FEMALE SEXUAL DYSFUNCTION
Men and women initiate or agree to sexual activities for reasons that include sharing sexual excitement and physical pleasure and experiencing affection, love, romance, or intimacy. However, women are more likely to report emotional motivations such as
- To please or placate a partner
- To confirm their desirability
- To experience and encourage emotional intimacy
- To increase their sense of well-being
Especially in established relationships like marriage, women often have little or no initial sense of sexual desire, but they access sexual responsive desire once sexual stimulation triggers excitement and pleasure and physical genital arousal. The desire for sexual satisfaction, which may, or may not include one or multiple orgasms, builds as sexual activity and intimacy continue, and a physically and emotionally rewarding experience fulfills and reinforces the woman's original motivations.
Every woman's sexual response cycle is strongly influenced by her mental health and by the quality of relationship with her partner. Her initial desire typically lessens with age but increases with a new partner at any age.
Persistent, recurrent problems with sexual response, desire, orgasm or pain that distresses a woman or strain her relationship with her partner are known medically as sexual dysfunction.
Many women experience problems with sexual function at some point, and some may have difficulties throughout their lives. Female sexual dysfunction can occur at any stage of life. It can occur only in certain sexual situations or in all sexual situations.
Sexual response involves a complex interaction of physiology, emotions, experiences, beliefs, lifestyle and relationships. Disruption of any component can affect sexual desire, arousal or satisfaction, and treatment often involves more than one approach.
TYPES
Common types of sexual dysfunction in women include:
- Painful intercourse
- Lack of orgasm
- Subdued sexual desire
- Inability to become aroused
Hormone fluctuations may play a role in female sexual dysfunction. Lack of sex drive can be caused by many factors including hormonal changes and fatigue.
Inability to Become Aroused
The inability to become aroused is another common sexual dysfunction symptom in women. Insufficient vaginal lubrication in women may trigger the inability to become physically aroused during sexual activity. Problems with blood flow to the vagina and clitoris may also affect lubrication and arousal. Lubricants may help women become aroused more easily. If a woman is postmenopausal, estrogen cream may help.
Inhibited Sexual Desire
The lack of sexual desire or lack of interest in sex is inhibited sexual desire. This can have many causes, including hormonal changes, certain medical conditions and treatments, depression, pregnancy, stress, fatigue, lifestyle influences such as work stress or child care, and even boredom with regular sexual routines. Changing daily routines may help if lack of desire is a problem. Having sex in new places, at different times of the day, or trying different sexual positions may help reignite the desire.
Painful Intercourse
Painful intercourse can be a result of poor lubrication, vaginitis, and more. It can also be the result of a number of conditions such as endometriosis, a pelvic mass, ovarian cysts, vaginitis, poor lubrication, vaginal dryness, the presence of scar tissue from surgery, or a sexually transmitted disease. Vaginismus, a painful, involuntary spasm of the muscles that surround the vaginal entrance is a condition that may occur in women who fear that penetration will be painful, who may have sexual phobias, or who has previous traumatic or painful sexual experiences. Dyspareunia is pain during intercourse or other sexual activity involving the penetration or attempted penetration. The pain may be superficial or deep.
Lack of Orgasm
The absence of sexual climax (orgasm) is called anorgasmia. Anorgasmia can be caused by anxiety, inexperience, and other factors. Many factors can contribute to anorgasmia, including sexual inhibition, inexperience, or lack of knowledge. Psychological contributors to anorgasmia may include guilt, anxiety, or a past sexual trauma or abuse. Insufficient stimulation, drugs or medications, and chronic diseases can also result in lack of orgasm. One potential treatment for lack of orgasm is Kegel exercises.
CAUSES
A lot of factors cause or contribute to various types of sexual dysfunction. Traditionally, causes are considered either physical or psychologic. However, this distinction is not strictly accurate. Psychologic factors can lead to 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.
- 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 their emotions, a useful defense mechanism. The problem however is that 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 in some cases 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 partner's sexual performance.
- Situational factors
Factors related to the situation may involve the following:
The woman's own situation: Women may for example have a low sexual self-image if they are encountering fertility problems or have had surgery to remove a breast, the uterus, or another body part associated with sex.
The relationship: The lack of trust or negative feelings about their sex partner may make a woman feel less attracted to their partner than earlier in their relationship.
The surroundings: The thinking that the scenery may not be erotic, private, or safe enough for uninhibited sexual expression.
The culture: The background may be that of a woman 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: Certain factors like family, work, finances, or other things can preoccupy women and thus interfere with sexual arousal.
- Physical factors
Various physical conditions and drugs may lead to, or contribute to sexual dysfunction. Hormonal changes, which may occur with aging or result from a disorder, can interfere. The tissues of the vagina for example, can become thin, dry, and inelastic after menopause because estrogen levels decrease. This condition which is known as atrophic vaginitis, can make intercourse painful. Oophorectomy, (the removal of both ovaries) can also have this effect.
If taken by mouth, estrogen therapy is sometimes used to control symptoms associated with menopause and may enhance sexual function in postmenopausal women by helping relieve atrophic vaginitis. However, estrogen that is inserted into the vagina can be just as effective for treating atrophic vaginitis. Vaginal estrogen can be inserted as a cream, as a tablet, or in a ring (similar to a diaphragm).
SYMPTOMS
Symptoms vary depending on what type of sexual dysfunction is being experienced:
- Low sexual desire. This is the most common of female sexual dysfunctions. It involves a lack of sexual interest and willingness to be sexual.
- Sexual pain disorder. A woman may have pain associated with sexual stimulation or vaginal contact.
- Sexual arousal disorder. A person's desire for sex might be intact, but would still have difficulty with arousal or are unable to become aroused or maintain arousal during sexual activity.
- Orgasmic disorder. A woman may have persistent or recurrent difficulty in achieving orgasm after sufficient sexual arousal and ongoing stimulation.
RISK FACTORS
Some factors may increase the risk of sexual dysfunction:
- Depression and/or anxiety
- Gynecological conditions, such as Vulvovaginal atrophy,
- Heart and blood vessel disease
- Neurological conditions, such as spinal cord injury or multiple sclerosis
- A history of sexual abuse
- Certain medications (e.g. antidepressants or high blood pressure medications)
- Emotional or psychological stress, especially concerning the relationship with her partner
WHEN TO SEE A DOCTOR
Sexual problems in women are common, and nearly every woman will experience them on occasion. However, if the problems persist they can be very upsetting for a woman and can affect her relationship with her partner.
If any woman should experience any sexual problems on a regular basis, they should talk to their doctor.
DIAGNOSIS
Diagnosis often involves a 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.
If women are experiencing pain, doctors do a pelvic 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, which may help her feel more in control. In case she is fearful of anything entering her vagina, she can place her hand on the doctor's in order to control the internal examination.
Doctors usually do not need to use an instrument, such as a speculum, to do the internal examination to diagnose sexual problems.
However, if doctors suspect a sexually transmitted disease, they insert a speculum into the vagina to spread the walls of the vagina apart (as done during a Pap test) and take a sample of fluids from the vagina. They examine the sample for organisms that can cause sexually transmitted diseases and may send the sample to a laboratory, where the organisms are cultured (grown) to make identification easier.
TREATMENT
Certain treatments depend on the cause of dysfunction. However, some general measures can help regardless of the cause:
Making time for sexual activity: Women, who are used to multitasking, may be preoccupied with or distracted by other activities (work, household chores, children, and community). In such cases, making sexual activity a priority and recognizing how counterproductive distractions are may help.
Practicing mindfulness: Mindfulness involves learning to focus on what is happening at that 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.
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. Ensuring 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 are qualities that 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.
Becoming aware of what is required for a healthy sexual response may be enough to help women change their thinking and behavior. However, often times more than one treatment is required because many women have more than one type of sexual dysfunction.
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. More in-depth psychotherapy may be needed when issues from childhood are interfering with sexual function.
Medical treatment for female sexual dysfunction
Effective treatment for sexual dysfunction often requires addressing an underlying medical condition or hormonal change. Your doctor may suggest changing a medication or prescribing a new one.
Treating female sexual dysfunction linked to a hormonal cause might include:
Estrogen therapy. Localized estrogen therapy comes in the form of a vaginal ring, cream or tablet. Estrogen therapy benefits sexual function by improving vaginal tone and elasticity, increasing vaginal blood flow and enhancing lubrication.
The risks of hormone therapy may vary depending on age, the risk of other health issues such as heart and blood vessel disease and cancer, the dose and type of hormone and whether estrogen is given alone or with a progestin.
Some cases of hormonal therapy might require close monitoring by the doctor.
Ospemifene (Osphena). This medication is a selective estrogen receptor modulator. It helps to reduce pain during sex for women with Vulvovaginal atrophy.
Androgen therapy. Testosterone plays a role in healthy sexual function in women as well as men, although women have much lower levels of testosterone.
Flibanserin (Addyi). A medication originally developed as an antidepressant, flibanserin is approved as a treatment for low sexual desire in premenopausal women.
A daily pill, Addyi may boost sex drive in women who experience low sexual desire and find it distressing. Potentially serious side effects include low blood pressure, sleepiness, nausea, fatigue, dizziness and fainting, particularly if the drug is mixed with alcohol.
How Hormones Affect Sexual Function
Hormones play a large role in sexual function in women. As women age, the hormone estrogen decreases, which can lead to poor vaginal lubrication and decreased genital sensation. Low levels of the male hormone testosterone in women may also contribute to reduced sexual arousal, genital sensation, and orgasm. As long as it is not indicated contrary, hormone replacement therapy may help women enjoy improved sexual function. Estrogen combats urogenital atrophy, menopausal mood disorders, and vasomotor symptoms, like flushing, which can negatively impact female sexual function.
How Menopause Affects a Woman's Sexual Function
Menopause and its associated loss of estrogen can affect women's sexual function such as a loss of vaginal lubrication and genital sensation. Other emotional aspects of menopause may contribute to a loss of interest in sex or an inability to become aroused. Loss of estrogen causes thinning and loss of elasticity of the vagina. Estrogen suppositories may help this problem.
However, many postmenopausal women have increased sexual satisfaction. This is thought to be attributable to less anxiety about getting pregnant, or having the time to relax and enjoy being intimate with their partners.
