Female Sexual Problems

Female sexual problems include painful sex, difficulty reaching orgasm, and a lack of sexual desire.

Long considered a taboo subject, women's sexuality is now openly discussed and portrayed on television, in magazines, and on the Internet. Most importantly, women themselves are becoming increasingly aware of their sexuality and their sexual health. Women of all ages are learning more about their sexuality.

What is "sexuality"? For a woman, as for a man, sexuality encompasses a very broad range of physical activities and psychological experiences. These activities fulfill an important physical and emotional need for closeness and intimacy.

• Sexuality doesn't include just your sexual practices. Your feelings about yourself, how you relate to others, and about sex and previous sexual experiences are part of your sexual makeup.
• Your feelings about your partner and your relationship definitely affect your sexual satisfaction.
• Women's interest in sex and responses to sexual stimulation vary widely. Although most women's sexual responsiveness peaks in the late 30s and early 40s, a woman can have satisfying sexual experiences throughout her life.
• The quality of her experiences is affected by individual differences, by life situation, by age and hormonal levels, and by overall health and well-being.
• A sexual problem is anything that interferes with a woman's satisfaction with a sexual activity. When this happens, it is often referred to by health professionals as female sexual dysfunction (FSD).

Sexual response cycle

To understand why sexual problems occur, it is important to understand the sexual response cycle. This cycle is the same in both men and women, although at different rates and, obviously, with different physical changes. The cycle has four steps.

• Desire (excitement phase): Desire is a sexual "charge" that increases interest in and responsiveness to sexual activity. You feel "in the mood." Your heartbeat and breathing quicken, and your skin becomes reddened (flushes).
• Arousal (plateau phase): Sexual stimulation -- touch, vision, hearing, taste, smell, or imagination -- brings about further physical changes. Fluids are secreted within the vagina, moistening the vagina, labia, and vulva. These fluids provide lubrication for intercourse. The vagina expands, and the clitoris enlarges. The nipples become hardened or erect.
• Orgasm (climax): At the peak of arousal, the muscles surrounding the vagina contract rhythmically, causing a pleasurable sensation. This is often referred to as the sexual climax.
• Resolution: The vagina, clitoris, and surrounding areas return to their unaroused states. You feel content, relaxed, and possibly sleepy.

Every woman progresses through the cycle at her own rate, which is normal for her. A sexual problem may occur if any of these stages does not occur.

Sexual problems

The types of sexual problems in women correspond to the stages of the sexual response cycle. Inability to achieve any of the stages can interfere with sexual satisfaction and thus create a problem. Any of these can be very distressing for a woman because everyone deserves a satisfying sex life. They can be distressing for her partner, too, and can lead to problems in the relationship.

• The sexual problems reported by women commonly consist of three types:
  • Lack of sexual desire: Lack of interest in sex, or desire for sex, is a common problem in both men and women, but especially in women. Lack of desire stops the sexual response cycle before it starts. Lack of desire is temporary in some people and an ongoing problem in others.
  • Difficulties becoming sexually aroused or achieving orgasm: Inability to become sexually aroused is sometimes related to lack of desire. In other cases, the woman feels sexual desire but cannot become aroused. Orgasm may be delayed or not occur at all (anorgasmia). This can be very distressing for a woman who feels desire and becomes aroused. It can create a vicious cycle in which the woman loses interest in sex because she does not have an orgasm. It has been estimated that 7% to 10% of women suffer from some sort of orgasmic disorder.
  • Pain during intercourse: Pain during intercourse (dyspareunia) is not uncommon. Like other sexual problems, it can cause a woman to lose interest in sex.

The causes of sexual problems are as varied and complex as the human race. Some problems stem from a simple, reversible physical problem. Others can stem from more serious medical conditions, difficult life situations, or emotional problems. Still, others have a combination of causes. Any of the following can contribute to sexual problems:

• Relationship problems: Discord in other aspects of the relationship, such as distribution of labor, childrearing, or money, can cause sexual problems. Issues of control or even abuse in the relationship are especially harmful to sexual harmony. Such problems can prevent a woman from communicating her sexual wants and needs to her partner.
• Emotional problems: Depression, anxiety (about sex or other things), stress, resentment, and guilt can all affect a woman's sexual function.
• Insufficient stimulation: A woman's (or her partner's) lack of knowledge about sexual stimulation and response may prevent a woman from achieving a satisfactory experience. Poor communication between partners can also be a culprit here.
• Gynecologic problems: A number of pelvic disorders can cause pain in intercourse and thus decrease satisfaction.
  • Vaginal dryness: The most common reason for this in younger women is insufficient stimulation. In older women, the decrease in estrogen that occurs in perimenopause or menopause is the cause of vaginal dryness. Poor lubrication can also be linked to hormone imbalances and other illnesses and to certain medications. It can inhibit arousal or make intercourse uncomfortable.
  • Vaginismus: This is a painful spasm of the muscles surrounding the vaginal opening that causes the vaginal opening to "tighten." It can prevent penetration or make penetration extremely painful. Vaginismus can be caused by injuries or scars from surgery, abuse, or childbirth, by infection, or by irritation from douches, spermicides, or condoms. It can also be caused by fear.
  • Sexually transmitted diseases: Gonorrhea, herpes, genital warts, chlamydia, and syphilis are infectious diseases spread by sexual contact. They can cause changes in the genitals that make sex uncomfortable or even painful.
  • Vaginitis: Inflammation and irritation of vaginal tissues due to infection or other causes can make intercourse uncomfortable or painful.
  • Endometriosis, pelvic mass, ovarian cyst, surgical scars: Any of these can cause an obstruction or anatomical changes that prevent intercourse or make it difficult or painful.
  • Pelvic inflammatory disease: This is an infection of the vagina that moves up into the cervix, uterus, and ovaries. It can be very painful on its own and make intercourse extremely painful.
  • Nerve damage after surgery: Unavoidable cutting of small nerves during pelvic surgery (such as hysterectomy) may decrease sensation and response.
• Physical conditions: Many physical or medical conditions can decrease a woman's satisfaction with her sex life.
  • Tiredness (fatigue)
  • Chronic diseases such as diabetes, heart disease, liver disease, kidney disease
  • Cancer
  • Neurologic disorders
  • Vascular (blood flow) disorders
  • Hormonal imbalances
  • Menopause
  • Pregnancy
  • Alcohol or drug abuse
• Medications: Certain medications can reduce desire or arousal. One well-known group of drugs that have this effect are the selective serotonin-reuptake inhibitor (SSRI) group of antidepressants, which includes drugs such as Prozac and Zoloft. Others include certain chemotherapy drugs, drugs for high blood pressure, and antipsychotic medications.
• Other medical treatments: Treatments such as radiation therapy for certain types of cancer can reduce vaginal lubrication. They can also make skin and the membranes lining the genitals tender and sensitive.
• History of abuse: A woman who has suffered sexual or other abuse may have trouble trusting her partner enough to relax and become aroused. She may have feelings of fear, guilt, or resentment that get in the way of a satisfactory experience, even if she cares deeply about her current partner.
• Attitudes toward sex: Many people, either because of the way they were brought up or because of earlier bad experiences, don't view sex as a normal and enjoyable part of a couple's relationship. They may associate sex or sexual feelings with shame, guilt, fear, or anger. On the other hand are people who have unrealistic expectations about sex. Portrayals of sex in television and movies as always easy and fantastic mislead some people into believing that is how it is in real life. These people are disappointed or even distressed when sex is sometimes not earth-shattering or when a problem occurs.
• Sexual problems of the partner: If a woman's partner has sexual problems, such as impotence or lack of desire, this can inhibit her own satisfaction.

Not all sexual problems require medical attention. Many people have temporary sexual problems, usually due to medical problems, anxiety, or stress in another area of life. If you are distressed by the problem or you are afraid your relationship is threatened, don't be afraid or embarrassed to seek outside help. If your health care professional is unable to help you beyond ruling out physical problems, a mental health counselor should be able to help or point you in the right direction.

Any sexual problem that persists for more than a few weeks is worth a visit to your doctor. He or she can rule out medical or medication causes of the problem and can offer advice on solving other types of problems. He or she can help you sort out exactly what the problem is if you aren't sure. He or she can refer you to other specialists if necessary: a psychotherapist, a marriage counselor, or a sex therapist.

Certain problems require attention right away.

• If intercourse suddenly becomes painful when it wasn't before, for example, you may have an infection or other medical condition that requires prompt attention.
• If you have reason to believe you have a sexually transmitted disease, you and your partner both need to be treated right away, as do any other sexual partners either of you may have.
• Any unusual reaction to sexual activity, such as headache, brief chest pain, or pain elsewhere in the body, also warrants a visit to your health care professional.

Evaluation for a sexual problem will start with an extensive medical interview. Be sure to tell your health care professional about any medical or mental illnesses and surgeries you have or have had in the past and any medications you take, including over-the-counter medications, herbs, and supplements.

A complete physical examination also will be done. Depending on the type of problem you are having, your health care professional may choose to include a pelvic examination or may refer you to a gynecologic specialist for that part of the examination. For certain other types of problems, consultation with other specialists may be needed.

In most cases lab tests are not needed, although your health care professional may request tests to rule out certain conditions. You may have blood drawn to check hormone levels. X-rays and other radiology tests are needed only in unusual circumstances.

Treatment for sexual problems varies depending on the type of problem. Sometimes no treatment is required.

Treatment is not needed for all sexual problems. Some problems can be solved by you and your partner alone with a little openness and creativity.

• Some problems go away by themselves over time -- patience and understanding are all that is required.
• Sometimes talking the problem out with your partner is enough. Women who learn to tell their partners about their sexual needs have a better chance of having a satisfying sex life.
• Try to make the solution is fun -- think up ways to inject a little romance and excitement into your sexual routine.

Some strategies women use to overcome sexual problems:

• Set aside time to be alone or alone with your partner, without children and other distractions.
• Use erotic videos or books to increase stimulation.
• Masturbate to learn about what increases your arousal.
• Fantasize about what arouses you sexually; if appropriate, tell your partner about these fantasies.
• Use sensual massage and other forms of touch.
• Try new sexual positions or scenarios.
• Use relaxation techniques such as a warm bath before having sex.
• Use a vaginal lubricant to relieve arousal problems due to vaginal dryness.

Several excellent books are available in mainstream bookstores or from mail-order sources to help couples deal with sexual and communication problems. Many people prefer this "do-it-yourself" method to talking about these problems with an outsider.

If the sexual problem is caused by a medical or physical problem, your health care professional or consulting specialist will suggest an appropriate treatment plan. This will vary, of course, depending on the nature of the problem. The plan may include medication, lifestyle changes, or surgery. Your health care professional may recommend counseling even if the problem is physical.

Effective therapies are readily available for some physical problems.

• Vaginal lubricants: These products are highly recommended for women with vaginal dryness. They can be bought in a drugstore without a prescription. They are available as creams, gels, or suppositories. Water-based products are the best choices. Oil-based products such as petroleum jelly, mineral oil, or baby oil can interact with latex condoms and cause them to break.
• Topical estrogen: These products can help make sex more comfortable for menopausal women with vaginal dryness or sensitivity. Estrogen is applied as a cream or vaginal insert. These products are available by prescription and are very effective for some women.
• Clitoral therapy device: The Eros clitoral therapy device has been approved by the U.S. Food and Drug Administration (FDA) to treat women with disorders of sexual arousal. The device consists of a small suction cup, which is placed over the clitoris before sex, and a small, battery-operated vacuum pump. The gentle suction provided by the vacuum pump draws blood into the clitoris, increasing pressure on the clitoral nerve. This device increases lubrication, sensation, and even the number of orgasms in many women who have used it. The device is available by prescription.
• Drugs: Sildenafil (Viagra) is the well-known "erection drug" for men. It is used to treat erectile dysfunction, a common sexual problem among men. No similar drug is yet available for women. The effects of Viagra in women have been studied, but the results are not conclusive. In some studies, the drugs helped with arousal problems, but in other important studies, they did not. The drug has the same side effects in women as in men, including headache, flushing, nasal congestion and irritation, abnormal vision, and stomach upset. It can worsen retinitis pigmentosa, a hereditary degenerative disease affecting the eye. Most importantly, it can cause dangerously low blood pressure and has been linked to unexplained heart attacks in men. Viagra cannot be taken by people who take a nitrate drug for a heart condition, because the combination can be deadly.
• Bupropion (Wellbutrin) is an antidepressant drug that has been used to treat certain cases of orgasmic disorders, and preliminary studies have confirmed its effectiveness in some patients. More research is needed to fully clarify the potential therapeutic role of bupropion in the management of female sexual disorders in general.

Hormone therapy (HT), formerly referred to as hormone replacement therapy (HRT): HT has been used to relieve symptoms of menopause for years.

• It comes in two forms, estrogen-only and combination estrogen-progestin, a synthetic form of the hormone progesterone. Estrogen generally is used for women who have had a hysterectomy, while HRT is used for women who still have their uterus because the progestin protects the uterus from the effects of too much estrogen, especially uterine cancer.
• For many years, HRT was believed to have many beneficial effects for menopausal women, continuing the protective effect that estrogen provides naturally before menopause. These benefits were thought to include protecting against heart disease, high cholesterol, colon cancer, Alzheimer's disease, and osteoporosis. New research findings published in 2002 called these beliefs into question. Long-term use of HT was linked to significantly higher risks of breast cancer, heart attack, stroke, blood clots (from one kind of HT), and ovarian cancer (from estrogen therapy). The research did show that HT protects against osteoporosis and colon cancer, but the risks are considered to outweigh the benefits.
• HRT can be very effective in some women in relieving vaginal dryness and discomfort during intercourse, as well as "vasoactive" symptoms such as "hot flashes" and sleep problems.
• Most experts believe that short-term use of HT for treatment of menopausal symptoms is safe; it is recommended that women who choose to take HT do so for the shortest period of time possible and at the lowest effective dose.
• Each woman's need for HT and risks in taking HT is unique to her. These should be discussed in detail with your health care professional.
• The use of HT in menopausal women is now considered on a case-by-case basis.

Psychotherapy

If the problem is one of lack of knowledge, your health care professional or a sex therapist can teach you (and your partner) about the sexual response cycle and the elements of sexual stimulation. Armed with this new knowledge, many couples can go forward on their own.

Psychotherapy can help a woman identify problems in her life that may be expressed as sexual problems.

• For some women, these problems are fairly clear, including past sexual or other abuse, rape, or traumatic sexual encounters.
• For others, the problems may be less clear-cut, involving unresolved emotional issues or dissatisfaction with other areas of life.
• In either case, the therapist usually focuses on resetting the woman's attitudes toward sex.
• The goal is to get rid of old attitudes that got in the way of enjoyable sex, establishing new attitudes that increase sexual responsiveness.

If the problem relates to your relationship, couples counseling is recommended.

The couples therapist is trained and experienced at helping couples recognize, understand, and solve their problems.

• First, the counselor explores the relationship to find the trouble spots.
• The counselor will recommend exercises and activities that will improve the couple's communication and trust.
• If that can be accomplished, often the sexual problem can be solved more easily.

Sex therapy

A sex therapist may take couples therapy one step further by focusing on the couple's physical relationship. After identifying the couple's attitudes about sex and the sexual problem, the sex therapist recommends specific exercises to refocus the couple's attention and expectations. Specific objectives may include any of the following:

• Learning to relax and eliminate distractions
• Learning to communicate positively what you would like
• Learning nonsexual touching techniques
• Increasing or enhancing sexual stimulation
• Minimizing pain during intercourse

Sex therapists often use what are called "sensate focus" exercises to treat sexual problems. The exercises start with nonsexual touching and encourage both partners to express how they like to be touched. The goal is to help both partners understand how to recognize and communicate their preferences.

Sex therapists can recommend exercises to help with vaginismus.

• One successful technique is the use of Kegel exercises. Many women are familiar with these from their childbirth education classes. Kegel exercises involve voluntary contraction and relaxation of the muscles around the opening of the vagina.
• Some women have been helped by using dilators to relax the vaginal spasms. A small dilator is placed in the vagina for 10 minutes, then removed. Larger dilators are used over time to train the vaginal muscles. Kegel exercises may improve the chance of success with this technique.

Group therapy or a support group may be very helpful for a woman. There she can discuss her problems with others who share them. Women often gain insight and practical solutions from these groups, as well as greater confidence from knowing she is not alone. Couples groups also can be very helpful if both partners are willing. A sex therapist usually recommends such a group if he or she thinks it would be helpful.

Surgery is indicated only for very specific physical problems that impede enjoyable sexual activity, including tumors and cysts.

The most important thing you can do to prevent or recover from sexual problems is to communicate openly and honestly with your partner.

Adopt a healthy lifestyle to promote overall well-being. This will increase your confidence and self-esteem, which will, in turn, increase your interest in sex and your responsiveness.

• Eat a healthy diet.
• Don't use tobacco.
• Get active physically for at least 30 minutes every day.
• Get plenty of rest.
• Keep stress under control.
• If you drink alcohol, do so in moderation.
• Have regular recommended health screenings, such as Pap tests and mammograms.

Some sexual problems resolve naturally with time or with changes in life situation. Most, however, do not. Ignoring persistent sexual problems does not make them go away. Ongoing sexual problems lead to resentment and problems in the relationship.

The outlook for sexual problems depends on the cause of the problem. Problems due to reversible or treatable medical conditions often resolve with appropriate treatment. Some mild problems caused by anxiety, stress, or relationship problems can improve with counseling, education, and improved communication.

American Association for Marriage and Family Therapy
112 South Alfred St.
Alexandria, VA 22314
703-838-9808

American Association of Sex Educators, Counselors, and Therapists
P.O. Box 5488
Richmond, VA 23220-0488