Sexual Dysfunction in Women

Sexual dysfunction includes pain during intercourse, involuntary painful contraction (spasm) of the muscles around the vagina, and lack of interest in (desire for) sex and problems with arousal or orgasm. For a sexual dysfunction disorder to be diagnosed, these problems must cause distress to the woman.

• Depression or anxiety, other psychologic factors, disorders, and drugs can contribute to sexual dysfunction, as can the woman’s situation, including relationship difficulties.
• To identify a problem, doctors often talk to both partners separately and together, and a pelvic examination is often necessary when the woman has pain or problems with orgasm.
• Improving the relationship, communicating more clearly and openly, and arranging the best circumstances for sexual activities can often help, regardless of the cause of sexual dysfunction.
• Cognitive-behavioral therapy, mindfulness, or a combination of the two, can also help, as can other forms of psychotherapy.

About 30 to 50% of women have sexual problems at some time during their life. If the problems are severe enough to cause distress, they may be considered sexual dysfunction.

Sexual dysfunction can be described and diagnosed in terms of specific problems, such as the following:

• Difficulty reaching orgasm despite normal interest in sexual activity (called female orgasmic disorder)
• Involuntary tightening of the muscles around the vagina or pain during sexual activity (called genitopelvic pain/penetration disorder)
• Lack of interest in sexual activity and/or difficulty becoming aroused (called sexual interest/arousal disorder)
• Substance/medication–induced sexual dysfunction
• Other sexual dysfunction (doctors refer to this as “other specified and unspecified sexual dysfunction”)

In substance/medication–induced sexual dysfunction, sexual dysfunction is related to initiation, change in dose, or stopping of a substance or drug. The drug may be a prescribed drug, a recreational drug, or a drug of abuse.

Other sexual dysfunction includes sexual dysfunction that does not fit in the other categories. It includes sexual dysfunction that has no identifiable cause or that does not precisely meet the criteria for a specific sexual dysfunction disorder.

Persistent genital arousal disorder is a rare disorder that is not included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which provides doctors with specific criteria for diagnosing psychologic disorders. Women with persistent genital arousal disorder experience excess physical arousal (indicated by increased blood flow to the genital organs and increased vaginal secretion), but sexual desire is absent. No cause for the arousal is identified, and arousal does not usually resolve after orgasm.

Almost all women with sexual dysfunction have features of more than one such specific problem. For example, women who have difficulty becoming aroused may enjoy sex less, have difficulty reaching orgasm, or even find sex painful. These women and most women who have pain during sexual activity often understandably lose their interest in and desire for sex.

Normal Sexual Function

Sexual function and responses involve mind (thoughts and emotions) and body (including the nervous, circulatory, and hormonal systems). Sexual response includes the following:

• Motivation is the wish to engage in or continue sexual activity. There are many reasons for wanting sexual activity, including interest in or desire for sex. Sexual interest or desire may be triggered by thoughts, words, sights, smells, or touch. Motivation may be obvious at the outset or may build once the woman is aroused.
• Arousal has a subjective element—sexual excitement that is felt and thought about. It also has a physical element—an increase in blood flow to the genital area. In women, the increased blood flow causes the clitoris (which corresponds to the penis in men) and vaginal walls to swell (a process called engorgement). The increased blood flow also causes vaginal secretions (which provide lubrication) to increase. Blood flow may increase without the woman being aware of it and without her feeling aroused.
• Orgasm is the peak or climax of sexual excitement. Just before orgasm, muscle tension throughout the body increases. As orgasm begins, the muscles around the vagina contract rhythmically. Women may have several orgasms.
• Resolution is a sense of well-being and widespread muscular relaxation. Resolution typically follows orgasm. However, resolution can occur slowly after highly arousing sexual activity without orgasm. Some women can respond to additional stimulation almost immediately after resolution.

Most people—men and women—engage in sexual activity for several reasons. For example, they may be attracted to a person or desire physical pleasure, affection, love, romance, or intimacy. However, women are more likely to have emotional motivations, such as

• To experience and enhance emotional intimacy
• To increase their sense of well-being
• To confirm their desirability
• To please or placate a partner

For women, desire may develop once sexual activity and stimulation begin. Sexual stimulation can trigger excitement and pleasure and physical responses (including increased blood flow to the genital area). Desire for sexual satisfaction builds as sexual activity and intimacy continue, and a physically and emotionally rewarding experience fulfills and reinforces the woman’s original motivations. Some women may feel sexually satisfied whether they have an orgasm or not. Other women have much more sexual satisfaction with an orgasm.

Desire before sexual activity typically lessens as women age but temporarily increases when women, regardless of their age, have a new partner.

Causes

Many factors cause or contribute to various types of sexual dysfunction. Traditionally, causes are considered physical or psychologic. However, the two types of causes cannot be separated. Psychologic factors can cause physical changes in the brain, nerves, hormones, and, eventually, the genital organs. Physical changes can have psychologic effects, which, in turn, have more physical effects. Some factors are related more to the situation than to the woman. Also, the cause of sexual dysfunction is often unclear.

Psychologic factors

Depression and anxiety commonly contribute to sexual dysfunction. In up to 80% of women with major depression and sexual dysfunction, sexual dysfunction becomes less severe when antidepressants effectively treat the depression.

Various fears—of letting go, of being rejected, or of losing control—and low self-esteem can contribute to sexual dysfunction.TABLEWhat Affects Sexual Function in Women?

Previous experiences can affect a woman’s psychologic and sexual development, causing problems, as in the following:

• Negative sexual or other experiences may lead to low self-esteem, shame, or guilt.
• Emotional, physical, or sexual abuse during childhood or adolescence can teach children to control and hide emotions—a useful defense mechanism. However, women who control and hide emotions may have difficulty expressing sexual feelings.
• If women lose a parent or another loved one during childhood, they may have difficulty becoming intimate with a sex partner because they are afraid of a similar loss—sometimes without being aware of it.

Various sexual worries can impair sexual function. For example, women may be worried about unwanted consequences of sex (such as pregnancy or a sexually transmitted disease) or about their or their partner’s sexual performance.

Situational factors

Factors related to the situation may involve the following:

• The woman’s own situation: For example, women may have a low sexual self-image if they are having fertility problems or have had surgery to remove a breast, the uterus, or another body part associated with sex.
• The relationship: Women may not trust or may have negative feelings about their sex partner. They may feel less attracted to their partner than earlier in their relationship.
• The surroundings: The setting may not be erotic, private, or safe enough for uninhibited sexual expression.
• The culture: Women may come from a culture that restricts sexual expression or activity. Cultures sometimes make women feel ashamed or guilty about sexuality. Women and their partners may come from cultures that view certain sexual practices differently.
• Distractions or emotional stress: Family, work, finances, or other things can preoccupy women and thus interfere with sexual arousal.

Physical factors

Various physical conditions and drugs may lead or contribute to sexual dysfunction. Hormonal changes, which may occur with aging or result from a disorder, can interfere.

After menopause, changes in the vagina and urinary tract (called genitourinary syndrome of menopause) can affect sexual function. For example, the tissues of the vagina can become thin, dry, and inelastic after menopause because estrogen levels decrease. This condition, called vulvovaginal atrophy (or atrophic vaginitis), can make intercourse painful. Urinary symptoms that can occur at menopause include a compelling need to urinate (urinary urgency) and frequent urinary tract infections.

Similar symptoms can also result from removal of both ovaries and hormonal changes that occur after a baby is delivered (postpartum).

Selective serotonin reuptake inhibitors, a type of antidepressant, commonly cause problems with sexual function. These drugs may contribute to several types of sexual dysfunction.

Alcohol can also cause problems with sexual function.

Did You Know…

Taking a selective serotonin reuptake inhibitor (a type of antidepressant) can interfere with sexual function, but so can depression.

Diagnosis

• An interview with the woman and her partner, separately and together when possible
• A pelvic examination

A sexual disorder is typically diagnosed when symptoms have been present for at least 6 months and cause significant distress. Some women may not be distressed or bothered by decreased or absent sexual desire, interest, arousal, or orgasm. In such cases, a disorder is not diagnosed.

Most sexual dysfunction disorders are diagnosed based on criteria described by the DSM-5. These disorders include genitopelvic pain/penetration disorder, female orgasmic disorder, female sexual interest/arousal disorder, and substance/medication–induced sexual dysfunction.

Female sexual dysfunction can be characterized by at least one of the following:

• Pain during sexual activities
• Loss of sexual desire
• Impaired arousal
• Inability to achieve orgasm

Female sexual dysfunction is diagnosed when any of these symptoms result in personal distress.

Diagnosis of sexual dysfunction disorders often involves detailed questioning of both sex partners, alone and together. Doctors first ask the woman to describe the problem in her own words. Then doctors ask about the following:

• Symptoms
• Other disorders
• Gynecologic and obstetric procedures done
• Injuries to the pelvic area
• Sexual abuse
• Drug use
• Her relationship with her partner
• Mood
• Self-esteem
• Childhood relationships
• Past sexual experiences
• Personality traits (such as her ability to trust, tendency to be anxious, and need to feel in control)

Doctors do a pelvic examination to look for abnormalities in the external and internal genital organs, including the vagina and cervix. Doctors can often identify where pain is coming from. Doctors try to do this examination as gently as possible. They move slowly and often explain the examination procedures in detail, which may help the woman to relax. If the woman wishes, they may give her a mirror to observe her genitals, which may help her feel more in control. If she is fearful of anything entering her vagina, she can place her hand on the doctor’s to control the internal examination. To diagnose sexual problems, doctors usually do not need to use an instrument, such as a speculum, to do the internal examination.

However, if doctors suspect a sexually transmitted disease or another infection (such as a yeast infection or bacterial vaginosis), they may insert a speculum into the vagina to spread the walls of the vagina apart (as done during a Papanicolaou, or Pap, test) and take a sample of fluids from the vagina. They examine the sample for organisms that can cause sexually transmitted diseases or other infections and may send a sample to a laboratory, where the organisms are grown (cultured) to make identification easier.

Treatment

• General measures to help correct factors that contribute to sexual dysfunction
• Psychologic therapies
• Drugs, including hormone therapy
• Physical therapy

Certain treatments depend on the cause of sexual dysfunction. However, some general measures can help regardless of the cause:

• For both partners, learning about the woman’s anatomy and ways to arouse her
• Making time for sexual activity: Women, who are used to multitasking, may be preoccupied with or distracted by other activities (involving work, household chores, children, and community). Making sexual activity a priority and recognizing how counterproductive distractions are may help.
• Practicing mindfulness: Mindfulness involves learning to focus on what is happening in the moment, without making judgments about or monitoring what is happening. Being mindful helps free women from distractions and enables them to pay attention to sensations during sexual activity by staying in the moment. Resources for learning how to practice mindfulness are available on the Internet.
• Improving communication, including about sex, between the woman and her partner
• Choosing a good time and place for sexual activity: For example, late at night—when a woman is ready for sleep—is likely not a good time. Making sure the place is private can help if the woman is afraid of discovery or interruption. Enough time should be allowed, and a setting that encourages sexual feelings may help.
• Engaging in many types of sexual activities: For example, stroking and kissing responsive parts of the body and touching each other’s genitals enough before initiating intercourse may enhance intimacy and lessen anxiety.
• Setting aside time together that does not involve sexual activity: Couples who talk to each other regularly are more likely to want and enjoy sexual activity together.
• Encouraging trust, respect, and emotional intimacy between partners: These qualities should be cultivated with or without professional help. Women need these qualities to respond sexually. Couples may need help learning to resolve conflicts, which can interfere with their relationship.
• Taking steps to prevent unwanted consequences: Such measures are particularly useful when fear of pregnancy or sexually transmitted diseases inhibits desire.

Just becoming aware of what is required for a healthy sexual response may be enough to help women change their thinking and behavior. However, more than one treatment is often required because many women have more than one type of sexual dysfunction. Sometimes a multidisciplinary team, including sex counselors, pain specialists, psychotherapists, and/or physical therapists, is needed.

Psychologic therapies

Psychologic therapies help many women. For example, cognitive-behavioral therapy can help women recognize a negative self-view that results from illness or infertility. Mindfulness-based cognitive therapy (MBCT) combines cognitive-behavioral therapy with the practice of mindfulness. As in cognitive-behavioral therapy, women are encouraged to identify negative thoughts. Women are then encouraged to simply observe these thoughts and to recognize that they are just thoughts and may not reflect reality. This approach can make such thoughts less distracting and disruptive. MBCT can be used to treat sexual interest/arousal disorder and pain that occurs whenever pressure is put on the opening to the vagina (called provoked vestibulodynia, a type of genitopelvic pain/penetration disorder).

More in-depth psychotherapy may be needed when issues from childhood (such as sexual abuse) are interfering with sexual function.

Sex therapy often helps women and their partner deal with issues that affect their sexual life, such as specific sexual problems and their relationship with each other.

Drugs

Estrogen therapy can be used to treat sexual dysfunction in women with genitourinary syndrome of menopause. When women have only vaginal and urinary symptoms, doctors usually prescribe forms of estrogen that are inserted into the vagina as a cream (with a plastic applicator), as a tablet, or in a ring that is similar to a diaphragm (vaginal forms). These forms can effectively treat symptoms that affect the vagina (such as dryness and thinning of the vagina, an urgent need to urinate, and frequent urinary tract infections), but they do not help with moodiness, hot flashes, or sleep problems.

Estrogen may also be applied externally to the skin (topical forms).

If women are also having bothersome hot flashes, doctors may prescribe estrogen taken by mouth or estrogen patches applied to the skin. These forms of estrogen affect the whole body and can thus help improve mood, lessen hot flashes and sleep problems, keep the vagina healthy, and maintain adequate lubrication for sexual intercourse.

If women have a uterus (that is, have not had a hysterectomy), they are given estrogen plus progestogen (a version of the hormone progesterone) because taking estrogen alone increases risk of cancer of the lining of the uterus (endometrial cancer). Low doses of estrogen are used.

Estrogen therapy may be started at menopause or within the next few years. Estrogen has potential risks (including a slightly increased risk of breast cancer) as well as benefits, so women should talk to their doctor about its risks and benefits before starting to take it.

Ospemifene (a selective estrogen receptor modulator) can be used to treat genitourinary syndrome of menopause.

In postmenopausal women, a synthetic form of dehydroepiandrosterone (DHEA) called prasterone, inserted into the vagina, can also relieve vaginal dryness and make sex less painful.

Because selective serotonin reuptake inhibitors (SSRIs) may contribute to several types of sexual dysfunction, substituting another antidepressant that impairs sexual response less may help. Such drugs may include bupropion, moclobemide, mirtazapine, and duloxetine. Also, taking bupropion with an SSRI may be better for sexual response than taking the SSRI alone. Some evidence suggests that if women stopped having orgasms when they started taking an SSRI, sildenafil (used to treat erectile dysfunction) may help them have orgasms again. However, this drug is not usually recommended because evidence of its effectiveness in women is unclear.

Testosterone, given through a patch, may help postmenopausal women with sexual interest/arousal disorder. However, doctors must regularly check women for side effects such as acne, excess hair growth (hirsutism), and development of masculine characteristics (virilization).

Other treatments

Several types of physical therapy may be useful in women with genitopelvic pain/penetration disorder.

Physical therapists can use several techniques to stretch and relax tight pelvic muscles:

• Soft-tissue mobilization and myofascial release: Using various movements (such as rhythmic pushing or massage) to apply pressure on and stretch the affected muscles or the tissues that cover muscles (myofasciae)
• Trigger-point pressure: Applying pressure to very sensitive areas of the affected muscles, which may be where the pain starts (trigger points)
• Electrical stimulation: Applying gentle electric current through a device positioned at the opening of the vagina
• Bladder training and bowel retraining: Having women follow a strict regimen for urination and recommending exercises to strengthen the muscles around the urethra and anus, sometimes with biofeedback
• Therapeutic ultrasonography: Applying energy (produced by high-frequency sound waves) to the affected muscles (increasing blood flow to the area, enhancing healing, and relaxing tight muscles)

If tight pelvic muscles are making sexual activity painful, women can insert self-dilation devices, available by prescription and over the counter, to stretch and to make the vagina less sensitive. Sexual activity may then be more comfortable.

Vaginal lubricants and moisturizers can reduce vaginal dryness, which causes pain during intercourse. These treatments include food-based oils (such as coconut oil), silicone-based lubricants, and water-based products. Water-based lubricants dry out quickly and may have to be reapplied, but they are preferred over petroleum jelly and other oil-based lubricants. Food-based oils can damage latex contraceptive devices such as condoms and diaphragms. They should not be used with condoms. Silicone-based lubricants can be used with condoms and diaphragms, as can water-based lubricants. Women can ask their doctor which type of lubricant would be best for them.

Depending on the type of dysfunction, sexual skills training (for example, instruction in masturbation) and exercises to facilitate communication with a partner about sexual needs and preferences can be implemented.

Devices such as vibrators or clitoral suction devices may be used by women with sexual interest/arousal or orgasmic disorder, but there is little evidence to support their effectiveness. Some of these products are available over the counter and may be tried.Spotlight on Aging: Sexual Dysfunction in Older Women

Spotlight on Aging: Sexual Dysfunction in Older Women

The main reason older women give up on sex is lack of a sexually functional partner. However, age-related changes, particularly those due to menopause, can make women more likely to experience sexual dysfunction. Also, disorders that can interfere with sexual function, such as diabetes, atherosclerosis, urinary tract infections, and arthritis, become more common as women age. However, these changes need not end sexual activity and pleasure, and not all sexual dysfunction in older women is caused by age-related changes.In older women as in younger women, the most common problem is lack of interest in sex.As women age, less estrogen is produced.The tissues around the vaginal opening (labia) and the walls of the vagina become less elastic and thinner (called vulvovaginal atrophy). Tissues can also become inflamed and irritated because production of estrogen is decreased (called atrophic vaginitis) Both of these changes can cause pain during sexual activity that involves penetration.Vaginal secretions are reduced, providing less lubrication during sexual intercourse.Less and less testosterone is produced starting when women are in their 30s, and testosterone production stops by about age 70. Whether this decrease leads to decreased sexual interest and response is unclear.The acidity of the vagina decreases, making the genitals more likely to become irritated and infected.Lack of estrogen may contribute to age-related weakening of muscles and other supportive tissues in the pelvis, sometimes allowing a pelvic organ (bladder, intestine, uterus, or rectum) to protrude into the vagina (called pelvic organ prolapse). As a result, urine may leak involuntarily, causing embarrassment.With aging, blood flow to the vagina is reduced, causing it to become shorter, narrower, and drier. Blood vessel disorders (such as atherosclerosis) can reduce blood flow even more.Other problems may interfere with sexual function. For example, older women may be distressed by changes in their body caused by disorders, surgery, or aging itself. They may think that sexual desire and fantasy are improper or shameful at an older age. They may be worried about the general health or sexual function of their partner or their own sexual performance. Many older women are interested in sex, but if their partner no longer responds to them, their interest may be slowly extinguished.Older women should not assume that sexual dysfunction is normal for older age. If sexual dysfunction is bothering them, they should talk to their doctor. In many cases, treating a disorder (including depression), stopping or substituting a drug, learning more about sexual function, or talking to a health care practitioner or counselor can help.If vulvovaginal atrophy and/or atrophic vaginitis is a problem, estrogen or testosterone can be inserted into the vagina as a cream (with a plastic applicator), as a tablet, or in a ring (similar to a diaphragm). Estrogen may be taken by mouth or applied in a patch or gel to an arm or a leg but only if menopause has just started or has lasted only a few years. These forms of estrogen affect the whole body and can thus help improve mood, lessen hot flashes and related sleep problems, keep the vagina healthy, and maintain adequate lubrication for sexual intercourse. Estrogen patches or gels are preferred over pills taken by mouth for postmenopausal women. If women have a uterus, they are also given a progestogen (a version of the hormone progesterone) because taking estrogen alone increases risk of cancer of the lining of the uterus (endometrial cancer). Estrogen has potential risks (including a slightly increased risk of breast cancer) as well as benefits, so women should talk to their doctor about its risks and benefits before starting to take it.Occasionally, testosterone to be taken by mouth is prescribed in addition to estrogen therapy if all other measures are ineffective, but prescribing this combination is not recommended. It is still considered experimental and long-term safety is unknown.