Female Sexual Dysfunction (FSD) is a multi-causal and a multi–dimensional medical problem, comprising anatomical, physiological, psychological as well as social-interpersonal components, that adversely affects physical health and emotional well-being. A meta study showed that 41% of women had some level or form of Female Sexual Dysfunction. FSD is especially prevalent among women with chronic diseases such as metabolic syndrome, type 2 diabetes, hypertension, dyslipidemia and coronary artery disease, Hashimoto’s thyroiditis, Graves’ disease and Parkinson’s disease. A plant-based diet can lower the risk of Female Sexual Dysfunction (FSD) by substantially by lowering the risk of several pathologies that are risk factors for it.
Female sexual function, especially arousal, is significantly affected by genital vascular impairment which can lead to vaginal dryness and impaired genital engorgement mediated arousal. The plant-based diet is a safe and effective prophylaxis and treatment for hypercholesterolemia and atherosclerosis. The Mediterranean diet is a plant-strong diet that results in better female sexual function in a dose-dependent manner, regardless of menopausal and metabolic syndrome status. The plant-based diet has the potential to be at least as good a treatment of FSD. A plant-based diet has the significant advantage of having no contraindications or adverse reactions, and is an affordable prophylaxis for all patients over the long-term.
A healthy and satisfying experience of sexuality is often an important component of overall well-being for women (defined for the purposes of this article as individuals who have female genitalia), associated with increased life satisfaction, higher perceived and objective health status, and even increased longevity [1-4].
In addition, several significant health benefits have been identified for women related to regular sexual activity. These include postponement of natural menopause (and the subsequent hypoestrogenism) , reduced frequency of hot flushes during menopause , better vaginal health and less vaginal atrophy in post-menopausal women , better cognitive function in older adult women,  and a reduced risk of subsequent new severe disabilities in disabled women living with their spouse . Some studies also showed that the thresholds for pain tolerance and pain detection were significantly increased when paired with genital self-stimulation, and considerably more so when achieving orgasm .
Female sexual function is a complex process coordinated by the neurological, vascular and endocrine systems . Female Sexual Dysfunction (FSD) is a multi-causal and a multi–dimensional medical problem, comprising anatomical, psychological, physiological, as well as social-interpersonal components, that adversely affects physical health and emotional well being [12-16]. FSD is a general term comprising several sexual health concerns that can be distressing for patients, including female sexual interest/arousal disorder, female orgasmic disorder, and genito-pelvic pain/penetration disorders, including dyspareunia and vaginismus. [17,18].
Our understanding of female sexuality was only first formally addressed roughly 50 years ago. During this period and even today, the treatment of FSD has primarily focused on psychosocial/cultural therapy, and highlights that our limited knowledge is reflective of the inadequate treatment options available. Due
to the complexity of FSD, a multifaceted approach, addressing
neurobiological, vasoactive, hormonal as well as psychosocial/
cultural aspects is necessary . This article addresses only the
physical etiological factors and symptoms.
A 2016 systematic review and meta-analysis assessed
the prevalence rate of female sexual dysfunction in 215,740
reproductive-age women worldwide and found the 41% of
these women report some form of female sexual dysfunction
. Dysfunction is especially prevalent in women with chronic
health problems, including metabolic syndrome, hypertension,
dyslipidemia, coronary heart disease, diabetes, overweight and
obese body mass indices (BMIs), anxiety, and depression [3,21-
28]. In patients with overt cardiovascular disease, FSD is even
more prevalent . Studies have shown a positive association
between cardiovascular diseases and sexual dysfunction in
females . Diabetes, heart disease, urinary tract disorders, and
chronic illness are also significant risk factors for female sexual
The first phase of the female sexual response, associated with
neurotransmitter-mediated vascular smooth muscle relaxation,
results in increased vaginal lubrication, wall engorgement and
luminal diameter as well as increased clitoral length and diameter.
Physiologically, healthy pelvic blood flow is necessary for vaginal
lubrication. Normal blood pressure pushes a transudative fluid
through capillaries, which ultimately coalesces at the vaginal
surface epithelium [32,33]. This process relies on vessels
being both patent and able to dilate effectively. Therefore, low
atherosclerotic burden and sufficient nitric oxide (NO) activity are
protective against sexual dysfunction .
Evidence shows that female sexual function, especially arousal,
is significantly affected by genital vascular impairment, which can
lead to FSD. Specific physiologic impairments of vasculogenic
female sexual dysfunction include vaginal engorgement and clitoral
erectile insufficiency. Orgasmic female sexual dysfunction may be
related in part to vasculogenic impairment of the hypogastricvaginal/
clitoral arterial bed . These syndromes exist when
during sexual stimulation, abnormal arterial circulation into the
vagina or clitoris, usually from atherosclerotic vascular disease,
interferes with normal vascular physiologic processes .Clinical
symptoms may include delayed vaginal engorgement, diminished
vaginal lubrication, dyspareunia, diminished vaginal sensation,
diminished vaginal orgasm, diminished clitoral sensation or
diminished clitoral orgasm .
Some chronic illnesses, such as vascular disease,
diabetes mellitus, neurologic disease, and malignancy, can
directly or indirectly impact sexual function [36,37]. Type 2
diabetes, hypertension, dyslipidemia, chronic kidney disease,
atherosclerosis, and traumatic injury are associated with
diminished vaginal and clitoral blood flow and impaired sexual
functioning [38,39]. For many cardiometabolic risk factors
and diseases, such as hypertension, diabetes, dyslipidemia and
metabolic syndrome, an adverse impact on women’s endothelial
function, as well as an association with FSD, has been recognized
A doppler ultrasound study found that the Clitoral Pulsatility
Index - an index of vascular resistance in the clitoris - was
positively correlated with body mass index, waist circumference,
insulin, triglycerides, total cholesterol, and low density lipoprotein
cholesterol . Women who have neurologic diseases such
as Parkinson’s disease or multiple sclerosis may also have FSD
. Chronic diseases affecting multiple systems, such as thyroid
disease, may also have an impact upon the female sexual function
Nutrition plays a significant role in cardiometabolic disease,
suggesting one pathway through which diet influences sexual
health in females in the form of vaginal dryness and impaired
genital engorgement-mediated arousal [43,44]. Atherosclerotic
risk is minimized with a nutrient-dense diet whose foundation is
plant-based foods . Meanwhile, nitric oxide (NO) can function
best when inflammation is minimal . . A high-quality diet
can be a source of antioxidants, and nitrate-rich foods can directly
increase NO stores [47,48]. Diet can also indirectly support NO
availability through preventing and ameliorating conditions
associated with inflammatory and pro-oxidant activity, such as
metabolic syndrome, obesity, and atherosclerosis [33,48,49].
A plant-based diet can help prevent and treat diseases such
as type II diabetes and cardiovascular disease, and can be very
efficacious [50,51]. For instance in one study, a plant-based diet
was found to be twice as efficacious in treating type 2 diabetes as
Metformin . A plant-based diet can also lower cholesterol as
much as lovastatin . In addition, a plant-based diet can reduce
the risk of other chronic diseases that have been shown to promote
FSD, such as Graves’ disease and Hashimoto’s disease, rheumatoid
arthritis, chronic kidney disease, and Parkinson’s disease [54-57].
With regards to specific foods, consumption of soy is
associated with increased vaginal blood flow, lubrication, and
vaginal collagen content and decreased dyspareunia [58-60].
Fruits such as apples, watermelon, and cacao have been linked
to enhanced vascular and sexual health. Daily apple consumption
is associated with improved vaginal lubrication and general
sexual function . Apples are high in polyphenols, other
antioxidants, and phytoestrogens, which together support an antiinflammatory
and anti-atherosclerogenic environment. It can be
expected that other fruits would perform similarly, though further
research is needed to confirm this. Watermelon in particular
supports vascular health via an additional distinct mechanism. It
is a rich source of citrulline, which the body readily converts to
the NO precursor, arginine [62-64]. Chocolate, derived from the
cacao bean, is rich in flavonoids and has been found to increase
NO-mediated vasodilation, with promise for supporting sexual
function [65,66]. Although more research is needed, these findings
on individual foods offer support and further insight into how a
plant-based dietary pattern can benefit female sexual health.
The Mediterranean diet (MD) is the most widely studied
dietary pattern in this context. The Mediterranean diet is
characterized by a high intake of plant foods, a high intake of olive
oil, a moderate intake of dairy products, zero to four eggs a week,
with fish and poultry consumed in low to moderate amounts and
red meat consumed in low amounts . Multiple randomized
controlled trials and cross-sectional studies have analyzed the
long-term effect of the MD on reported sexual function. They find
that adherence to this diet results in better sexual function in a
dose-dependent manner, regardless of menopausal and metabolic
syndrome status [67-69]..
Other lifestyle changes may help improve sexual function.
These modifications include physical activity, nutrition counseling,
and adequate sleep, in addition to a healthy plant-based diet. .
Based on cultural norms and biases, conversations about sex
are sometimes thought of as taboo in American society and in
many other cultures worldwide. This is especially true for women,
and particularly when sex is for pleasure rather than reproductive
purposes. Failure to have informative discussions about sex often
leads to misperceptions about sex and sexuality, including a sense
that pain or lack of interest in sexual activity is inevitable and
nonmodifiable, which can also lead to women not seeking the
care they need. In addition, women sometimes assume that older
people do not, or should not, engage in sexual activity .
Several U.S. and international surveys of women recently found
that the majority of women surveyed did not discuss their sexual
health-related symptoms with their health care provider, and
discomfort and/or embarrassment with having this discussion
was often cited as a reason for avoiding the conversation [72-
75]. This finding was consistent for women across different
demographics, including age, sexual orientation, race/ethnicity,
educational level, and relationship status . Given this situation,
physicians need to develop clinical strategies when approaching
their patient. For instance, a physician treating a female patient
with type 2 diabetes should inquire as to her sexual function since
their patient might not raise the issue. One study showed that
54% of women with type 2 diabetes had FSD . Identification of
concurrent comorbidities and implementation of lifestyle changes
will help improve overall health and may improve sexual function
A plant-based diet has the significant advantage of having
no contraindications or adverse reactions, and is an affordable
prophylaxis for all patients over the long-term. When treating a
patient with a plant-based diet it is important to titrate relevant
medications, for pathologies such as hypertension and type II
diabetes in particular, as the effects of the diet become evident.
Patient compliance on plant-based diets has been good in almost
all studies. The degree of compliance has often been very high.
For instance, one study obtained a 99% compliance . In a
22-week study 94% of subjects on a vegan diet were compliant
. In a somewhat longer study, 84% of the participants in each
group completed all 24 weeks . In studies of patients placed
on plant-based diets for coronary artery disease, high compliance
has been noted even over several years. For instance, one study of
patients placed on a plant-based diet showed 89% compliance for
3.7 years .
Evidence suggests that vitamin D and iron deficiencies are risk
factors for sexual dysfunction, and resolution of these deficiencies
may well be therapeutic [80-83]. Vitamin D receptors exist on
the uterus and ovaries, where they can influence steroidogenesis
and testosterone aromatization, with consequent effects on
sex hormone levels [84-86]. In iron-deficiency anemia, fatigue
is thought to mediate the relationship between deficiency and
sexual dysfunction . Testing for vitamin D and iron deficiency
may be considered as a relatively simple and low-cost addition to
the workup for female sexual dysfunction.
Quality of life has become a large concern of patients with
a wide variety of diseases. Patients with diseases ranging from
several forms of cancer to rheumatoid arthritis want a satisfying
sex life. Patient and nonprofit organizations are offering
patients general advice on how they can have sex while they
are being treated. While many patients may be reluctant to ask
their physician about FSD, they may well be appreciative of the
physician asking them about it.
While a plant-based diet can’t treat aspects of FSD such as
psychological and social factors, it does deserve a place in its
treatment. It can be used as a monotherapy in some cases, or as an
adjunct to other treatments. It may be especially helpful in treating
vascular causes of FSD. It can also help prevent and can efficaciously
treat several risk factors for FSD including atherosclerosis,
metabolic syndrome, type 2 diabetes, dyslipidemia and chronic
kidney disease. It has no adverse reactions or contraindications
and is affordable. This becomes even more important considering
that many patients with FSD have comorbidities.
A plant-based diet, and specifically manufactured plantbased
foods, are now considered mainstream and several studies
have shown good patient compliance. Increasing numbers of
physicians are prescribing a plant-based diet for their patients in
order to prevent and treat disease. Asking a patient about their
diet, and prescribing a plant-based diet, should be considered a
new standard of care for FSD.