Sexual Dysfunction

A woman's sexuality is a complex interplay of physical and emotional responses that affects the way she thinks and feels about herself. A sexual problem can hurt her personal relationships and her self-esteem. Yet, many women hesitate 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 needlessly suffer in silence when their problems could be treated.

Women can experience a variety of sexual problems, such as lack of desire, difficulty becoming aroused or having an orgasm or having pain during sex. When a physical or emotional problem persists, it's time to contact a health care professional.

For the first time, there's even a drug approved by the U.S. Food and Drug Administration to treat low sexual desire in women. Flibanserin (brand name Addyi) was approved in 2015 for premenopausal women who do not have underlying physical or psychological causes for their disorder. Reports are encouraging on the drug's results so far.

Just as there are many types of sexual health problems, there is a range of sexual activity. Intimate activities include 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.

Research on the sexual response in the mid-1960s by Masters and Johnson established what is known as the traditional linear sexual-response cycle: excitement/arousal, plateau, orgasm and 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.

More contemporary research suggests that a woman's sexual response is more complex, varied and less linear than this model suggests, particularly when the woman is involved in a long-term relationship. In 2002, Rosemary Basson, MD, a psychiatrist and expert in sexual medicine, introduced a new cycle for the female sexual response that reflects the nonlinear nature of the sexual response and in particular the concept of responsive desire.

The variability among women and the multiple factors impacting a woman's sexual function are important to understanding 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 as much to relationship and intimacy as to physical needs, and that variability does not always equate to being "dysfunctional."

In addition, it's important to recognize the concept of responsive desire. That is, the sexual response does not always follow the order of desire then arousal. Many women may become aroused without much desire as a result of engaging in sexual stimulation. Once sexually aroused, desire is then kindled. The overlap of desire and arousal is now reflected in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which has combined the previously separate disorders of "hypoactive sexual desire disorder" and "female sexual arousal disorder" into "female sexual interest and arousal disorder."

Sexual dysfunctions are disturbances in one or more of the sexual response cycle's phases or pain associated with sexual activity. An estimated 43 percent of women in the United State experience a sexual problem, and 22 percent experience sexually related personal distress, according to the PRESIDE study, published in 2008 in Obstetrics and Gynecology journal. According to that 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
• suffering from a thyroid condition
• dealing with urinary incontinence

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:

• 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
• fatigue

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

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 32 percent of women lacked interest in sex for at least a few months in the previous year.

Sexual response is very individual, and different women feel different degrees of sexual response at different times in their lives. Women in their 50s have about half the testosterone they had in their 20s, causing reduced sexual response. 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, the highest prevalence of sexual problems with distress is in women aged 45 to 64.

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.

Sexual Problems

There are three major classifications of female sexual problems, as defined by the DSM-5. They are:

Female sexual interest/arousal disorder occurs when sexual fantasies or thoughts and desire for sexual activity are persistently reduced or absent and/or a woman is unable to experience adequate sexual arousal causing distress or relationship difficulties. Often, a woman's sexual desire is affected by her 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. But when disinterest persists and causes problems, it is classified as a disorder.

Female orgasmic disorder refers to the persistent absence or recurrent delay in orgasm after sufficient stimulation and arousal, causing personal distress. About one in three women have problems reaching orgasm.

Never having an orgasm, or not having one in certain situations, are problems that can sometimes 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.

Genito-pelvic pain/penetration disorder refers to pain during or after intercourse. Also called dyspareunia, this disorder occurs in nearly two out of three women at some time during their lives, according to The American College of Obstetricians and Gynecologists. 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.

Persistent genital arousal disorder (PGAD) refers to persistent or recurrent distressing feelings of genital arousal or being on the verge of orgasm not associated with concomitant sexual interest, thoughts or fantasies for greater than six months. This disorder is not included in the DSM-5 and can affect both men and women. It is extremely distressing and thoughts of suicide are common.

There are multiple causes of PGAD, and the syndrome is not well understood. There is typically a perception of increased genital engorgement and sensitivity, which may be from a foreign body under the clitoral prepuce, pathology in the nerve enervating the clitoris or impingement on that nerve at the level of the spine from a bulging disc or a Tarlov cyst. It is sometimes concomitant with restless leg syndrome or overactive bladder.

Treatment of PGAD is directed at reducing or eliminating the increased stimulation to the nerves, which are misinterpreted by the brain as sexual stimulation. Oral medicines, such as tramadol or varenicline, are sometimes helpful, while physical therapy or TENS units are also sometimes used. Referral to a center familiar with spinal surgical procedures is sometimes necessary when there is impingement on nerves.

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 vulvar and/or pelvic exam and blood tests.

Given the biopsychosocial nature of sexual problems, even if there is a biological cause, the psychological impact can still be significant, and you may be referred for psychological counseling. If you are not offered a referral, feel free to ask for 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 International Society for the Study of Women's Sexual Health, the Society for Sex Therapy and Research or the American Association of Sexuality Educators, Counselors and Therapists.

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. Because topical estrogen is often contraindicated in these women, vaginal massage with the use of vaginal moisturizers or coconut oil can be very helpful and improve blood flow.

• 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 can be 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. The vaginal dryness and thinning associated with breastfeeding can be treated safely with small amounts of a topical estrogen cream.

• 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.

• Infertility

  Infertile couples trying to get pregnant often complain that sex becomes goal-directed and less pleasure focused.

• 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, certain skin conditions, or infections.

• Vulvodynia

  Vulvar pain that occurs without identifiable pathology is referred to as vulvodynia and may be present in as many as 25 percent of women during their lifetime. It can be localized to the vaginal opening (vestibulitis) or the clitoris or can involve the entire vulva. There are multiple contributing causes, often occurring together to create this syndrome. There is a sometimes a nerve-cell proliferation on the vulva that causes the hypersensitivity. This hypersensitivity and pain commonly leads to pelvic floor muscle tightness, which in turn, increases the pain and leads to a vicious cycle of pain and increased muscle dysfunction. The syndrome occurs more frequently in women with a personal or family history of other types of pain syndromes involving a "sensitive nervous system" such as migraine headaches, fibromyalgia, irritable bowel syndrome or interstitial cystitis.

  Treatment of vulvodynia may involve several connected approaches, including pelvic floor physical therapy, topical or systemic medications to treat nerve sensitivity, and hormonal treatments to improve tissue thickness and integrity. It is important to also aggressively treat any other contributing cause of pain such as yeast infections or reactions to soaps or pads. Some women with vulvodynia have been found to be extremely sensitive to very low levels of yeast. Surgical approaches have also been very effective, as have nerve blocks or botulinum toxin injections into the pelvic floor muscles.

• Vaginismus

  Vaginismus is an old term still commonly used to refer to involuntary muscle contractions around the opening of the vagina, in the pelvic floor muscles. The diagnosis is often given to women who additionally have a strong fear of vaginal penetration. Many women with vaginismus have a chronically tight pelvic floor, which causes pain with any vaginal penetration and often occurs with vulvodynia. This condition has many effective treatments, including vaginal dilators, pelvic floor physical therapy, biofeedback and botulinum toxin injections. Oral medications for pain and anxiety are sometimes helpful.

• Vaginal pain

  This type of pain is felt inside the vagina. Pain can be caused by a lack of lubrication from inadequate arousal, medications, medical conditions, pregnancy, breastfeeding or menopause. The pelvic floor muscles surrounding the lower third of the vagina are often tight and are a very common cause of vaginal pain. 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.

• 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 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.

Vibrators are increasingly recommended by medical professionals and come in many types. They can be used independently or as part of partnered sex. They can be used to treat orgasmic disorders where orgasm is first achieved with a vibrator or masturbation and then bridged to a partner. The vibrator facilitates arousal, which improves genital blood flow leading to improved tissue elasticity and responsiveness.

Medical Treatment

• FlibanserinFlibanserin (brand name Addyi) is the first drug approved by the U.S. Food and Drug Administration to treat low sexual desire among premenopausal women. The prescription drug was approved in 2015 for women who do not have underlying physical or psychological causes for their disorder. Women who take the once-daily drug for eight weeks and see no improvement are advised to discontinue use. Women who use it are also advised to avoid alcohol. The most common adverse effects in clinical trials were dizziness, sleepiness, nausea, fatigue, insomnia and dry mouth.
• Lubricating creams, gels or suppositoriesIf 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. Coconut oil is a commonly used lubricant and may be safely used for daily vulvar comfort. It is mildly anti-inflammatory and can improve the skin's barrier function, which is disrupted by thinning in menopause or use of soaps. Do not use oil-based products, such as petroleum jelly, baby oil or mineral oil with latex condoms because they can cause a condom break.
• Hormonal treatments for vaginal symptoms of menopause (now called genito-urinary syndrome of menopause or GSM)For menopausal women with vaginal thinning, dryness or insensitivity, your health care professional may prescribe a topical estrogen cream such as Estrace or Premarin, or a vaginal ring, such as Estring, to ease sexual discomfort. A vaginal tablet (Vagifem or Yuvafem) containing estradiol, a type of estrogen, is also available by prescription for vaginal dryness. Small amounts of cream can also be used vaginally and inserted with a finger if the applicator is cumbersome to use. It is critical that estrogen be applied to the vaginal opening for sexual comfort because low dose vaginal methods do not affect that area, and the area frequently contracts from lack of estrogen and leads to pain. Estrogen cream can also be applied to the clitoris for improved sensitivity. Low dose vaginal estrogen such as the Estring, the estradiol tablet or tiny amounts of cream are not considered systemic estrogen treatment and are associated with far lower risks of blood clots or other estrogen related risks.Ospemifene is an oral medication with estrogenic effects on the vagina and is FDA-approved in the United States for the treatment of GSM. It has stronger effects on the vaginal tissue and minimal effects on the lining of the uterus.Intrarosa is a vaginal suppository with the hormone dehydroepiandrosterone, or DHEA, also approved by the FDA for menopausal atrophy, which offers similar effects to estrogen in the vagina as well as into deeper layers of the vaginal wall.Laser-based treatments are performed in a medical office and treat vulvar and vaginal tissue by creating shallow tiny perforations in the tissue, which heal with improved thickness and elasticity. This new technology is promising, especially for women who cannot use estrogen.
• Hormone therapyFor 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 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. However, a position statement by the North American Menopause Society in 2017 modifies this advice and notes that starting systemic estrogen therapy in the first 10 years after menopause might be significantly safer with potential benefits outweighing risks.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.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. Studies have found conflicting results regarding the risk of breast cancer in women using testosterone. The use of testosterone in men and women is highly controversial, so be sure to discuss with your health care professional whether androgen supplements are right for you.

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.

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, lovemaking at different times of 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.

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 partnerEmotional 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 desiresTell 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 experiencesPartners 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 prioritiesDon'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 menopauseRegular 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.

1. Sexual problems occur in approximately 40 percent of women in the United States.
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, 32 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.
4. About one in three women have problems reaching orgasm.
5. Pain during or after intercourse occurs in nearly three out of four 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. An extremely common cause of pain with sex is lack of arousal, which causes pain because of a lack of lubrication and failure of the engorgement of erectile tissue in the clitoris and surrounding the vaginal opening. Additionally, the uterus might be more painful with lack of arousal because it elevates in the aroused state.
8. It is common for women who breastfeed to notice a lack of vaginal lubrication and sexual interest caused by a lack of estrogen, caused by elevation of the hormone prolactin, which itself 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.

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 to minimize 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?

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: https://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: https://www.aasect.org
Address: P.O. Box 1960
Ashland, VA 23005
Phone: 804-752-0026
Email: aasect@aasect.org

American Psychological Association
Website: https://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: https://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: https://www.abct.org
Address: 305 7th Avenue, 16th Floor
New York, NY 10001
Phone: 212-647-1890

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

Books

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

Spanish-language resources

Medline Plus: Sexual Health
Website: https://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: https://familydoctor.org/online/famdoces/home/women/reproductive/sex-dys/612.html
Email: https://familydoctor.org/online/famdoces/home/about...