Adrenal production of testosterone precursors gradually decreases with age, beginning in the late 30s. Large epidemiological studies have not shown serum levels of testosterone to correlate with women’s sexual function (48,49). Available assays were not sufficiently sensitive in the female range of serum testosterone to detect particularly low levels. When mass spectroscopy was used: serum testosterone levels were similar in 121 women carefully assessed and diagnosed with disorders of low desire and arousability to levels in 125 women similarly carefully assessed but to exclude any sexual dysfunction (50). A second difficulty, over and beyond the unreliable assays for serum testosterone, was the fact that intercellular production of testosterone in peripheral tissues (from adrenal and ovarian) precursor hormones—DHEA, DHEA sulfate (DHEAS), and androstenedione (A4)—previously could not be measured. Total testosterone activity (ovarian and peripherally produced “intracrine production”) has been measured using mass spectrometry assays for androgen metabolites, most notably androsterone glucuronide (ADT-G). There appears to be a wide range of ADT-G among women of any given age, and levels decrease with age. Importantly there were no group differences in ADT-G between 121 women carefully diagnosed with desire and arousal disorders and 124 sexually healthy controls (50).
Illnesses that accompany aging may have an impact on sexual dysfunction. The association is weaker than that between male erectile dysfunction and hypertension, hyperlipidemia, diabetes, and coronary artery disease. Depression is the major factor inﬂuencing sexual function in women with chronic illness including end-stage renal disease (51), multiple sclerosis (52), or diabetes (53). Some sexual activities (e.g., intercourse) or responses (e.g., orgasmic intensity) may be limited by arthritic, cardiac, or respiratory disorders.
Personality Factors Studies show that, compared with functional women, those who have concerns about low levels of desire and arousability are characterized as having vulnerable self-esteem, high levels of anxiety and guilt, negative body image, introversion, and somatization (18). The clinical impression of women with orgasmic disorder is that many are extremely uncomfortable in conditions in which they are not in control of circumstances or their bodily reactions. For many women with vaginismus, there is a phobic quality to the fear of vaginal penetration. Many women with provoked vestibulodynia show a marked fear of negative evaluation by others, ultra conscientiousness, and self-criticism, as well as an increase in somatization and anxiety (54).
Relationships Most women who report loss of desire and arousability to physicians indicate that their partnerships are stable and satisfactory. An environment free of conﬂict, abuse, and the threat of separation or divorce is insufficient to nurture a woman’s sexual desire. Commonly, the woman reports that her partner is not emotionally intimate with her—not willing to reveal his (or her) feelings, fears, and hopes. Additionally, the woman’s need for eroticism and variety of sexual stimulation may not be met. These women frequently classify their relationship as being that of “very good friends.” Such a context is insufficiently sexual for nurturing or triggering a woman’s sexual desire. Change of partner is shown to be a major factor in increasing women’s desire and responsiveness, and there is a lessening of innate desire with the duration of a relationship (13,34). The woman’s feelings for her partner is one of the major determinants of lack of distress about sex; similarly, the woman’s feelings for her partner, or a change of partner, were major determinants of a woman’s desire (13,17,55).