmic disorder and genito-pelvic pain/penetration disorder as distinct entities. The ICD-11 retains the older split. The International Society for the Study of Women's Sexual Health (ISSWSH) clinical-practice ecosystem treats acquired generalized HSDD as a separately diagnosable condition for which a distinct pharmacology now exists. The same patient may receive different diagnostic labels and different drug recommendations depending on the framework her clinician uses (Clayton et al. 2018; McCabe et al. 2016).

The Fourth International Consultation on Sexual Medicine (ICSM 2015) reported that desire and arousal complaints are the most common sexual concerns women report, with a substantial proportion experiencing multiple co-occurring dysfunctions (McCabe et al. 2016, J Sex Med 13:144–152). Population self-report puts lifetime prevalence of any sexual concern at roughly 40%; the proportion meeting DSM-level distress criteria is closer to 10–15%. Reproductive status partitions the landscape further: premenopausal FSIAD differs in mechanism and treatment from postmenopausal dyspareunia secondary to genitourinary syndrome of menopause (GSM), which differs again from medication-induced dysfunction on top of either substrate.

This dossier covers the female-specific dive beyond what the sexual function decision guide treats as cross-sex comparative reference, and complements the male-axis andropause-and-peptides dossier on the parallel hormonal trajectory. The framing is the gap between what is FDA-approved (narrowly), what is widely off-label (broadly), and what is investigational (kisspeptin in particular). PT-141 / bremelanotide is the only peptide with a female-indication FDA approval. The non-peptide adjuncts — flibanserin, transdermal testosterone, vaginal DHEA, ospemifene, vaginal estradiol — share the same patient population and require the same comparative honesty about which condition each is actually approved for.