A sexual problem, or sexual dysfunction, refers to a problem during any phase of the sexual response cycle that prevents the individual or couple from experiencing satisfaction from the sexual activity. The sexual response cycle has four phases: excitement, plateau, orgasm, and resolution.
While research suggests that sexual dysfunction is common (43% of women and 31% of men report some degree of difficulty), it is a topic that many people are hesitant or embarrassed to discuss. Fortunately, most cases of sexual dysfunction are treatable, so it is important to share your concerns with your partner and doctor.
Persistent, recurrent problems with sexual response, desire, orgasm or pain — that distress you or strain your relationship with your partner — are known medically as female sexual dysfunction.
Many women experience problems with sexual function at some point. Female sexual dysfunction can occur at any stage of life. It can be lifelong or be acquired later in life. It can occur only in certain sexual situations or in all sexual situations.
Sexual response involves a complex interplay of physiology, emotions, experiences, beliefs, lifestyle and relationships. Disruption of any component can affect sexual desire, arousal or satisfaction, and treatment often involves more than one approach.
What Causes Sexual Dysfunction?
Sexual dysfunction can be a result of a physical or psychological problem.
- Physical causes. Many physical and/or medical conditions can cause problems with sexual function. These conditions include diabetes, heart disease, neurological diseases, hormonal imbalances, menopause plus such chronic diseases as kidney disease or liver failure, and alcoholism or drug abuse. In addition, the side effects of certain medications, including some antidepressant drugs, can affect sexual desire and function.
- Psychological causes. These include work-related stress and anxiety, concern about sexual performance, marital or relationship problems, depression, feelings of guilt, or the effects of a past sexual trauma.
Your symptoms will depend on the type or types of female sexual dysfunction you have:
- Low sexual desire. This most common of female sexual dysfunctions involves a lack of sexual interest and willingness to be sexual.
- Sexual arousal disorder. Your desire for sex might be intact, but you have difficulty with arousal or are unable to become aroused or maintain arousal during sexual activity.
- Orgasmic disorder. You have persistent or recurrent difficulty in achieving orgasm after sufficient sexual arousal and ongoing stimulation.
- Sexual pain disorder. You have pain associated with sexual stimulation or vaginal contact.
Pain during sex
Pain during sex – also called dyspareunia – can be a result of vaginismus.
Vaginismus is when muscles in or around the vagina go into spasm, making sexual intercourse painful or impossible. It can be very upsetting and distressing.
It can occur if the woman associates sex with pain or being “wrong”, or if she’s had vaginal trauma, such as childbirth or an episiotomy.
It can also stem from relationship problems, fear of pregnancy, or painful conditions of the vagina and the surrounding area.
It can be treated by focusing on sex education, counselling and using vaginal trainers, also known as vaginal dilators.
Vaginal trainers are cylindrical shapes that are inserted into the vagina. A woman will gradually use larger sizes until the largest size can be inserted comfortably. Some women may wish to try using their fingers instead.
Sex after menopause
Pain during sex is common after the menopause as oestrogen levels fall and the vagina feels dry.
This can affect a woman’s desire for sex, but there are lubrication creams that can help. Ask your GP or pharmacist.
Find out more about sex after menopause.
Female genital mutilation
Women who have experienced female genital mutilation (FGM) can find it difficult and painful to have sex.
FGM is where the female genitals are deliberately cut, injured or changed, but there is no medical reason for this to be done.
It can also result in reduced sexual desire and a lack of pleasurable sensation.
Talk to your GP or another healthcare professional if you have sexual problems that you feel may be the result of FGM, as they can refer you to a therapist who can help.
Who Is Affected by Sexual Dysfunction?
Both men and women are affected by sexual dysfunction. Sexual problems occur in adults of all ages. Among those commonly affected are older adults, and they may be related to a decline in health associated with aging.
How Does Sexual Dysfunction Affect Women?
The most common problems related to sexual dysfunction in women include:
- Inhibited sexual desire. This involves a lack of sexual desire or interest in sex. Many factors can contribute to a lack of desire, including hormonal changes, medical conditions and treatments (for example, cancer and chemotherapy), depression, pregnancy, stress, and fatigue. Boredom with regular sexual routines also may contribute to a lack of enthusiasm for sex, as can lifestyle factors, such as careers and the care of children.
- Inability to become aroused. For women, the inability to become physically aroused during sexual activity often involves insufficient vaginal lubrication. This inability also may be related to anxiety or inadequate stimulation. In addition, researchers are investigating how blood flow problems affecting the vagina and clitoris may contribute to arousal problems.
- Lack of orgasm (anorgasmia). This is the absence of sexual climax (orgasm). It can be caused by a woman’s sexual inhibition, inexperience, lack of knowledge, and psychological factors such as guilt, anxiety, or a past sexual trauma or abuse. Other factors contributing to anorgasmia include insufficient stimulation, certain medications, and chronic diseases.
- Painful intercourse. Pain during intercourse can be caused by a number of problems, including endometriosis, a pelvic mass, ovarian cysts, vaginitis, poor lubrication, the presence of scar tissue from surgery, or a sexually transmitted disease. A condition called vaginismus is a painful, involuntary spasm of the muscles that surround the vaginal entrance. It may occur in women who fear that penetration will be painful and also may stem from a sexual phobia or from a previous traumatic or painful experience
How Is Female Sexual Dysfunction Diagnosed?
To diagnose female sexual dysfunction, the doctor likely will begin with a physical exam and a thorough evaluation of symptoms. The doctor may perform a pelvic exam to evaluate the health of the reproductive organs and a Pap smear to detect changes in the cells of the cervix (to check for cancer or a pre-cancerous condition). He or she may order other tests to rule out any medical problems that may be contributing to the woman’s sexual dysfunction.
An evaluation of your attitudes regarding sex, as well as other possible contributing factors (such as fear, anxiety, past sexual trauma/abuse, relationship problems, or alcohol or drug abuse) will help the doctor understand the underlying cause of the problem and make appropriate treatment recommendations.
Female sexual dysfunction can be subdivided into desire, arousal, orgasmic and sexual pain disorders. Sexual pain disorders include dyspareunia and vaginismus.
Estimates of the number of women who have sexual dysfunction range from 19 to 50 percent in “normal” outpatient populations and increase to 68 to 75 percent when sexual dissatisfaction or problems (not dysfunctional in nature) are included. Yet, one review of physicians’ chart notes revealed a recorded sexual problem in only 2 percent. In another review, physician inquiry of patients in a gynecologic office setting about sexual problems increased reported complaints about sexual dysfunction sixfold. This discrepancy demonstrates a need for physician education in this area.
The diagnosis of female sexual dysfunction requires the physician to obtain a detailed patient history that defines the dysfunction, identifies causative or confounding medical or gynecologic conditions, and elicits psychosocial information. Preappointment questionnaires or appointments at which only the history is taken allow patient-physician communication to be unhindered by time constraints or patient fears of an upcoming physical examination.
Establishment of the patient’s sexual orientation is necessary for appropriate evaluation and management. Nonjudgmental, direct questions best achieve this goal. Because gender identity conflicts are often a cause of sexual dysfunction, the mode and type of questions asked by physicians should create an environment where patients may openly express their concerns. Specialized counseling is important for these patients.
The sexual dysfunction should be defined in terms of onset and duration and situational versus global effect. A situational dysfunction occurs with a specific partner, in a certain setting or in a definable circumstance.
The presence of more than one dysfunction should be ascertained, because considerable interdependence may exist. For example, a patient complaining about decreased desire might have a primary orgasmic disorder from insufficient stimulation, with decreased desire developing secondarily as a result of unsatisfying sexual encounters Thus, treating the orgasmic disorder would indirectly enhance desire; whereas, treating a desire disorder would be unsuccessful and perhaps add to patient frustration and perpetuate the cycle of dysfunction.
How Is Female Sexual Dysfunction Treated?
The ideal approach to treating female sexual dysfunction involves a team effort between the woman, doctors, and trained therapists. Most types of sexual problems can be corrected by treating the underlying physical or psychological problems. Other treatment strategies focus on the following:
- Providing education.Education about human anatomy, sexual function, and the normal changes associated with aging, as well as sexual behaviors and appropriate responses, may help a woman overcome her anxieties about sexual function and performance.
- Enhancing stimulation. This may include the use of erotic materials (videos or books), masturbation, and changes in sexual routines.
- Providing distraction techniques. Erotic or non-erotic fantasies; exercises with intercourse; music, videos, or television can be used to increase relaxation and eliminate anxiety.
- Encouraging non-coital behaviors. Non-coital behaviors (physically stimulating activity that does not include intercourse), such as sensual massage, can be used to promote comfort and increase communication between partners.
- Minimizing pain. Using sexual positions that allow the woman to control the depth of penetration may help relieve some pain. Vaginal lubricants can help reduce pain caused by friction, and a warm bath before intercourse can help increase relaxation.
Can Female Sexual Dysfunction Be Cured?
The success of treatment for female sexual dysfunction depends on the underlying cause of the problem. The outlook is good for dysfunction that is related to a treatable or reversible physical condition. Mild dysfunction that is related to stress, fear, or anxiety often can be successfully treated with counseling, education, and improved communication between partners.
How Do Hormones Affect Female Sexual Dysfunction?
Hormones play an important role in regulating sexual function in women. With the decrease in the female hormone estrogen that is related to aging and menopause, many women experience some changes in sexual function as they age, including poor vaginal lubrication and decreased genital sensation. Research suggests that low levels of the male hormone testosterone also contribute to a decline in sexual arousal, genital sensation, and orgasm. Researchers still are investigating the benefits of hormones and other medications, including drugs like Viagra, to treat sexual problems in women.
What Effect Does a Hysterectomy Have on Female Sexual Dysfunction?
Many women experience changes in sexual function after a hysterectomy (surgical removal of the uterus). These changes may include a loss of desire, and decreased vaginal lubrication and genital sensation. These problems may be associated with the hormonal changes that occur with the loss of the uterus. Furthermore, nerves and bloodvessels critical to sexual function can be damaged during the surgery.
How Does Menopause Affect a Female Sexual Dysfunction?
The loss of estrogen following menopause can lead to changes in a woman’s sexual functioning. Emotional changes that often accompany menopause can add to a woman’s loss of interest in sex and/or ability to become aroused. Hormone replacement therapy (HRT) or vaginal lubricants may improve certain conditions, such as loss of vaginal lubrication and genital sensation, which can create problems with sexual function in women. Also, an oral drug taken once a day, ospemifene (Osphena), makes vaginal tissue thicker and less fragile.
It should be noted that some postmenopausal women report an increase in sexual satisfaction. This may be due to decreased anxiety over getting pregnant. In addition, postmenopausal woman often have fewer child-rearing responsibilities, allowing them to relax and enjoy intimacy with their partners.
When Should I Call my Doctor About Sexual Dysfunction?
Many women experience a problem with sexual function from time to time. However, when the problems are persistent, they can cause distress for the women and her partner, and can have a negative impact on their relationship. If you experience any of these problems, see your doctor for evaluation and treatment.
Treatment varies by disorder and cause; often, more than one treatment is required because disorders overlap. Sympathetic understanding of the patient and careful evaluation may themselves be therapeutic. Contributing factors are corrected if possible. Mood disorders are treated. Explaining what is involved in the female sexual response may also help.
Because SSRIs may contribute to several categories of sexual dysfunction, switching to an antidepressant that has fewer sexual adverse effects (eg, bupropion, moclobemide, mirtazapine, duloxetine) may be considered. Alternatively, some evidence suggests that adding bupropion to an SSRI may help.
Psychologic therapies are the mainstay of treatment. Cognitive-behavioral therapy targets the negative and often catastrophic self-view resulting from illness (including gynecologic disorders) or from infertility.
Mindfulness, an eastern practice with roots in Buddhist meditation, may help. It focuses on nonjudgmental awareness of the present moment. Its practice helps free women from distractions that interfere with attention to sexual sensations. Mindfulness lessens sexual dysfunction in healthy women and in women who have pelvic cancer or provoked vestibulodynia.
Women can be referred to community or Internet resources to learn how to practice mindfulness. Mindfulness-based cognitive therapy (MBCT) combines an adapted form of cognitive-behavioral therapy with mindfulness. As in cognitive-behavioral therapy, women are encouraged to identify maladaptive thoughts, but then to simply observe their presence, realizing that they are just mental events and may not reflect reality. This approach can make such thoughts less distracting. MBCT is used to prevent recurrent depression and can be adapted to treat sexual arousal disorder and sexual desire/interest disorder as well as the chronic pain of provoked vestibulodynia.
To find out what is causing a sexual problem and how to treat it, a doctor, practice nurse or therapist will need to ask you questions about your medical, sexual and social history.
Your GP or practice nurse can carry out tests for underlying medical conditions.
If your problem is related to lack of hormones such as testosterone or oestrogen, hormone replacement therapy (HRT) can help.
Treating other conditions, such as diabetes or depression, might also alleviate symptoms of sexual dysfunction.
Sexual therapy can help. Talk with your partner about your problem, and see a therapist together if you can. Don’t be embarrassed. Many people experience sexual dysfunction and there are ways to get help.
Your GP can refer you to a therapist, or you can see one privately. Look for a therapist who is an accredited member of the College of Sexual and Relationship Therapists.
This means they will be fully qualified and able to advise on physical, psychological and medical factors that can affect sexual wellbeing.
If needed, they can also refer you to a GP or another medical practitioner, who can carry out the required tests or examination.
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