AS THE NAMES IMPLY, we typically refer to a “vaginal orgasm” when the primary site of stimulation is the vagina (without stimulation of the cervix) and a “cervical orgasm” when the focus of stimulation is the cervix. A “clitoral orgasm” is one in which the stimulation is specifically applied to the clitoris. Some women prefer stimulation that is confined to the vagina or cervix or both, and others prefer stimulation that is focused on the clitoris. However, some women seem to experience the greatest intensity of orgasm when the clitoris and the vagina or cervix—or all three areas—are stimulated simultaneously. Combined stimulation of all three areas activates three or four pairs of different nerves and provides a cumulative effect.
FOR SOME WOMEN, STIMULATION of the nipples and breasts can increase the likelihood of having an orgasm and increase its intensity. However, some women find this stimulation has either no effect or a negative effect. The orgasm-inducing effect of breast or nipple stimulation may be due to sensory activity from the breast traveling (“projecting”) to some of the same neurons, in the region of the brain known as the hypothalamus, that receive sensory activity from the genitals. Because of this convergence of nerve impulses from genital and breast stimulation onto the same neurons in the hypothalamus, breast stimulation may enhance the effect of genital stimulation on orgasm.
AT PRESENT, THERE ISN’T enough information to answer this question. These exercises were developed for women in the 1940s by gynecologist Arnold Kegel, and this workout became popularly known as “Kegels.” Kegel taught women who suffered with “urinary stress incontinence” (USI)—the leakage of urine when a woman coughs, jumps, or sneezes—how to strengthen their pelvic floor muscles. Kegel argued that his technique could avert the need for surgery, and indeed it did for most of his patients. Coincidentally, many of his patients experienced orgasm for the first time. In the decades that followed, several researchers reported that men can experience multiple orgasms when they practice contracting their pelvic floor muscles.
Kegel exercises mainly strengthen the PC (pubococcygeus) muscles, which are really a group of several muscles. In men and women, the PC muscles connect the pubic bone to the coccyx (the tailbone at the end of the spine). In other animals, this muscle group wags the tail. In humans, it supports the internal sexual organs, urethra, bladder, and rectum, preventing them from sagging. To use an analogy, the PC muscles (a flat, broad sheet of muscles) are like the flexible jumping surface of a trampoline. The pubic bone at the front of the body and the coccyx at the tip of the spine are like the rigid frame of the trampoline. Kegel exercises tighten the PC muscles, ensuring that the vagina, urethra, bladder, and rectum are well supported and don’t sag.
The PC (pubococcygeus) muscles. This sheet of muscles stretches between, and is attached to, the pubic bone and the coccyx. The urethra, vagina, and rectum penetrate through the muscle sheet. Kegel exercises are designed to strengthen it and prevent it from sagging.
Kegel invented a device to help him evaluate the PC muscles of his female patients and to assist in training them. This instrument, called a Kegel perineometer, may have been the world’s first biofeedback device.
Using the perineometer, researchers in the 1970s measured the strength of women’s PC muscles in relation to their orgasmic experience. They analyzed data from 281 women who had visited their sex therapy clinic, then divided the women into three groups: those who could not experience orgasm, those who could experience orgasm from clitoral stimulation only, and those who could experience orgasm from clitoral or vaginal stimulation. The group of women who experienced orgasm with clitoral or vaginal stimulation had the strongest PC muscles, and those who could not experience orgasm had the weakest PC muscles. The group who could experience orgasm only from clitoral stimulation had intermediate muscle strength. In other words, there was a correlation between the strength of the women’s pelvic muscles and their orgasmic responses. A study in 1981 reported that women who experienced female ejaculation had stronger PC muscles than women who never experienced ejaculation.
Taken together, these studies suggest that Kegel exercises probably do increase the likelihood of orgasm.
To locate your PC muscles, start to urinate with your legs apart and then stop the flow of urine. The muscles you squeeze are the PC muscles. Practice stopping the flow a few times to become familiar with the muscles. If you are interested in performing Kegel exercises, we recommend the instructions at www.mayoclinic.com/health/kegel-exercises/ WO00119.
TWO MAIN TYPES OF fluid are associated with women’s orgasms: vaginal lubricant and female ejaculate. The clear vaginal lubricant is not secreted by glands. Instead, it seeps into the vaginal canal from blood capillaries in the vaginal lining (a process termed “transudation”), beginning as small beads and ultimately coalescing until the fluid moistens the entire inner surface of the vagina. (Incidentally, antihistamines may interfere with vaginal lubrication, as a side effect of their desired treatment for a runny nose.)
During orgasm, women may expel fluid from their urethra (the tubular structure through which urine passes out of the body), a process referred to as “female ejaculation.” Female ejaculation has a controversial past. Many women reported that they underwent surgery to correct this “problem,” and others reported that they inhibited their orgasms to prevent “wetting the bed.” Some people are under the impression that the secreted fluid is urine. It is not. The fluid resembles dilute fat-free milk and has a sweet taste. Although the volume may seem large during an orgasm, the total amount of liquid expelled rarely exceeds one teaspoonful (five milliliters).
Several researchers chemically analyzed the fluid produced by female ejaculation and found that it contains high levels of glucose and an enzyme called prostatic acid phosphatase, and low levels of urea and creatinine. This chemical composition differs substantially from that of a woman’s typical urine, which contains high levels of urea and creatinine and no prostatic acid phosphatase or glucose. A woman may experience ejaculation regularly, on rare occasions, or never. We are aware of no credible evidence that women can learn to control this process (that is, either enhance or decrease it). The important point is that female ejaculation is a normal, though not universal, process. One study suggested that perhaps all women ejaculate during orgasm, but the volume of the ejaculate is often so small that it’s undetected, remaining in the urethra or passing back into the urinary bladder.
Aristotle was probably the first to write about female ejaculation, and the Greco-Roman physician and philosopher Galen is said to have known about it in the second century AD. Many others have written about female ejaculation, including the gynecologist Ernst Gräfenberg in 1950.
We should note, however, that during sexual activities and orgasm, some women may ejaculate and other women may expel urine. A review of the scientific literature that was published in 1991 found that in some women, G spot stimulation, orgasm, and female ejaculation are related (but this is certainly not universal). Other studies reported that some women experience ejaculation with orgasm in response to clitoral stimulation and some women experience ejaculation without orgasm. Most women who do experience ejaculation say that it feels pleasurable.
ALTHOUGH INCREASED SENSITIVITY OF the clitoris is common after orgasm, there seems to be no research that specifically reveals the cause of this increased sensitivity. However, we can make an educated guess, based on what we do know about sensations during sex, at a plausible explanation.
One of the changes that a woman’s body goes through when sexually aroused is the dilation (opening wider) of blood vessels. This increases the flow of blood to the genital area, resulting in swelling (“engorgement”) of the clitoris. This may itself make the clitoris more sensitive to stimulation. And, in addition to the physical changes in the clitoris, the mental and emotional changes occurring in the brain increase the woman’s attention to her clitoral sensations. When overdone, physical stimulation of the clitoris may become painful or even result in the clitoris becoming numb. Heightened sensitivity of the clitoris may persist after orgasm and slowly subside as the engorgement decreases over a period of minutes. During the period right after orgasm, a woman may be caught between two worlds. Her sexual intensity has diffused, but her sensory awareness may remain high. So she may now pay more attention to the sensitivity of her clitoris.
Some women say that their nipples also become very sensitive to touch after orgasm. Some like to continue the stimulation of the highly sensitized clitoris or nipples after the initial orgasm, to experience multiple orgasms. Clearly, there are major differences among women in both sensitivity and preference.
A few rare cases have been reported of women having an overly sensitive clitoris, so that even the mild friction of their clothing creates discomfort. In such cases, medical consultation is advisable.
YES, BODY POSITIONS DURING vaginal intercourse can affect orgasms in women. To stimulate the G spot during vaginal intercourse (the G spot is an erogenous region just behind the pubic bone), the penis must make contact with the anterior wall of the vagina (the side of the vaginal wall closest to the belly). For most couples, the best positions for stimulating this area are: (1) the woman on top, so that she can direct the positioning of the penis in her vagina; (2) the rear entry position, in which the head of the penis can most directly contact the area of the G spot; and (3) the man on top, kneeling, so his penis will contact the anterior wall of the vagina.
To stimulate the cervix during vaginal intercourse, the couple should use a position in which there is deep penetration of the penis. One position is with the woman lying on her back with her legs elevated and around the man’s back or neck. Deep penetration is more likely if the woman pulls her legs toward her body. Placing a pillow under the woman’s lower back can also allow deep stimulation.
In the “coital alignment technique” (CAT), the woman lies on her back and the man lies flat on top of her, aligned as close to the woman’s head as possible. In this position, the penis can stimulate the clitoris and the G spot simultaneously. Some women like to have their clitoris stimulated manually during vaginal intercourse. For these women, positions such as woman on top, either facing away from her partner (the “cowgirl” position) or facing toward her partner, can allow stimulation of the clitoris with a finger.
Certain positions are preferred by couples in which one or both partners are overweight. For an overweight man, he can sit on a chair, with the woman sitting on top of him. For the “missionary position” (man on top), it’s important for the man to avoid placing all his weight on the partner. He can put his weight on his knees and hands to control the weight he puts on his partner. If the woman is overweight, she can expose her vulva and vagina by lying on her back, bending her knees and pulling them toward her belly, making penetration easier.
There are also positions that are recommended for couples in which one or both partners have a chronic illness or disability. Whipple and Welner discuss positions for vaginal intercourse and provide line drawings of suggested positions in their chapter “Sexuality Issues” in Welner’s Guide to the Care of Women with Disabilities. Some suggested positions are the person with disability in a wheelchair, or lying on a table or bed, while the partner is standing.
FOR MOST COUPLES, THE answer to this question is probably not. Although some women do say that the length and girth of their partner’s penis is important (one study suggests that girth is far more important than length), most studies indicate that the dimensions of the penis don’t affect women’s overall satisfaction or probability of having an orgasm. Indeed, just as penises vary in shape and size, so too do vaginas vary in shape, size, and sensitivity among individuals. So, size preference between partners—the idea of “a good fit”—probably does not lend itself to generalizations.
Typically, if a penis is of average length (four to six inches when erect) and each partner is familiar with the pleasurable areas of the other’s body, the size of the penis will probably matter less than how it is used. When a penis is larger or smaller than average, extra effort may be required with some partners to increase contact or avoid uncomfortable pressure.
YES, ALTHOUGH THERE IS considerable variation among women. Some women enjoy bodily intimacy with their partner during their menstrual period, whereas others prefer not to be physically intimate during that time. Similarly, a woman’s partner may be reluctant to be sexually intimate with her because of hygienic considerations, fear of causing discomfort, or cultural factors.
Researchers at Yale University reported that when a woman is not menstruating, her orgasms during sexual intercourse produce traveling wave-like uterine contractions that can suck semen into the uterus. By contrast, during menstruation, orgasms produce uterine contractions that travel in the opposite direction, which has the effect of pushing debris out of the uterus instead of sucking inward. The changing levels of hormones over the menstrual cycle play an important role in affecting the direction of these uterine contractions. This changing direction of uterine contractions could account for the observation that orgasms during menstruation may produce a surge of menstrual blood flow. The use of the Instead Softcup, which is a menstrual cup, not a contraceptive, may be used to collect this menstrual blood when a woman has vaginal intercourse during her period.
The research team of Morris and Udry explored differences in women’s sexual activity on menstrual and nonmenstrual days, using daily report data from eighty-five women and their spouses over about a hundred days. They concluded that in their group of respondents, the desire for intercourse and the frequency of intercourse and orgasm decreased during menstruation. The women responded to increases in their husband’s sexual frustration at this time by providing more noncoital orgasms on menstrual days. By contrast, the wives did not experience any increased sexual frustration during menstruation. The heterosexual non-intercourse-related orgasm rate among these women was relatively stable throughout their cycle. Morris and Udry suggested that the different patterns of desire levels for husbands and wives may have a biological base and that the behavioral patterns observed in their study represent a social adjustment to this difference.
The level of estrogen and progesterone (hormones secreted by the ovaries) is lower during menstruation, which may play a role in decreased sexual desire. The lowered hormone levels may also reduce vaginal lubrication. These two factors may combine to decrease a woman’s sexual enjoyment during menstruation. It’s likely that additional factors also play a role in sexuality in relation to the menstrual cycle. Many women, however, don’t experience any differences in their sexual desire or activity across their menstrual cycle. Some women even find it easier to express their sexuality and to experience orgasms during menstruation, perhaps because they know their chance of pregnancy is lower (although it’s not zero) than at other times of the month.
POSSIBLY. ONE EFFECT OF orgasm is to increase a suction produced by wave-like contractions of the uterus. During orgasm in sexual intercourse, suction draws ejaculated semen that is deposited near the cervix into the uterus. When a woman experiences orgasm, the hormone oxytocin is released into the bloodstream by the pituitary gland. The oxytocin then stimulates the muscles of the uterus, which contract more forcefully and increase the amount of suction. With female orgasm, more semen (and so more sperm) enters the uterus, where it is then pulled more toward the left or right side, depending on whether the left or right ovary will release a mature egg (ovum) during that particular menstrual cycle.
Further evidence of the effect of orgasm on pregnancy is a report that women whose orgasm occurs just after their partner ejaculates retain more semen (and so more sperm) in their vagina than women whose orgasm occurs just before their partner ejaculates. The study authors speculated that, by increasing the suction action of the uterus, a woman’s orgasm can increase the retention of sperm in the vagina, which could make more sperm available for fertilizing an egg. Some valid criticisms have been made of the methods used in these experiments, but there is still good evidence to suggest that a woman’s orgasm may increase the chance of pregnancy.
THERE IS CONTROVERSY AMONG researchers about whether or not intercourse during pregnancy affects (causes or prevents) premature delivery. One scientific report, published in 2001, found that intercourse during the “last few weeks of pregnancy appears to increase the risk of preterm delivery.” The study supported an earlier claim by researchers who stated that the male-on-top position was associated with premature rupture of the membranes. However, other researchers have concluded that intercourse during late pregnancy is associated with a reduced risk of preterm delivery. Yet another study found that intercourse earlier in pregnancy was not associated with an increased risk of preterm delivery (although intercourse during pregnancy was associated with an increased incidence of preterm delivery in women with a lower genital tract infection). So, given all these contradictory findings, couples should consult with their physician for individualized advice on the safety of intercourse during pregnancy.
On a different but related topic: many women worry that sexual activity and orgasm during pregnancy could harm the fetus. In addition to the possible risks associated with preterm delivery mentioned above, there is a risk to the fetus if the woman acquires a sexually transmitted infection, so safer sex practices are advisable.
YES, ORGASM CAN BE affected in a variety of ways by childbirth. The birth process itself has been described as orgasmic. In a 2007 interview study of eleven women, Danielle Harel characterized two types of sexual experience during childbirth as described by these women: “Unexpected birthgasms were described as surprising orgasms while pushing out or delivering the baby . . . They occurred without any sexual stimulation or use of fantasy, and were not perceived by the women in this sample as erotic or ‘sexual’ in nature . . . Passionate birth was experienced by the women in the sample who chose to incorporate their sexuality openly and intentionally in the birth process, and who allowed themselves to fully explore it. They made love, vocalized, kissed passionately, and some of them masturbated to ease the pain.”
A different facet of the effect of childbirth involves its effect on the sexual interaction between the parents. Researcher Kirsten von Sydow analyzed fifty-nine research articles published between 1959 and 1996 that were related to parents’ sexual function and behavior during pregnancy and up to six months after the birth of their child. On average, female sexual interest and frequency of intercourse decline slightly in the first trimester of pregnancy and decrease sharply in the third trimester. Many couples don’t have intercourse during the two months or so before the due date. After delivery, sexual interest and activity tend to be diminished for several months compared with pre-pregnancy levels, and sexual problems are common. However, not all couples follow this pattern. Sexual responsiveness and capacity to experience orgasm differ from one couple to another.
When a child is born, the mother undergoes major emotional, psychological, and physiological changes, especially if she is a first-time mother. At the same time, the father undergoes major emotional changes of his own. Changing roles within the relationship can bring the couple closer or drive them apart. The mother and the father, having adjusted to each other as independent adults, now must direct their attention to, and become responsible for, a newborn dependent being. The prior dual relationship, which may have involved a strong sexual bond and sharing the experience of orgasm, suddenly becomes a triangular relationship.
A simple lack of information about sexual relations and orgasms during and after pregnancy could affect a couple’s relationship after childbirth. For example, the couple might abstain from sexual intercourse if they are unsure of the risk of infection or, in the case of a caesarian delivery, they worry about rupturing the stitches. A woman may experience a decline in sexual interest and activity in the period after delivery (the “postpartum” period) for many reasons, including the physical effects of breastfeeding, vaginal delivery, surgical vaginal delivery (in more complicated births), instrument delivery (use of vacuum extraction or forceps to help deliver the baby), trauma to the perineum (the skin between the vagina and anus), vaginal tearing, and episiotomy (a surgical incision made in the perineum during childbirth). Vaginal delivery can reduce the strength of the pelvic floor muscles, although studies have not shown that this adversely affects a woman’s sexual functioning. Nevertheless, some women do find that starting Kegel exercises before and after childbirth can restore their strength and can empower a woman who wants to resume her prior level of sexual activity.
Most women say that the main reasons for not having an active sex life for at least a few weeks after childbirth are simply physical exhaustion from the birth, lack of sleep, and adjusting to the changed lifestyle with the new bundle of joy. It’s important to reinstate sexual life gradually after childbirth. Some of the major organs of a woman’s body are involved in the process of childbirth. After a painful vaginal birth, a woman may associate the vagina with pain rather than with pleasure. A new mother may need time to reintroduce her vagina to pleasurable sensations. Nipples and breasts, perhaps once thought of as part of the sexual relationship, now take on a new purpose.
The reactions of the father can have an important impact on the mother’s interest in resuming the couple’s sexual relationship. Physical affection, not necessarily genital or even sexual, can help reestablish a man’s intimate relationship with the new mother. The new father should reassure the new mother about her bodily changes after pregnancy and birth and should appreciate that it will take time for her to become ready, physically and emotionally, to resume her sexual life.
HORMONES ARE SECRETED BY the endocrine glands, which include the gonads (ovaries and testicles), adrenals, pituitary, thyroid, and pancreas. The gonads are directly involved in the development and control of sexual behavior through the secretion of their hormones: estrogens, androgens (including testosterone), and progestogens (including progesterone).
There is a general belief that sexual activity, including orgasm, is strongly influenced by hormones. So it’s logical to expect that taking hormones, for any reason, will affect orgasm and other components of sexual behavior. This turns out to be sometimes true, sometimes not, depending on the hormone and the preexisting levels of that hormone in the body.
Surprisingly, testosterone, which is commonly thought of as the “male hormone,” is actually the hormone that is most closely related to the expression of sexual response in women. A large number of carefully controlled studies have recently shown that the application of a transdermal androgen patch—designed to release low amounts of testosterone through the skin (transdermally) and into the bloodstream—has positive effects on all components of women’s sexual response, including orgasm and sexual satisfaction. This is found to occur for postmenopausal women, women who have had their ovaries removed, and women who have an androgen-insufficiency disorder. These treatments are designed to provide women with amounts of testosterone that are high enough to mimic the normal levels produced by the ovaries (and by the adrenals), but low enough to avoid unwanted (masculinizing) side effects.
Recently, a synthetic steroid known as tibolone (which has estrogenic, progestogenic, and androgenic effects) has been introduced in Europe and other countries, but not in the United States, for the treatment of sexual disorders in women. Results coming from different institutions indicate that this synthetic hormone effectively improves most aspects of sexual response, including orgasm. Tibolone has been associated with a slightly increased risk of stroke.
Another use of hormones, of course, by millions of women worldwide, is as a method of contraception. Oral contraceptives use a combination of estrogens and progestins (synthetic progestogens). Reports on the effects of these contraceptives on sexual response are extremely variable—a small percentage of women complain of negative effects, and a similarly small percentage report a positive effect. In most cases, studies show that these effects are not significantly different from those obtained with a placebo (an intentionally inactive pill that is identical in outward appearance to the active pill containing the hormones).