Sexual Dysfunction

What is it?

Overview

What Is It?
Sexual dysfunction is a persistent physical or emotional problem associated with sex. Such problems may include lack of desire, difficulty becoming aroused, difficulty having an orgasm or pain during sex.
A woman's sexuality is a complex interplay of physical and emotional responses that affects the way she thinks and feels about herself. When a woman has a sexual problem, it can impact many aspects of her life, including her personal relationships and her self-esteem. Many women are hesitant to talk about their sexuality with their health care professionals, and many health professionals are reluctant to begin a discussion about sexuality with their patients. Instead, women may needlessly suffer in silence when their problems could be treated.

Sexual activity includes a wide variety of intimate activities, such as fondling, self-stimulation, oral sex, vaginal penetration and intercourse. Every woman differs in her sexual interest, response and expression. A woman's feelings about sexuality can change according to the circumstances and stages of her life. Women also can experience a variety of sexual problems, such as lack of desire, difficulty becoming aroused, difficulty having an orgasm or pain during sex. When a physical or emotional problem associated with sex persists, it's time to contact a health care professional.

Characteristics of Sexual Arousal: Scientific Research

Early Research: Masters & Johnson
Research on the sexual response in the mid-1960s by Masters & Johnson established what is known as the traditional linear sexual-response cycle: desire-arousal-orgasm-resolution. The stages are defined as follows:

  • Excitement/Arousal: The feeling that you want to have sex, followed by physical changes that occur in your body as you become sexually excited. These include moistening of the vagina; relaxation of the muscles of the vagina; and swelling of the labia, (skin folds that are part of the vulva), and the clitoris (a small, sensitive organ above the vagina, where the inner labia, which surround the vagina, meet). The nipples also become erect.
  • Plateau: The above changes in the genitals continue, there is an increase in blood flow to the labia, the vagina grows longer, and glands in the labia produce secretions. There is an overall increase in muscle tension.
  • Orgasm: Known as the peak of the sexual response, the muscles of the vagina and uterus contract leading to a strong, pleasurable feeling.
  • Resolution: You return to your normal state.


Contemporary Research: Rosemary Basson, MD

More contemporary research suggests that a woman's sexual response is both more complex and varied than this model suggests, particularly when the woman is involved in a long-term relationship. In 2002, the leader in this field, Rosemary Basson, MD, introduced a new cycle for the female sexual response that focuses on women's need for intimacy.

These differences are important to understanding your sexual health as well as for accurately diagnosing and treating sexual dysfunction. The differences, in part, include recognizing that women's sexual responses are connected more to relationship and intimacy than to physical needs, and that the orgasm stage can be highly variable for women without actually being "dysfunctional."

In addition, it's important to distinguish a woman's sexuality and sexual response from a man's. In men, thinking about sex translates to erection, but in women, arousal often comes about after the actual lovemaking begins. In other words, a woman may start out making love with her partner somewhat uninterested, but as things progress and she focuses on the stimulation and sensations she's feeling, she becomes increasingly more aroused.

Sexual Dysfunctions in Women
Sexual dysfunctions are disturbances in one or more of the sexual response cycle's phases or pain associated with arousal or intercourse. A study published in the Journal of the American Medical Association (JAMA) involving a national sample of 1,749 women estimated that sexual dysfunctions occur in 43 percent of women in the United States. According to this 1999 study, you may be at greater risk for sexual problems if you are:

  • single, divorced, widowed or separated
  • not a high school graduate
  • experiencing emotional or stress-related problems
  • experiencing a decline in your economic position
  • feeling unhappy, or physically and emotionally unsatisfied
  • a victim of sexual abuse or forced sexual contact


Causes of Sexual Dysfunctions

There are several types of sexual dysfunctions. They can be lifelong problems that have always been present, acquired problems that develop after a period of normal sexual function or situational problems that develop only under certain circumstances or with certain partners. Causes of sexual dysfunctions can be psychological, physical or related to interpersonal relationships or sociocultural influences.

Psychological causes can include:

  • stress from work or family responsibilities
  • concern about sexual performance
  • depression/anxiety
  • unresolved sexual orientation issues
  • previous traumatic sexual or physical experience
  • body image and self-esteem problems

Physical causes can include:

Interpersonal relationship causes may include:

  • partner performance and technique
  • lack of a partner
  • relationship quality and conflict
  • lack of privacy

Sociocultural influence causes may include:

  • inadequate education
  • conflict with religious, personal, or family values
  • societal taboos



Types of Sexual Dysfunctions
Lack of sexual desire is the most common sexual problem in women. The Association of Reproductive Health Professionals reports in the National Health and Social Life Survey that 33 percent of women lacked interest in sex for at least a few months in the previous year.

The American College of Obstetricians and Gynecologists (ACOG) reports that a woman's sexual response tends to peak in her mid-30s to early 40s. That's not to say, however, that a woman can't have a full physical and emotional response to sex throughout her life. Most women will have a passing sexual problem at some point in their lives, and that is normal. However, sexual dysfunction in its true sense is most common in women aged 45 to 64.

Often, sexual desire is affected by a woman's relationship with her sexual partner. The more a woman enjoys the relationship, the greater her desire for sex. The stresses of daily living can affect desire, however, and occasionally feeling uninterested in sex is no cause for concern.

  • Hypoactive Sexual Desire Disorder: When sexual fantasies or thoughts and desire for sexual activity are persistently reduced or absent causing distress or relationship difficulties, the problem is known as hypoactive sexual desire disorder, or inhibited sexual desire disorder. The Merck Manual estimates hypoactive sexual desire disorder occurs in about 20 percent of women.
  • Sexual aversion disorder: Diagnosed when you avoid all or almost all genital sexual contact with a sexual partner to the point that it causes personal distress and relationship difficulties. This condition may affect women who have experienced some type of sexual abuse or who grew up in a rigid atmosphere in which sex was taboo. A study in the journal Archives of Sexual Behavior found that among patients with panic disorder, 75 percent had sexual problems, and that sexual aversion disorder was the most common complaint, affecting 50 percent of women with the disorder.
  • Sexual arousal disorder: The persistent or recurrent inability to reach or sustain the lubrication and swelling reaction in the arousal phase of the sexual response to the point that it causes personal distress. It is the second most common sexual problem among women, affecting an estimated 20 percent of women, and most frequently occurs in postmenopausal women. Low estrogen levels after menopause can make vaginal tissue dry and thin and reduce blood flow to genitals. As a result, the arousal phase of the sexual response may take longer and sensitivity of the vaginal area may decline. However, this can happen at any age.
  • Female orgasmic disorder: The persistent absence or recurrent delay in orgasm after sufficient stimulation and arousal, causing personal distress. According to the Association of Reproductive Health Professionals, 24 to 37 percent of women have problems reaching orgasm. Most women are biologically able to experience orgasm. Never having an orgasm, or not having one in certain situations, are problems that can often be resolved by learning how the female body responds, how to ensure adequate stimulation and/or how to overcome inhibitions or anxieties. Some medications, including but not limited to those used to treat high blood pressure, depression and psychosis, can reduce your sexual desire and sexual arousal and interfere with orgasm. If you are taking such drugs and experiencing sexual side effects, talk with your health care professional about changing your dosage or prescription.


Another type of sexual arousal disorder has the opposite effect. Some women may always feel sexually aroused, an experience that can be quite uncomfortable and upsetting. Although most health care professionals recognize hyperactive sexual desire as a problem, it is not an official condition according to the DMS-IV. Women who have a hyperactive sexual drive tend to be very demanding sexually because their desire for sex is constant.

Sexual Disorders Involving Pain

Dyspareunia: Pain during or after intercourse, called dyspareunia, occurs in nearly two out of three women at some time during their lives, according to ACOG. Like other sexual disorders, it can have physical and/or emotional causes. The most common cause of pain during sex is inadequate vaginal lubrication occurring from a lack of arousal, medications or hormonal changes. Painful sex also can be a sign of illness, infection, cysts or tumors requiring medical treatment or surgery, another reason why you should discuss the problem with your health care professional.

Vaginismus: The involuntary spasm of the muscles at the opening of the vagina, making anything entering the vagina painful. Vaginismus can have medical causes, including:

  • scars in the vagina from an injury, childbirth or surgery
  • irritations from douches, spermicides or latex in condoms
  • pelvic infections

Vaginismus also can have psychological causes. It can be a response to a fear, such as fear of losing control or fear of pregnancy. It can also stem from pain or trauma such as rape or sexual abuse.

Vulvodynia: Defined as any pain in the vulva. It could be outside the vulva on the labia or an itching, burning or sharp pain within.

Treating Sexual Dysfunctions
If your relationship or sexual problem is new, try having an open, honest talk with your partner to relieve concerns and clear up disagreements or conflicts. Women who learn to tell their partners about their sexual needs and concerns have a better chance at a more satisfying sex life. If the sexual problem persists, discuss your concerns with your health care professional. Most sexual problems can be treated.

Diagnosis

Diagnosis

If you're having sexual problems, your health care professional will try to rule out medical causes first by conducting a thorough medical history and exam, including a pelvic exam and blood tests. If there is no physical or biological cause, you may be referred for psychological counseling. Askfor a referral to a sex therapist. These specialists are trained to provide the type of therapy you need and, with your input, make a diagnosis and recommend treatment. When possible, your partner should be included in this therapy with you. To find a certified, trained sex therapist contact the American Association of Sexuality Educators, Counselors and Therapists at http://www.aasect.org.

Be sure to tell your health care professional if you have any of the following conditions that can have a significant impact on sexual functioning, both physically and psychologically:

  • Chronic illness, such as diabetes and heart, kidney or liver disease

    These conditions can lead to nerve damage and affect blood flow to the pelvic organs, affecting arousal and decreasing vaginal lubrication. Additionally, having a lifelong illness can hurt a woman's self-image and make her feel less sexual, affecting desire.

  • Cancer

    Radiation treatment, as well as certain medications used to treat cancer, may result in lubrication problems, and, in turn, painful sex. Anti-estrogen hormonal medications for breast cancer or drugs used to prevent recurrence of breast cancer, such as tamoxifen (Nolvadex), may also produce low desire, vaginal dryness and difficulties with vaginal penetration. Chemotherapy for cancer can affect many physical functions and responses, including sexual desire and arousal. Additionally, cancer treatment can produce fatigue, decreased self-esteem, fear of death, disfigurement and/or rejection that can affect a woman's sexual feelings.

  • Pregnancy

    Women differ in their sexual activity patterns during pregnancy. Some curb their activity in the first three months and again near the end of pregnancy when physical discomfort can lead to decreased desire. Some have an increase in activity when the initial discomfort wanes. Generally, however, sexual activity doesn't have to stop because of pregnancy. Sex won't hurt the fetus. However, if you are at risk for a preterm birth, your health care professional may advise against sex during pregnancy.

    Some pregnant women find sexual interest decreases steadily over the course of the pregnancy. After the baby is born, changing hormone levels, fatigue and/or a healing episiotomy may lead to reduced sexual desire. Additionally, it is common for women who breastfeed to notice a lack of vaginal lubrication. This is caused by high levels of the hormone prolactin, which is stimulated by nursing. Also, as prolactin increases, testosterone, a hormone that contributes to sexual desire, decreases, another reason for declining sexual desire.

  • Menopause

    Low estrogen levels can cause vaginal dryness, thinning of vaginal tissues, reduced blood flow to the genital area and reduced vaginal sensitivity that may contribute to arousal and, in turn, orgasm problems. Postmenopausal women often find that the arousal phase of the sexual response cycle takes longer or is less intense. Changing hormone levels also can produce mood swings that make some women nearing menopause feel less interested in sex.

  • Substance abuse

    Alcohol affects the arousal states and inhibits orgasm. Chronic alcohol use reduces desire. Abusing drugs, especially narcotics such as morphine, codeine and heroin, impairs sexual function and reduces desire.

If you are having a sexual problem, make sure you tell your health care professional about any medications you're taking. Blood pressure medications, antipsychotics and antidepressants are commonly prescribed drugs that can interfere with the sexual response. Selective serotonin reuptake inhibitors (SSRI) such as paroxetine (Paxil) and fluoxetine (Prozac) frequently produce side effects that inhibit or prevent orgasm. Other antidepressants can affect sexual function as well, including tricyclic antidepressants such as imipramine (Tofranil) and clomipramine (Anafranil), monoamine oxidase inhibitors such as phenelzine (Nardil) and mixed antidepressants such as venlafaxine (Effexor). Anticonvulsants for seizures also can cause sexual problems.

A change in dosage or medication may help resolve your sexual problem.

If you have pain associated with sexual activity, it's important to accurately describe where the pain is located so your health care professional can determine its cause. The types of pain associated with sex include:

  • Vulvar pain

    This type of pain is felt on the outside of the vagina and often occurs when some part of the vulva is touched. It can be caused by irritation from soaps, feminine hygiene sprays or douches, scars, cysts or infections.

  • Vaginal pain

    This type of pain is felt inside the vagina. The most common cause is a lack of lubrication from inadequate arousal, medications, medical conditions, pregnancy, breastfeeding or menopause. Vaginal pain also can be caused by an inflammation of the vagina, known as vaginitis. Additional symptoms of vaginitis are a vaginal discharge, itching and burning of the vagina and vulva. It can be caused by a yeast or bacterial infection or a sexually transmitted disease.

    Vaginal pain also can be caused by vaginismus. This pain occurs when anything attempts to enter the vagina, including tampons or even during a pelvic examination. It can be caused by irritation from douches, spermicides or latex in condoms, infections, scars from an injury, childbirth, surgery or psychological problems from sexual trauma or abuse.

  • Deep pain

    Pain that is felt deep inside the vagina, lower back, pelvic area, uterus or bladder can be a sign of an internal medical problem. It can be caused by:

    • pelvic inflammatory disease

    • endometriosis, a condition in which the tissue that lines the uterus grows outside the uterus

    • pelvic tumor

    • bowel or bladder disease, such as interstitial cystitis

    • scar tissue

    • ovarian cysts

If you are experiencing deep pain during sex, your health care professional may recommend a variety of tests including but not limited to blood tests, urine tests and scans to check for possible causes.

Treatment

Treatment

Treatment for sexual dysfunction depends on the cause of the problem. If the cause is physical, medical treatment is aimed at correcting the underlying disorder. If the cause is psychological, treatment consists of counseling. Treatment can include a combination of medical and psychological approaches.

Sometimes, treatment may be behavioral. For example, with loss of desire, changes in the environment, timing, lovemaking techniques or foreplay can produce desire. With arousal disorder, the use of toys and vibrators can help with vaginal circulation. A warm bath and a massage from your partner can also help.

Medical Treatment

  • Lubricating creams, gels or suppositories

    If you are suffering from vaginal dryness caused by medications, a chronic condition or declining estrogen levels, your health care professional may suggest water-based, over-the counter vaginal lubricants such as Astroglide or K-Y Jelly to make sex more comfortable. Or you might try Replens, a long-acting vaginal moisturizer that releases purified water to produce a moist film over the vaginal tissue. Do not use oil-based products, such as petroleum jelly, baby oil or mineral oil with latex condoms because they can cause a condom to break.

  • Topical estrogen

    For menopausal women with vaginal thinning, dryness or insensitivity, your health care professional may prescribe an estrogen cream such as Estrace or Premarin, or a vaginal ring, such as Estring, Phadia (low-dose) or Femring (higher dose), to ease sexual discomfort. And a vaginal tablet (Vagifem) containing estradiol, a type of estrogen, is available by prescription for vaginal dryness. Unlike creams, which usually are used at night, Vagifem can be inserted any time of day.

  • Hormone therapy

    For menopausal women, hormone therapy (either a combination of estrogen and progestin or estrogen-only therapy) may improve the sensitivity of the clitoris, ease discomfort caused by vaginal thinning and dryness and improve blood flow to the pelvic area. In addition, hormone therapy (HT) can help relieve other bothersome menopausal symptoms, including hot flashes, which can interfere with intimacy. A woman should not take any form of HT until she has weighed the pros and cons and discussed the risks and benefits with her doctor. Because of the potential risks that go along with HT, the U.S. Food and Drug Administration (FDA) now advises health care professionals to prescribe it at the lowest possible dose and for the shortest possible length of time to achieve treatment goals.

    Although HT can result in increased sensitivity and decreased discomfort during sex for menopausal women, the therapy may not improve sexual desire. Some health care professionals add testosterone, a hormone produced by the ovaries and adrenal glands that plays a role in sexual desire, to HT to stimulate sexual arousal. Treatment with testosterone is controversial, however. Estratest, an estrogen/testosterone combination, is currently the only testosterone treatment available. However, there is conflicting evidence and opinion in the medical community concerning whether or not the benefits of the drug outweigh the risks, which include increased risk of breast and endometrial cancer, adverse effects on blood cholesterol and liver toxicity. Studies on other androgen products used to treat sexual dysfunction have also had mixed results.

    Although there is no FDA-approved form of testosterone available to treat women's sexual dysfunction, many doctors prescribe it "off label" in small amounts, particularly for women whose ovaries have been removed. Removing the ovaries drastically reduces testosterone levels, and some research shows that women who have had their ovaries removed are most likely to benefit from androgen therapy.

    Supplementing with testosterone has potential risks. In too high a dose, testosterone can produce masculinizing effects, such as increased facial hair and enlargement of the clitoris. The oral form can also produce liver damage, acne and a decrease in HDL cholesterol (the "good" cholesterol). The use of testosterone in men and women is highly controversial, so be sure to discuss with your health care professional whether androgen supplementation is right for you.

Clitoral therapy device

The Eros Clitoral Therapy device is an FDA-approved device designed to treat female sexual arousal disorder. It consists of a small, soft suction cup attached to a palm-sized, battery-operated vacuum pump. The suction cup is placed over the clitoris before sex. The gentle vacuum increases genital blood flow, thus increasing sexual arousal and enhancing orgasm. Studies have shown that the Eros Clitoral Therapy device effectively boosts sensation, orgasms, lubrication and overall sexual satisfaction. The device is available by prescription.

Vaginal weights

Women with orgasmic disorders may benefit from treatment with vaginal weights. Vaginal weights are used to strengthen the pelvic floor muscles, improving awareness of sexual response and also potentially correcting urine leakage, which can cause problems during sexual activity.

Vaginal weights are usually available in sets of five. To use them, you insert the lightest weight and remain upright for 15 minutes, two times a day. When the weight is in place, you should feel the urge to hold it in. After a few days, as the muscles strengthen, this urge will go away, and you will be able to move up to the next weight. When you get to the fifth weight, you will insert it for five to seven consecutive days each month to maintain strength in your pelvic muscles.

Sildenafil (Viagra)

The drug that treats erectile dysfunction in men is also being studied in clinical trials for female sexual arousal disorder. Some studies have found it may increase blood flow to the female genital area and increase relaxation of clitoral and vaginal muscles. However, several large placebo-controlled studies including about 3,000 women with female sexual arousal disorder had inconclusive results. Therefore, the manufacturer of Viagra has decided not to seek FDA approval to use the drug for female sexual arousal disorder.

Other Medical Approaches

Better control of chronic diseases, switching prescriptions to reduce side effects and treating vaginal infections by taking antibiotics can eliminate sexual problems related to desire, arousal, orgasm and pain. On very rare occasions, surgery may be needed to remove structural problems, such as cysts, tumors or growths that produce pain during sex.

Psychological Treatment

Psychological treatment for sexual dysfunction usually involves a series of steps identifying and modifying emotions and behaviors that interfere with sexual response, changing behaviors that act as barriers to sexual responsiveness and learning new physical and emotional behaviors that encourage sexual responsiveness.

Sex therapy is talk therapy in which you and your counselor, along with your partner, discuss problems, how and why they occur and ways to solve them. You and your partner receive exercises and techniques to try at home, then report on the results at the following session. Depending on your needs, goals and diagnosis, such counseling typically can involve a one-hour session once a week for about two to six months.

Poor communication between partners is often present with sexual dysfunction. Learning to communicate, resolving conflict and dealing with negative emotions are the focus of therapy designed to address this issue. Group therapy or support groups also may be recommended.

Behavioral changes may also help. These include: changes in the environment, love making at different times of the day, warm baths, masturbation, massage and the use of sexual toys and vibrators.

Sensate focus exercises are often recommended by therapists to treat sexual arousal disorder and orgasm disorder. These exercises help you and your partner relate to each other physically without any pressure to perform sexually. You begin by touching each other, slowly progressing to genital stimulation and possibly eventually proceeding to intercourse.

Learning the functions of sexual organs and how the body responds sexually, including clitoral and vaginal stimulation, can help with arousal and orgasm disorders. Kegel exercises can strengthen voluntary control of pelvic muscles, improving the sense of control and quality of orgasms.

Treatment for vaginismus (involuntary spasm of the muscles at the vaginal opening) may focus on techniques to relax the vagina. One option is using dilators in graduated sizes that are placed into the vagina and kept in place for 10 minutes. The woman usually places the dilators herself. Performing Kegel exercises while the dilator is in place helps you learn to control your vaginal muscles. The exercises also can be done with your fingers. Sometimes, waiting for the muscle to relax after penetration may help.

FSD Research

Research is progressing on a couple of drugs aimed at helping women with sexual problems. At a recent meeting of the International Society for the Study of Women's Sexual Health, a study was released on bremelanotide, a drug undergoing trials for treatment of female sexual dysfunction (FSD). In the trials, the drug was well-tolerated and increased arousal, desire and the number of sexually satisfying events in women with hypoactive sexual desire disorder (HSDD) and women with both HSDD and female sexual arousal disorder. The final phase of testing could start near the end of this year.

Another drug that is being studied for possible treatment of overall sexual function is tibolone. It is a synthetic steroid currently used in Europe and Australia to treat postmenopausal osteoporosis, but, in one study, it was also shown to enhance sexual function in postmenopausal women. It has not been approved for use in the United States because of concerns over increased risk of breast cancer and stroke.

Studies also are looking at the effectiveness of phosphodiesterase inhibitors, the class of drugs that includes sildenafil (Viagra). So far, results show little effectiveness in treating FSD, but these drugs may help women who experience sexual dysfunction as the result of taking certain antidepressants. However, sildenafil should not be taken by anyone using nitroglycerin for angina.

If you suffer from sexual dysfunction, be sure to discuss it with your health care provider.

Prevention

Prevention

A healthy lifestyle can go a long way toward preventing chronic illnesses and diseases that can contribute to sexual dysfunction. Eating a balanced diet, getting plenty of exercise, stopping smoking, limiting alcohol consumption and controlling stress will help you feel well, build a healthy self-image, boost your energy and help you maintain confidence in your sexuality. Visit your health care professional regularly to avoid medical problems that may affect your sexual responses.

Other things you can do to enhance your sexual desire and pleasure include:

  • Communicate with your partner

    Emotional intimacy is the essential beginning for sexual intimacy for many women. Talk frankly and honestly about your feelings with your partner to help build your relationship. Silence can result in repressed feelings, anger and alienation that can harm your well-being and even your long-term mental and physical health.

  • Express your desires

    Tell your partner what you want sexually and what "turns you on," and guide your partner to do those things that please you.

  • Be less predictable and more spontaneous in your sexual experiences

    Partners who have been together for years can get into patterns in which sex is always the same. Try new ways to be intimate, and prolong your sexual experience by being more creative with touching, positions, timing and location of sexual activities.

  • Examine your priorities

    Don't let work or family responsibilities take time away from your relationship with your partner. Spending time together is part of building intimacy and helps both partners feel connected to each other.

  • Stay sexually active after menopause

    Regular sexual activity, with a partner or through self-stimulation, can improve vaginal lubrication and elasticity as estrogen levels decline.

Sexuality is highly personal and varies from woman to woman. A woman's sexual responses can vary from one time to another, and no one pattern is more "normal" than another. Nearly everyone has a problem with sex at some time in their lives, and often the problem can be worked out with patience and talking with your partner. When the problem is life-disrupting, causes trouble in your relationships or involves physical pain, it's time to talk with your health care professional. In many cases, your sexual problem can be treated with medical treatments, psychological therapy or both.

Facts to Know

Facts to Know

  1. Sexual problems occur in 43 percent of women in the United States, according to a study published in 1999 in the Journal of the American Medical Association.

  2. A lack of desire is the most common sexual problem in women The Association of Reproductive Health Professionals reports that in the National Health and Social Life Survey, 33 percent of women lacked interest in sex for at least a few months in the previous year.

  3. Sexual arousal disorder is the second most common sexual problem among women, affecting an estimated 20 percent of women.

  4. Twenty-four to 37 percent of women have problems reaching orgasm, according to the Association of Reproductive Health Professionals.

  5. Pain during or after intercourse occurs in nearly two out of three women at some time during their lives, according to the American College of Obstetricians and Gynecologists.

  6. Low estrogen levels can cause vaginal dryness, thinning of vaginal tissues, reduced blood flow to genital areas and reduced vaginal sensitivity that can contribute to arousal and, in turn, orgasm problems. Low androgen levels may contribute to desire problems. Hormone therapy often can help.

  7. The most common cause of pain during sex is inadequate vaginal lubrication, which can occur from a lack of arousal, medications or hormonal changes.

  8. It is common for women who breast-feed to notice a lack of vaginal lubrication and sexual interest caused by an elevation of the hormone prolactin, which is stimulated by lactation.

  9. Sexual disorders can have medical causes, psychological causes or both.

  10. One way women can help prevent sexual dysfunction is to have sex frequently. Sexual activity increases blood flow, which leads to better overall sexual function.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about sexual dysfunction so you're prepared to discuss this important health issue with your health care professional.

  1. What sexual response side effects can I expect from my medications?

  2. Can my prescription be changed tominimize any sexual side effects?

  3. What medical problem might I have that is contributing to my sexual problem and will its treatment solve my sexual problem?

  4. How is my sexual problem related to my chronic illness or disease?

  5. What can be done to better manage my illness or disease to improve my sexual problem?

  6. What are my estrogen and androgen hormone levels, and are they causing or contributing to my sexual problem?

  7. Are bodily changes related to menopause causing my sexual problem? What can be done to minimize those effects?

  8. What treatments are available for my sexual problem?

  9. Am I a candidate for hormonal therapy to help my sexual problem, and if so, what hormones would work best for me? What are the risks and benefits of hormone therapy?

  10. Could counseling help my sexual problem, and whom do you suggest I contact?

Key Q&A

Key Q&A

  1. What is the sexual response cycle?

    Masters & Johnson, pioneering sex therapists, defined a classic sexual response cycle in the mid-1960s. The stages of this model are:

    • Excitement/Arousal: The feeling that you want to have sex followed by physical changes that occur in your body as you become sexually excited. These include moistening of the vagina, relaxation of the muscles of the vagina; swelling of the labia, (skin folds that are part of the vulva) and the clitoris (a small, sensitive organ above the vagina, where the inner labia, which surrounds the vagina, meet that acts as a source of sexual excitement). The nipples also become erect.

    • Plateau: The above changes in the genitals continue, there is an increase in blood flow to the labia, the vagina grows longer, and glands in the labia produce secretions. There is an increase in muscle tension.

    • Orgasm: Known as the peak of the sexual response, the muscles of the vagina and uterus contract leading to a strong, pleasurable feeling.

    • Resolution: You return to your normal state.

    However, it's important to point out that more contemporary research suggests that women's sexual response is more complex and includes more elements than the traditional model outlines. Relationship and intimacy needs appear to play a greater role in women's sexual health. According to sexual health experts, a better understanding of the complexity of women's sexuality will help to more accurately diagnose and treat sexual dysfunction.

  2. How do I know if I have sexual dysfunction?

    Sexual dysfunctions are defined as one or more disturbances in the sexual response cycle, or pain associated with arousal or intercourse. Lack of desire, difficulty becoming aroused, lack or delay in orgasm or pain during or after sex are all examples of sexual problems faced by women. Such problems can be occasional and seem to go away on their own. But when they are persistent or recurrent, disrupting your life or your relationships and causing you emotional upset, they may be dysfunctions that should be discussed with your health care professional.

  3. What causes sexual dysfunctions?

    Causes of sexual dysfunctions can be physical, psychological or related to interpersonal relationships or sociocultural influences. Psychological causes can include:

    • stress or anxiety from work or family responsibilities

    • concern about sexual performance

    • conflicts in the relationship with your partner

    • depression

    • unresolved sexual orientation issues

    • previous traumatic sexual experience

    • body image and self-esteem problems

    Physical causes can include:

    • diabetes

    • heart disease

    • liver disease

    • kidney disease

    • pelvic surgery

    • pelvic injury or trauma

    • neurological disorders

    • medication side effects

    • hormonal changes, including those related to pregnancy and menopause

    • thyroid disease

    • alcohol or drug abuse

  4. How are sexual dysfunctions treated?

    Treatment depends on the cause. If the cause is physical, the treatment will be aimed at correcting the medical or biological problem. For example, if the cause is hormonal imbalance, hormonal supplements may be prescribed. If the cause is a structural problem, such as a cyst or tumor, surgery may be needed. Sometimes, treatment can involve changes in behavior. Better control of chronic illnesses and disease often solves sexual problems associated with them.

    Some medications can cause sexual problems, and changing prescriptions to those with fewer side effects can treat the problem. Regardless of the cause, counseling, ideally with a sexual therapist, is recommended and should include both partners together. Treatment can include both treating the physical or medical problem and counseling.

  5. I just don't feel like having sex anymore. Is there something wrong with me?

    Lack of desire is the most common sexual problem in women. It can be caused by problems in a woman's relationship with her partner, stress, fatigue, medications and low levels of the hormones estrogen or androgen. Often, lack of desire is affected by a woman's relationship with her sexual partner. The more a woman enjoys the relationship, the greater the desire for sex.

    The stresses of daily living can affect desire, and occasionally feeling uninterested in sex is no cause for concern. But, when sexual fantasies or thoughts and desire for sexual activity are persistently or recurrently reduced or absent and cause distress or interpersonal difficulties, the problem is known as hypoactive sexual desire disorder or inhibited sexual desire disorder.

    If you are approaching menopause (a time frame, typically in a woman's mid- to late 40s, known as perimenopause) or have reached menopause, declining estrogen levels can cause vaginal lubrication problems that make sex uncomfortable, and, as a result, less desirable to you. Changing hormone levels during and after pregnancy can also contribute to decreases in sexual desire. Talk with your health care professional about your problem and what treatment may be best for you.

  6. Does menopause mean the end of my sex life?

    No. Many women find the end of their reproductive years sexually invigorating because they no longer face the risk of pregnancy. Plus, regular sexual activity for postmenopausal women improves vaginal lubrication and elasticity after estrogen declines. However, menopause can bring bodily changes that contribute to arousal problems, and in turn, orgasm problems. Low estrogen levels can cause vaginal dryness, thinning of vaginal tissues, reduced blood flow to the genital area and reduced vaginal sensitivity. Postmenopausal women often find the arousal phase of the sexual response cycle takes longer or is less intense.

    Changing hormone levels also can produce mood swings and emotional upsets that make some women nearing menopause feel less interested in sex. Hormone replacement therapy relieves these symptoms for many perimenopausal women. Using over-the-counter vaginal lubricants may help with dryness problems. Discuss your treatment options with your health care professional, particularly the latest research regarding the safety of HT and ET and how the risks and benefits affect your personal health needs.

  7. I have pain during intercourse. Should I see my health care professional about it?

    Yes, especially if the pain is felt deep inside the vagina, lower back, pelvis, uterus or bladder. Pain associated with sexual activity can be a sign of a medical problem that needs treatment. Deep pain can be a sign of pelvic inflammatory disease, endometriosis, a pelvic tumor, ovarian cysts, bowel or bladder disease or scar tissue.

    Pain felt in the vagina can be caused by inflammation from an infection or sexually transmitted disease, but it is most commonly caused by lack of vaginal lubrication. Pain felt at the opening of the vagina can be a sign of infection, cysts or scarring. Such vulvar pain also can be caused by irritation from soaps or feminine hygiene products.

  8. What kinds of medications can cause sexual problems?

    Blood pressure, antipsychotic and certain antidepressant medications are commonly prescribed drugs that can interfere with the sexual response. Birth control pills change your hormone levels and can cause a decrease in desire or vaginal dryness.

    Anti-estrogen hormonal medications for breast cancer or drugs used to prevent recurrence of breast cancer, such as tamoxifen (Nolvadex), also can produce vaginal dryness and difficulties with vaginal penetration. Chemotherapy for cancer can impair many bodily functions and responses, including sexual desire and arousal. Anti-convulsants for seizures also can cause sexual problems.

Lifestyle Tips

  1. Be aware of the "silent" STD rampant in the United States

    If you are sexually active, ask your health care professional for a chlamydia test, even if you feel fine. Chlamydia, a sexually transmitted bacterial disease, is extremely common; more than one million people were diagnosed with the disease in 2007 alone, and women are three times more likely to contract chlamydia than men. The bacteria often infect the cells of the cervix. If not treated with antibiotics, the infection can spread to the uterus or fallopian tubes, causing pelvic inflammatory disease, which can lead to chronic pain, infertility and ectopic pregnancy.

    The best way to avoid chlamydia and other STDs is to abstain from sexual contact or to be in a long-term mutually monogamous relationship with a partner who is known to be STD-free. Male latex condoms can also help prevent chlamydia when used consistently and correctly. In addition, the Centers for Disease Control and Prevention (CDC) recommends annual chlamydia tests for all sexually active women age 25 or younger, older women with risk factors for chlamydia infection (those with a new sexual partner or multiple partners) and pregnant women.

  2. Use condoms to help prevent sexually transmitted diseases

    The consistent and correct use of latex condoms can help protect against sexually transmitted diseases (STDs). However, condoms do not provide complete protection against herpes or human papillomavirus (HPV) because the condom may not cover the herpes sore(s) or genital warts caused by these respective viruses, and viral shedding may nevertheless occur. If either you or your partner have genital herpes or HPV, it's best to abstain from sex when signs or symptoms of the infection are present and to use latex condoms between outbreaks.

  3. Realize that multiple factors can lead to sexual dysfunction

    If you are having persistent sexual difficulties, such as diminished sex drive, painful intercourse or inability to achieve orgasm, the cause could be physical, psychological, social, medication-induced or any combination thereof. For example, all of these factors can affect sexual functioning: acute or chronic diseases, including cancer and diabetes; hormonal changes; medications, including certain antidepressants, oral contraceptives and high blood pressure pills; alcohol and illicit drug abuse; stress or anxiety; and early sexual trauma. Medical and psychological evaluations may be necessary to pinpoint the source of your problem and determine an effective treatment.

  4. Talk out your sexual problems

    If physical causes of your sexual dysfunction have been ruled out or treated and you are still having problems, consider talk therapy with a psychotherapist who specializes in couples therapy. You can go alone or with your partner, and don't let embarrassment stop you; most of these mental-health professionals are used to talking to patients about their sexual lives. In therapy, you may gain a better understanding of relationship dynamics and background issues that may be influencing what happens in the bedroom.

  5. Protect against the human papillomavirus

    Human papillomavirus (HPV) is one of the most common causes of sexually transmitted disease in the world, with approximately 6.2 million new cases reported annually. At least 20 million Americans are already infected with HPV. Some but not all people with sexually transmitted HPV develop genital warts. About 30 types of HPV spread through sexual contact. Some types of HPV that cause genital infections can also cause cervical cancer and other genital cancers. There are several treatments for genital warts, including imiquimod (Aldara), an immune response cream that is applied to affected area. Today, there is also a vaccine available to prevent HPV infection in women. However, it should be given before a girl becomes sexually active.

    HPV screening is also an important part of preventing potential complications of the disease. The easiest way to screen for HPV is with a Pap test, which was designed to identify cervical cancer in its earliest stage but can also find abnormal and HPV cells.

    In conjunction with the Pap test, the HPV test can be used in women over age 30 to help detect HPV infection. When combined with a Pap test in women of this age group, the HPV test is better at identifying women at risk for developing cervical cancer than the Pap test alone.

Organizations and Support

Organizations and Support

For information and support on coping with Sexual Dysfunction, please see the recommended organizations, books and Spanish-language resources listed below.

American Association for Marriage and Family Therapy
Website: http://www.aamft.org
Address: 112 South Alfred Street, Suite 3000
Alexandria, VA 22314
Phone: 703-838-9808
Email:central@aamft.org

American Association of Sexuality Educators, Counselors and Therapists (AASECT)
Website: http://www.aasect.org
Address: P.O. Box 1960
Ashland, VA 23005
Phone: 804-752-0026
Email: aasect@aasect.org

American Psychological Association
Website: http://www.apa.org
Address: 750 First St., NE
Washington, DC 20002
Hotline: 1 -800-374-2721
Phone: 202-336-5500

American Society for Reproductive Medicine (ASRM)
Website: http://www.asrm.org
Address: 1209 Montgomery Highway
Birmingham, AL 35216
Phone: 205-978-5000
Email: asrm@asrm.org

Association for Behavioral and Cognitive Therapies (ABCT)
Website: http://www.aabt.org
Address: 305 7th Avenue, 16th Floor
New York, NY 10001
Phone: 212-647-1890

Association of Reproductive Health Professionals (ARHP)
Website: http://www.arhp.org
Address: 1901 L Street, NW, Suite 300
Washington, DC 20036
Phone: 202-466-3825
Email: arhp@arhp.org

Sexuality Information and Education Council of the United States (SIECUS)
Website: http://www.siecus.org
Address: 90 John Street, Suite 704
New York, NY 10038
Phone: 212-819-9770

Ever Since I Had My Baby: Understanding, Treating, and Preventing the Most Common Physical Aftereffects of Pregnancy and Childbirth
by Roger Goldberg

For Women Only: A Revolutionary Guide to Reclaiming Your Sex Life
by Dr. Jennifer Berman, Dr. Laura Berman, and Elisabeth Bumiller

Safe Encounters: How Women Can Say Yes to Pleasure and No to Unsafe Sex
by Kathryn Hall Ph.D.

The G Spot: And Other Discoveries About Human Sexuality
by Alice Khan Ladas, Beverly Whipple , and John D. Perry

The Science of Orgasm
by Barry R. Komisaruk , Carlos Beyer-Flores, and Beverly Whipple

Medline Plus: Sexual Health
Website: http://www.nlm.nih.gov/medlineplus/spanish/sexualhealth.html
Address: US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

American Academy of Family Physicians
Website: http://familydoctor.org/online/famdoces/home/women/reproductive/sex-dys/612.html
Email: http://familydoctor.org/online/famdoces/home/about/contact.html

Last date updated: 
Wed, 2009-08-19

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Last date updated: 2009-08-19