CHAPTER 237
Sexual Dysfunction in Women
Sexual dysfunction includes painful intercourse, painful contraction (spasm) of the vaginal muscles, or a problem with sexual desire, arousal, or orgasm that causes distress.
Depression or anxiety, other psychologic factors, disorders, and drugs can contribute to sexual dysfunction, as can the situation.
To identify a problem, doctors often talk to both partners separately and together, and a pelvic examination is often done to check the woman.
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.
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 lack of interest or desire, difficulty becoming aroused or reaching orgasm, pain during sexual activity, or involuntary tightening of the muscles around the vagina. However, these distinctions are not always useful. 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. Women who have pain during sexual activity often understandably lose their interest and desire for sex.
Normal Sexual Function
Sexual function and responses involve mind (thoughts and emotions) and body (including the nervous, circulatory, and endocrine systems). Sexual response consists of the following:
Desire is the wish to engage in or continue sexual activity. Desire may be triggered by thoughts, words, sights, smells, or touch. Desire 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. As women age, blood flow may increase less. Blood flow also 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.
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. Many 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. Many women initiate or agree to sexual activity because they want one or more of the following:
To experience emotional intimacy
To increase their sense of well-being
To confirm their desirability
To please or placate a partner
Especially after a relationship has lasted a long time, women often have little or no desire for sex before sexual activity (initial desire), but desire can develop once sexual activity and stimulation begin. Desire before sexual activity typically lessens as women age but increases when women, regardless of their age, have a new partner. Some women may feel sexually satisfied whether they have an orgasm or not. Other women have much more sexual satisfaction with an orgasm.
Did You Know…
Women in a long-term relationship often have little or no desire for sex until sexual activity and stimulation begin.
Causes
Many factors cause or contribute to various types of sexual dysfunction. Traditionally, causes are considered physical or psychologic. However, this distinction is not strictly accurate. 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.
Psychologic Factors: Depression and anxiety commonly contribute. Previous experiences can affect a woman’s psychologic and sexual development, causing problems, as in the following:
Harsh 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 or about their or their partner’s sexual performance.
Situational Factors: Factors related to the situation may involve the following:
WHAT AFFECTS SEXUAL FUNCTION IN WOMEN?
| TYPE | FACTOR |
| Psychologic factors | Abuse (emotional, physical, or sexual) during childhood or adolescence Anxiety Depression Fear of intimacy Fear of losing control Fear of losing the partner Low self-esteem Worry about inability to have an orgasm or about sexual performance in a partner Worry about unwanted consequences of sex (such as unwanted pregnancy or sexually transmitted diseases) |
| Situational factors | Cultural background that restricts sexual expression or activity Distractions Relationship problems Surroundings that are not conducive to sexual activity |
| Physical factors | Atrophic vaginitis (thinning of tissues of the vagina) Fatigue Hyperprolactinemia (high levels of prolactin, a hormone produced by the pituitary gland) Poor health Surgical removal of both ovaries in premenopausal women Underactive thyroid gland (hypothyroidism) Some nerve disorders, such as multiple sclerosis |
| Drugs | β-Blockers (used to treat hypertension or heart disorders) Drugs that block the production and activity of testosterone (including the diuretic spironolactone) Hormones (such as hormonal contraceptives or oral estrogen therapy) Certain antidepressants, particularly selective serotonin reuptake inhibitors |
The relationship: Women may not trust or 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: 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. For example, the tissues of the vagina can become thin, dry, and inelastic after menopause because estrogen levels decrease. This condition, called atrophic vaginitis, can make intercourse painful. Other conditions, such as the removal of both ovaries, can also cause estrogen levels to decrease and thus contribute to sexual dysfunction.
Selective serotonin reuptake inhibitors, a type of antidepressant, commonly cause problems. Estrogen therapy, if taken by mouth, sometimes used to control symptoms associated with menopause, can cause sexual dysfunction, but not always. In fact, estrogen therapy may enhance sexual function in postmenopausal women.
Did You Know…
Taking a selective serotonin reuptake inhibitor (a type of antidepressant) can interfere with sexual function, but so can depression.
Diagnosis
Diagnosis often involves detailed questioning of both sex partners, alone and together. Doctors ask about symptoms, other disorders, drug use, the relationship between the partners, mood, self-esteem, childhood relationships, past sexual experiences, and personality traits.
Doctors also often need to do a pelvic examination. Doctors try to do this examination as gently as possible. They move slowly and often explain the examination procedures in detail. If the woman wishes, they may give her a mirror to observe her genitals. If she is fearful of anything entering her vagina, she can place her hand on the doctor’s to control the internal examination. Usually, doctors do not need to use an instrument, such as a speculum, to diagnose sexual problems. Such instruments are needed to do a Papanicolaou (Pap) test.
If doctors suspect a sexually transmitted disease, tests are done.
Treatment
Certain treatments depend on the cause of dysfunction. However, some general measures can help regardless of the cause:
Making time for and learning to focus on 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. That is, women can concentrate their awareness (be mindful) during sexual activity and thus stay in the moment.
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 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 feel sexual desire.
Encouraging trust, respect, and emotional intimacy between partners: These qualities should be cultivated with or without professional help. Women need them 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.
Often, more than one treatment is required because many women have more than one type of sexual dysfunction. Psychotherapy benefits some women, particularly when psychologic factors are prominent. However, just becoming aware of what is required for a healthy sexual response may be enough to help women change their thinking and behavior.
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 venlafaxine. 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 SSRIs, sildenafil may help them have orgasms again.
Dyspareunia
Dyspareunia is pain when women try to begin sexual intercourse or pain during intercourse.
The pain may be superficial or deep.
It may result from vaginal dryness or disorders of the genital organs.
The diagnosis is based on symptoms and a pelvic examination.
Anesthetic ointments, lubricants, exercises to relax pelvic muscles, or a change in the position for intercourse may help.
The cause, if identified, is treated.
The pain may be superficial, felt in the area around the opening of the vagina (genital area or vulva). Or the pain may be deep, felt within the pelvis when the penis or a dildo is thrust further inside. The pain may be burning, sharp, or cramping. Pelvic muscles tend to become tight, which increases the pain, whether it is superficial or deep.
Causes
Causes vary depending on whether the pain is superficial or deep.
Superficial Pain: Intercourse can be painful because the vagina does not secrete enough fluids. Then the vagina feels dry, and lubrication for intercourse is inadequate. Inadequate lubrication often results from insufficient foreplay. Also, as women age, the lining of the vagina thins and can become dry because estrogen levels decrease. This condition is called atrophic vaginitis. During breastfeeding, the vagina may become dry because estrogen levels are low. Taking antihistamines can cause slight, temporary dryness of the vagina.
Superficial pain may also result from the following:
Increased sensitivity of the genital area to pain (provoked vestibulodynia—see page 1509), which is the most common cause
Inflammation or infection in the genital area (including genital herpes), the vagina, or Bartholin’s glands (the small glands on either side of the vaginal opening)
Inflammation or infection of the urinary tract
Injuries in the genital area
An allergic reaction to contraceptive foams or jellies or to latex condoms
Involuntary contraction of the vaginal muscles (vaginismus)
Rarely, a congenital abnormality (such as an abnormal partition within the vagina)
Surgery that narrows the vagina (for example, to repair tissues torn during childbirth or to correct a pelvic floor disorder—see page 1543)
A hymen that interferes with entry of the penis
The hymen is a membrane that encircles or, in a very few women, covers the opening of the vagina. When women have sexual intercourse the first time, the hymen, if not previously stretched (for example, from tampon use or sexual stimulation with a finger inside the vagina), may tear, causing some pain and bleeding. A few women are born with an abnormally tight hymen.
Deep Pain: Deep pain during or after sexual intercourse may result from the following:
Infection of the cervix, uterus, or fallopian tubes (pelvic inflammatory disease), which may cause collections of pus (abscesses) to form in the pelvis
Endometriosis
Growths in the pelvis (such as tumors and ovarian cysts)
Bands of scar tissue (adhesions) between organs in the pelvis, which may form after an infection, surgery, or radiation therapy for cancer
Radiation therapy can cause both superficial and deep pain. The vagina can be less stretchable, and scarring around it can make it smaller and shorter.
Sometimes one of these disorders causes the uterus to get stuck in a bent-backward direction (retroversion). The ligaments, muscles, and other tissues that hold the uterus in place may weaken, resulting in the uterus dropping down toward the vagina (prolapse— see art on page 1544). Such changes can also cause deep pain.
Pain is greatly affected by emotions. For example, minor discomfort may feel like severe pain after a traumatic sexual experience, such as rape. Anger toward a sex partner, fear of intimacy or pregnancy, a negative self-image, or a belief that the pain will never go away may amplify pain.
Diagnosis
The diagnosis is based on the woman’s description of the problem, including when and where the pain is felt, and on the results of a physical examination. The genital area is gently but thoroughly examined for possible causes, such as signs of inflammation or abnormalities. A doctor may touch the area gently with a cotton swab to determine where the pain occurs. The doctor checks the tightness of the pelvic muscles around the vagina by inserting one or two gloved fingers into the vagina. To check the uterus and ovaries, the doctor then places the other hand on the lower abdomen. A rectal examination may also be done.
Treatment
Couples are encouraged to find ways to attain mutual pleasure (including having orgasms and ejaculation) that do not involve penetration. Such means can include stimulation involving the mouth, hands, or a vibrator.
Pelvic muscle relaxation exercises may help relieve symptoms, regardless of the cause.
For superficial pain, applying an anesthetic ointment and taking sitz baths may help, as may liberally applying a lubricant before intercourse. Water-based lubricants rather than petroleum jelly or other oil-based lubricants are preferable. Oil-based lubricants tend to dry the vagina and can damage latex contraceptive devices such as condoms and diaphragms. Spending more time in foreplay may increase vaginal lubrication.
For deep pain, using a different position for intercourse may help. For example, being on top can give women more control of penetration, or another position may limit how deeply the penis can be thrust.
More specific treatment depends on the cause, as in the following:
Thinning and drying of the vagina after menopause: Estrogen applied as cream, inserted into the vagina as a pill or in a ring, or taken by mouth (as part of hormone therapy)
Infections: Antibiotics, antifungal drugs, or other drugs as appropriate (see table on page 1537)
Cysts or abscesses: Surgical removal
A rigid hymen or another congenital abnormality: Surgery to correct it
Prolapse of the uterus: Insertion of a pessary, which resembles a diaphragm, into the vagina to support and reposition the uterus or sometimes surgery
PROVOKED VESTIBULODYNIA
Provoked vestibulodynia (vulvar vestibulitis) is increased sensitivity to pain in the area around the opening of the vagina (vestibule), making even gentle touch or stimulation painful.
Provoked vestibulodynia is the most common cause of dyspareunia that occurs when the penis enters the vagina or moves. The pain starts immediately, lessens when the penis stops moving, and resumes when the penis moves again.
Doctors are not sure why it happens, but the nerve pathways that conduct pain signals from the vulva and the parts of the brain that process those signals are physically changed (remodeled) and become more sensitive. As a result, touch that normally would seem mild is perceived as very painful. Muscles in the pelvis may also be tight, increasing pain. After intercourse, women may have a burning sensation in the genital area or burning after urination.
This disorder involves chronic pain and often occurs with other types of chronic pain, such as jaw pain or pain due to irritable bowel syndrome.
Treatment
Treatment may include anti-inflammatory creams or anesthetics applied to the area and drugs taken by mouth, such as certain antidepressants and anticonvulsants, given in low doses. These drugs may help reverse changes in the nerve pathways that increase sensitivity to pain. Which treatments are most effective is not clear.
Avoiding possible irritants, such as soap, bubble bath, panty liners, and tight jeans, may help. Pelvic muscle relaxation exercises, yoga, and general relaxation exercises can help relax pelvic (and other) muscles. Women may benefit from cognitive-behavioral therapy (which is used to treat chronic pain), particularly when they are also taught the skill of mindfulness (concentration of awareness in the moment). Psychotherapy and sex therapy can help some women.
Surgery to remove part of the area around the vaginal opening is sometimes advised. This procedure removes the hypersensitive nerve endings, but the nerves can regrow, and pain can recur.
Botulinum toxin (a bacterial toxin used to paralyze muscles or to treat wrinkles) may be given to deaden the pain nerves but is currently considered experimental.
Because this disorder involves chronic pain, treatments are becoming more comprehensive, including management of stress and emotional reactions to the pain.
Vaginismus
Vaginismus is involuntary contraction of muscles around the opening of the vagina in women with no abnormalities identified during examination. The tight muscle contraction makes sexual intercourse painful or impossible.
Most women with vaginismus cannot tolerate sexual intercourse, and some cannot tolerate using tampons.
Doctors base the diagnosis on symptoms and a subsequent pelvic examination, done as gently as possible.
Women are taught how to touch their genital area, gradually moving closer to their vagina and becoming used to touching it without causing pain, and then to insert a finger, then progressively larger cones into the vagina.
These exercises may enable women to have sexual intercourse without pain.
In vaginismus, vaginal muscles tighten involuntarily despite women’s desire for sexual intercourse. Vaginismus usually begins when women first attempt to have sexual intercourse. However, it sometimes develops later, for example, when another factor makes intercourse painful for the first time or when women attempt intercourse while they are emotionally distressed. Because intercourse has become painful, women fear it. This fear makes muscles even tighter and attempts at sexual intercourse more painful. A reflex reaction develops so that when the vagina is pressed or sometimes even just touched, the vaginal muscles automatically (reflexively) tighten. Most women thus cannot tolerate sexual intercourse. Some women cannot tolerate the insertion of a tampon or have never wanted to try. However, most women with vaginismus enjoy sexual activity that does not involve penetration.
Diagnosis
The diagnosis is based on the woman’s description of the problem and her medical and sexual history, including childhood and adolescence, and a subsequent pelvic examination.
To make the examination as tolerable as possible, doctors often move slowly and gently while they explain what they are doing in detail. They may offer women a mirror to see their genitals and, in some cases, to guide the doctor’s hand or instruments into the vagina. Sometimes women must be treated before a pelvic examination can be done. Doctors look for scars, infections, or other abnormalities to determine whether they could be causing the symptoms. When vaginismus is the problem, no such abnormalities are found.
Treatment
Treatment aims to weaken the reflexive tightening of vaginal muscles and the fear of pain that occurs when the vagina and surrounding area are touched. To weaken this reflex, women are instructed to do certain touching exercises.
At first, women touch an area as close to the vaginal opening as they can without causing pain. Each day, they should move a little closer to the opening, slowly increasing how close they can come to the vagina without causing pain. When they can touch the tissues around the opening (called labia), they can practice opening the labia. Women are encouraged to use a mirror to see their genitals. They are taught to bear down (as when having a bowel movement), which makes the vaginal opening larger, so that it can be seen more easily. Once women can touch the vaginal opening without pain, they are instructed to insert their finger past the hymen, pushing or bearing down while inserting the finger to enlarge the opening and make insertion easier.
When they can do these exercises and experience no pain, they can start to use cone-shaped inserts, which are placed in the vagina. An insert is left in for 10 to 15 minutes. Then the vaginal muscles become used to pressure. As women become comfortable with an insert, they use progressively larger inserts, which gradually increase the pressure in the vagina. Eventually, women invite their partner to place an insert in the vagina. Thus, women learn to relax the vaginal muscles and override the reflexive tightening.
Only after completing these steps should the couple try intercourse again. Doctors usually recommend that women hold their partner’s penis and place it partly or completely in their vagina in the same way that they placed the insert. Some women are more comfortable being on top during intercourse at this point. Some men may be overly cautious and too reluctant to push or may lose their erection. They may benefit from a phosphodiesterase inhibitor (such as sildenafil, tadalafil, or vardenafil).
Low Sexual Desire Disorder
Low sexual desire disorder (sexual desire/interest disorder) is lack of interest in sexual activity and sexual thoughts.
Depression, anxiety, stress, relationship problems, past experiences, drugs, and, less often, hormonal changes can reduce sexual desire.
Improving the relationship and the setting for sexual activity and identifying what stimulates the woman sexually can help.
A temporary reduction in sexual desire is common, often caused by temporary conditions, such as fatigue. In contrast, low sexual desire disorder causes sexual thoughts, fantasies, and desire for sexual activity to be decreased over a long period and more than would be expected for a woman’s age and the length of the sexual relationship. Low sexual desire is considered a disorder only if it distresses women or their partner or if desire is absent throughout the sexual experience.
Causes
Depression, anxiety, stress, or problems in a relationship commonly reduce sexual desire. Having a poor sexual self-image also contributes.
Use of certain drugs, including antidepressants (particularly selective serotonin reuptake inhibitors), anticonvulsants (see table on page 716), chemotherapy drugs, beta-blockers (see table on page 340), and oral contraceptives, can reduce sexual desire, as can drinking excessive amounts of alcohol.
Because levels of sex hormones such as estrogen and testosterone decrease with aging, sexual desire might be expected to similarly decrease with aging. However, overall, low sexual desire disorder is as common among young healthy women as it is among older women. Still, changes in sex hormones sometimes cause low desire. For example, in young healthy women, sudden drops in levels of sex hormones may cause sexual desire to decrease. Similar reductions may occur during certain phases of the menstrual cycle and during the first few weeks after childbirth. In middle-aged and older women, sexual desire may decrease as testosterone production decreases, but the connection has not been proved. In younger women, removal of both ovaries (which make testosterone as well as estrogen) can reduce testosterone production. Even when such women take estrogen, sexual desire may be low. Oral contraceptives may reduce the effects of testosterone, as may oral estrogen taken as part of hormonal therapy by postmenopausal women.
Did You Know…
Young healthy women are as likely to have low sexual desire disorder as older women.
Desire most closely links to mood and relationship (rather than to hormones).
Diagnosis
Diagnosis is based on the woman’s history and description of the problem. A pelvic examination may also be done.
Treatment
One of the most helpful measures is for women to identify and tell their partner which things stimulate them. Women may need to remind their partner that they need preparatory activities—which may involve touching or not—to get ready for sexual intercourse. For example, they may want to talk intimately, watch a romantic or erotic video, or dance. Women may want to kiss, hug, or cuddle. They may want their partner to touch various parts of their body, then the breasts or genitals (foreplay) before moving to sexual intercourse. Couples may experiment with different techniques or activities (including fantasy and sex toys) to find effective stimuli.
Measures recommended to treat sexual dysfunction in general (see page 1508) can also help increase sexual desire. Treatment often focuses on factors that contribute to a low sexual desire, such as depression, a poor sexual self-image, and problems in a relationship. Psychotherapy may benefit some women.
Other treatments depend on the cause. For example, if drugs may be contributing, they are stopped if possible. If loss of interest in sex is due to atrophic vaginitis, women may benefit from estrogen applied to the genital area as a cream, inserted into the vagina in a ring or as a tablet, or taken by mouth. For women who are taking oral contraceptives, doctors may recommend substituting contraceptive skin patches or using a barrier method (condom or diaphragm). For women taking estrogen therapy by mouth, doctors may recommend instead taking estrogen another way, such as a skin patch or gel.
Whether testosterone (taken by mouth or through a patch) is useful is being studied. Although it is not standard practice, some doctors occasionally prescribe it for postmenopausal women who are taking estrogen therapy and who have tried all other measures. Women who take testosterone must be evaluated regularly by their doctor because testosterone may have side effects and long-term safety is not known.
Sexual Arousal Disorders
Sexual arousal disorders involve a lack of response to sexual stimulation—mental or emotional (subjective), physical (such as swelling, tingling, or throbbing in the genital area or vaginal wetness), or both.
Depression, low self-esteem, anxiety, stress, and relationship problems can interfere with sexual arousal.
Improving the relationship and the settings for sexual activity and identifying what stimulates the woman sexually can help.
Usually, when women are sexually stimulated, they feel sexually excited mentally and emotionally. They may also be aware of certain physical changes. For example, the vagina releases secretions that provide lubrication (causing wetness). The tissues around the vaginal opening (labia) and the clitoris (which corresponds to the penis in men) swell, the breasts swell slightly, and these areas may tingle.
In sexual arousal disorders, the usual types of sexual stimulation (such as kissing, dancing, watching an erotic video, and touching the genitals) do not cause arousal—mentally or emotionally (subjectively), physically, or both.
In genital arousal disorder (a type of sexual arousal disorder), stimulation that does not involve the genitals (such as watching an erotic video) makes women feel aroused, but when the genitals are stimulated (including during intercourse), women are unaware of any physical responses or physical pleasure. As a result, sexual intercourse is unrewarding and possibly difficult and painful.
Sometimes physical responses occur, but women do not notice them because sensitivity in the area is reduced.
Causes
Sexual arousal disorders tend to have the same causes as low sexual desire disorder (see page 1511). For example, depression, low self-esteem, anxiety, stress, other psychologic factors (see page 1506), drugs, and relationship problems commonly interfere with sexual arousal. Inadequate sexual stimulation or the wrong setting for sexual activity can also contribute.
Genital arousal disorder may result from a low level of estrogen or testosterone as occurs during or after menopause, from infection of the vagina (vaginitis) or the bladder (cystitis), or from skin changes in the vulva. This disorder may develop when certain chronic disorders, such as diabetes and multiple sclerosis, damage nerves. The nerve damage leads to decreased sensation in the genital area.
Diagnosis
Diagnosis is based on the woman’s history and description of the problem. A pelvic examination is also done.
Treatment
Measures that help couples with sexual dysfunction (see page 1508) can be particularly helpful. For example, treatment includes the following:
Enhancing trust and intimacy in the couple’s relationship
Making the setting as conducive to sexual activity as possible
Helping a woman learn to focus during sexual activity
Identifying and communicating what stimulates the woman, as for low sexual desire disorder (see page 1511)
Couples may experiment with different stimuli, such as a vibrator, fantasy, or erotic videos. Couples may also try activities other than vaginal intercourse. For example, couples may do sensate focus exercises. For these exercises, partners take turns touching each other in pleasurable ways. At first, certain areas, including the genitals, are off limits, and the focus is sensual rather than sexual stimulation. The recipient guides the giver in the type of stimulation wanted. Partners focus on the sensations of the moment. They progress to touching other parts of the body sensually, then sexually and finally to genital stimulation. Such exercises can enhance intimacy and lessen anxiety before sexual activity.
SPOTLIGHT ON AGING
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 low sexual desire.
As women age, the ovaries produce smaller amounts of estrogen, progesterone, and testosterone. Some evidence suggests that these hormonal changes may reduce sexual desire, and the resulting changes in the reproductive organs can make sexual intercourse uncomfortable.
The tissues around the vaginal opening (labia) and the walls of the vagina become less elastic and thinner (a disorder called atrophic vaginitis).
Vaginal secretions are reduced, providing less lubrication during sexual intercourse.
Less and less testosterone is produced starting when women are in their 30s and continuing through their 70s. Some evidence suggests that this decrease may lead to decreased sexual interest and response.
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.
Decreases in hormone levels and blood vessel disorders (such as atherosclerosis) reduce blood flow to the vagina, causing it to become shorter, narrower, and drier.
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 have sexual desire, but if their partner no longer responds to them, their desire 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 atrophic vaginitis is a problem, estrogen can be applied as a cream or inserted into the vagina as a pill or in a ring. Estrogen may be given by mouth or a patch or applied to an arm as a gel only if menopause occurred recently. Occasionally, testosterone is prescribed in addition to estrogen therapy if all other measures are ineffective, although testosterone is still considered experimental and long-term safety is unknown.
Drugs that are likely causes are stopped if possible. If a selective serotonin reuptake inhibitor (an antidepressant) is the cause, adding bupropion (a different type of antidepressant) may help. Or another antidepressant may be substituted.
For women who have atrophic vaginitis, doctors may prescribe estrogen, applied to the genital area as a cream, inserted into the vagina in a ring or as a tablet, or taken by mouth. For women who are taking oral contraceptives, doctors may recommend substituting contraceptive skin patches or using a barrier method (condom or diaphragm). For women taking estrogen therapy by mouth, doctors may recommend instead taking estrogen another way, such as a skin patch or gel.
Whether testosterone (taken by mouth or through a patch) is useful is being studied. Occasionally, some doctors prescribe testosterone, although it is considered experimental. Women who take testosterone must be evaluated regularly by their doctor because testosterone may have side effects and long-term safety is unknown.
Orgasmic Disorder
Orgasmic disorder is lack of or delay in sexual climax (orgasm) even though sexual stimulation is sufficient and the woman is sexually aroused.
Women may not have an orgasm if lovemaking ends too soon, there is not enough foreplay, or they are afraid of losing control or letting go.
Women are encouraged to use techniques, such as masturbation, to enhance pleasure and to learn about sexual function, and for some, psychotherapy is useful.
The amount and type of stimulation required for orgasm varies greatly from woman to woman. Most women can reach orgasm when the clitoris is stimulated, but less than half of women regularly reach orgasm during sexual intercourse. About 1 of 10 women never reaches orgasm, but many of them nonetheless consider sexual activity to be satisfactory. Women with orgasmic disorder cannot have an orgasm under any circumstances, even when they masturbate and when they are highly aroused. However, not having an orgasm usually occurs because the woman is not sufficiently aroused and thus is not considered orgasmic disorder. Inability to have an orgasm is considered a disorder only when the lack of orgasm distresses the woman. Lovemaking without orgasm can cause frustration and may result in resentment and occasionally in distaste for anything sexual.
Causes
Situational and psychologic factors can contribute to orgasmic disorder. They include the following:
Lovemaking that consistently ends (as when the man ejaculates) before the woman is aroused enough
Insufficient foreplay
Lack of understanding about how their genital organs function in one or both partners
Poor communication about sex (for example, about what sort of stimulation a person enjoys)
Problems in the relationship, such as unresolved conflicts and lack of trust
Anxiety about sexual performance
Fear of letting go, being vulnerable, and not being in control (possibly as part of a fear of not being in control of all aspects of their life or as part of a general tendency to keep emotions in check)
A physically or emotionally traumatic experience, such as sexual abuse
Psychologic disorders (such as depression)
Physical disorders can also contribute to orgasmic disorder. They include nerve damage (as results from diabetes, spinal cord injuries, or multiple sclerosis) and abnormalities in genital organs.
Certain drugs, particularly selective serotonin re-uptake inhibitors (SSRIs—see table on page 868), may specifically inhibit orgasm.
Treatment
Techniques that may enhance pleasure, such as masturbation and relaxation techniques, may help, as may sensate focus exercises. In sensate focus exercises, partners take turns touching each other in pleasurable ways (see page 1512). Couples may try using more or different stimuli, such as a vibrator, fantasy, or erotic videos. A vibrator may be especially useful when there is nerve damage.
Education about sexual function may help. For some women, incorporating stimulation of the clitoris (which corresponds to the penis in men) may be all that is needed.
Psychotherapy may help women identify and manage fear of relinquishing control, fear of vulnerability, or issues of trusting a partner. Psychotherapy may be particularly useful for women who have been sexually abused or have psychologic disorders.
If an SSRI is the cause, adding bupropion (a different type of antidepressant) may help. Or another anti-depressant may be substituted. Some evidence suggests that if women stopped having orgasms when they started taking SSRIs, sildenafil may help them have orgasms again.