Sexual Dysfunction in Women

Sexual Dysfunction in Women


Female sexual dysfunction (FSD) can be described as any problem that regularly interferes with a woman’s ability to achieve sexual gratification. To be considered a dysfunction, the symptoms must be persistent, pervasive and cause the woman distress. This broad definition can include difficulties with desire, arousal, orgasm or resolution. An estimated 43 percent of U.S. women experience some form of sexual dysfunction, according to the American Medical Association.

Sexual dysfunction can start early in a woman’s life, or may develop later in someone who previously enjoyed sex without difficulty. The causes of sexual dysfunction can be physical, psychological or a combination of the two. FSD consists of four main categories, and many women can experience problems in more than one category at a time. These are:

  • Sexual desire disorders
  • Sexual arousal disorders
  • Orgasm disorders
  • Sexual pain disorders

Women entering midlife may experience sexual dysfunction often attributed to changes brought on by menopause. Other reasons for female sexual dysfunction can include chronic conditions, such as severe endometriosis, or serious illness, such as gynecologic cancer that physically alters a woman’s body and often her body image as well.

Although it may be difficult to speak with a physician about intimate relationships, it is best to be candid. Healthy sexual function is an important part of a woman’s life. Women should be aware that FSD often can be treated successfully.

Not all sexual problems are dysfunctions. For instance, inadequate stimulation or having an impatient partner is not considered sexual dysfunction. Once the underlying reason is discovered, many cases of sexual dysfunction can be treated. A physician will most likely diagnose sexual dysfunction based on the patient’s symptoms. In addition, the patient’s medical history, sexual history and a physical examination can help to determine the cause.

About sexual dysfunction

Female sexual dysfunction (FSD) is any problem that routinely interferes with a woman’s ability to achieve sexual gratification. To be considered a dysfunction, the symptoms must be persistent, pervasive and cause the woman distress. This broad definition can include difficulties with desire, arousal, orgasm and resolution. FSD includes disturbances in one or more of the response cycle phases or pain associated with arousal or intercourse.

According to the American Medical Association, approximately 43 percent of U.S. women (and 31 percent of men) have experienced some form of sexual dysfunction at some time.

FSD can start early in a woman’s life, or it may develop later in someone who previously enjoyed sex without any difficulties. The causes of sexual dysfunction can be physical, psychological or both.

Sexual activity can include fondling, masturbation, oral sex, vaginal or anal penetration and intercourse. Each woman has individual interests, responses and ways of expression that can change as she enters different life stages and as circumstances change.

The normal stages of sexual response were initially explained by a research team in a model that includes four phases:

  • Excitement. Nerves are activated, increasing blood flow to the genital area. The vagina becomes lubricated, and changes begin in the labia and clitoris.
  • Plateau. More changes happen in the body as the genital area builds with tension. The vagina becomes increasingly lubricated, and the upper two-thirds of the vaginal wall expand.
  • Orgasm. The orgasm is a series of muscular contractions in the genital area, the uterus and vaginal walls, followed by an enormous release of muscle tension.
  • Resolution. The continuation of release of muscle tension evolves into resolution, which is the final phase of pleasantly diminishing sexual tension.

In addition to the four phases described by the researchers, a woman’s sexual response is affected by her biology, psychology, sociocultural influences and interpersonal relationships. Treatment of sexual dysfunction is more likely to be successful if all these components are considered rather than just one.

In many cases, female sexual dysfunction can be categorized into four main areas, including:

  • Sexual desire disorders. This includes a lack of desire for sex, sometimes referred to as a low libido.
  • Sexual arousal disorders. When a woman is sexually aroused, there are physical changes that occur in the body, including an erection of the nipples, the moistening of the vagina, the relaxation of vaginal muscles and the swelling of the labia (the skin folds of the vulva) and clitoris (the small, sensitive organ above the vagina). Problems can include difficulties with any of these arousal mechanisms.
  • Orgasmic disorders. An orgasm is the peak of the sexual response as the muscles of the vagina and uterus contract to create an intense pleasurable feeling.
  • Sexual pain disorders. Painful intercourse (dyspareunia) can mean pain in the vagina, clitoris or labia. The pain can result from sexual stimulation, vaginal contact or penetration. Although there are many possible causes for dyspareunia, one of the most common sexual pain disorders is vulvodynia, which is the painful burning, stinging and itching of the vulva. Vaginismus is another problem that is caused when the vaginal muscles at the opening tighten as part of the sexual response. This creates dyspareunia upon penetration and can be difficult to treat. 

Women entering midlife may experience sexual dysfunction caused by menopausal changes in the body. During this period, sexual response and a general interest in sex may diminish. Changes in vaginaltissue may include thinning, dryness, itchiness or burning, and in some cases, sex may become painful (dyspareunia). However, continuing to have sex (or to masturbate) will help to keep vaginal tissue healthy after menopause. Women who have a healthy sex life before menopause will likely have a healthy one after as well.

FSD may also be caused by a chronic condition, such as severe endometriosis, or a serious illness that physically alters a woman’s body and body image, such as breast cancer or gynecologic cancer. For many women, breasts are part of their female self-image and the loss of a breast in a mastectomy, or changes in a breast’s size or shape after a lumpectomy, can sometimes cause long-term psychological and sexual problems. As many as half of all breast cancer patients experience some form of long-term sexual difficulties, according to the National Cancer Institute (NCI).

Other causes of sexual dysfunction may include, but are not limited to, minor ailments, medications and psychosocial challenges, which could include prior physical or sexual abuse.

Types and differences of sexual dysfunction

There are several types of female sexual dysfunction (FSD). The five most common difficulties include:

  • Inhibited sexual desire. Oral contraceptives, antidepressants, tranquilizers and other medications can cause a lowered sex drive.
  • Painful intercourse (dyspareunia). Some women who have been through menopause find that they have less vaginal lubrication. At times, hormone replacement therapy or vaginal creams containing estrogen are recommended. Serious side effects are associated with some of these medications, and other options may be available. For example, many women find over-the-counter lubricants to be a successful remedy.
  • Lack of orgasm (anorgasmia). Sometimes referred to as female orgasmic disorder, a persistent delay or absence of orgasm can be caused by either physical or psychological factors. Common reasons for women failing to achieve orgasm include severe stress or anxiety, depression, or various medical conditions (e.g., incontinence). Certain medications, such as antidepressants, antipsychotics or antihypertensive drugs, can also cause a lack of orgasm. Lack of orgasm that is not physical or psychological in cause (e.g., an impatient partner) is not a form of sexual dysfunction.
  • Vaginismus. Characterized by a persistent or recurring spasm of the outer third of the vagina, vaginismus often interferes with sexual intercourse.
  • Hypoactive sexual desire disorder. Characterized by a persistent absence of sexual fantasy or desire.

Potential causes of female sexual dysfunction

There are many potential causes of sexual dysfunction in a woman. However, most can be broadly categorized as either physical or psychological, and sometimes a combination of both.

Physical reasons are often underlying medical conditions that can lead to female sexual dysfunction (FSD). Common examples include diabetes, heart disease, endometriosis and arthritis (inflammation of the joints). In addition, side effects from medications (prescription and nonprescription) may cause sexual dysfunction. These include:

  • Antihistamines (allergy drugs)
  • Oral contraceptives (birth control pills)
  • Hormonal preparations
  • Antihypertensives (blood pressure drugs)
  • Cardiovascular medications
  • GnRH agonists
  • Chemotherapy drugs
  • Medications for psychological disorders, such as:
    • Antidepressants (e.g., selective serotonin reuptake inhibitors [SSRIs])
    • Antipsychotics (schizophrenia drugs)
    • Mood stabilizers (e.g., lithium)
    • Drugs for anorexia nervosa
  • Narcotics (prescription and illegal)

Certain hormonal changes related to pregnancy or menopausemay also contribute to FSD. Other conditions that may cause difficulties include:

  • Neurological disorders (e.g., multiple sclerosis)
  • Pelvic surgery (e.g., hysterectomy, cancer surgery)
  • Pelvic injury or trauma (e.g., rape and sexual assault)
  • Urinary or bowel problems (e.g., incontinence)
  • Endocrine disorders (e.g., thyroid, pituitary or adrenal gland problems)
  • Alcoholism or drug abuse
  • Smoking or other forms of tobacco use

Psychological reasons may be expressed as anxieties or fears that cause a woman difficulty with one or more of the aspects of sexual intimacy. Some of the more common triggers include:

  • Anxiety, fatigue and stress from work or home life
  • Worries about sexual performance
  • Depression
  • History of sexual trauma (e.g., rape, incest)
  • An unresolved sexual orientation

Psychological factors also can have a tremendous impact on the sexual function of patients who have experienced gynecologic cancers. Fears of recurrence, an altered self-image and the after-effects of treatment can affect daily activities, careers and relationships.

Following a diagnosis of cancer or chronic disease, it is normal for a woman to experience anxieties regarding survival, family, finances, career and changes in body image and activity levels. All of these factors can lead to the strain a woman feels in expressing her sexuality and concerns about sexual desirability. If depression continues, the patient’s physician may recommend medications to help restore an interest in sex.

Painful intercourse (dyspareunia) is a common problem that is associated with hormonal changes, often related to pregnancy, menopause or female cancers. These hormonal changes can lead to vaginal dryness or vaginal atrophy, in which the shape and flexibility of the vagina gradually decline.

Signs and symptoms of sexual dysfunction

Some of the symptoms most commonly associated with female sexual dysfunction (FSD) are:

  • An inability to allow sexual intercourse because the vaginal muscles will not relax
  • A lack of lubrication in the vagina before and during intercourse
  • Inability to achieve orgasm
  • Pain on the vulva or in the vagina during penetration or contact

Diagnosis and treatment of sexual dysfunction

Primary care physicians, as well as obstetrician-gynecologists (ObGyns), are often trained in the diagnosis and treatment of female sexual dysfunction (FSD). However, not all sexual problems are dysfunctions such as inadequate stimulation. Once the underlying reason is uncovered, many cases of sexual dysfunction can be treated.

A physician will most likely diagnose sexual dysfunction based on the patient’s symptoms. In addition, the patient’s medical history, sexual history, a physical examination including a gynecologic examination will help determine the underlying cause. Patient education and reassurance, combined with early diagnosis and treatment, are the keys to effective treatment of FSD.

Although it may be difficult to speak with a physician about intimate relationships, it is best to be candid. Sexual function is an important part of a woman’s life. It is important for women to realize that sexual dysfunction may be treated. Perhaps the most important step in treating sexual dysfunction is keeping communication open between a woman and her partner.

Basic treatment strategies for FSD may include:

  • Medical treatment including management of chronic illnesses (e.g., diabetes). If the underlying cause of the sexual dysfunction is medical, then effective treatment must first address the condition or disease (e.g., surgery for endometriosis).
  • Education. This includes providing information and education about the body, sexual signals and receptors, sexuality changes during and after pregnancy and during menopause.
  • Psychological therapy (e.g., psychotherapy, counseling).
  • Sex therapy from a licensed sex therapist or counselor.

At times, a woman’s physician may prescribe testosterone, which is a male hormone. In many cases this will increase sexual desire, but there are side effects that a woman may find intolerable, such as growth of facial hair, weight gain or acne.

The Food and Drug Administration (FDA) approved a medical device for the treatment of female sexual arousal disorder in 2000. It is a clitoral engorgement device, called Eros-CTD, used to stimulate the clitoris and increase blood flow to the area. It is the only FDA-approved device for female sexual dysfunction.

Women who felt comfortable with and enjoyed their sexuality prior to being diagnosed with chronic disease or breast cancer are likely to maintain or preserve a healthy sexual self-image despite changes brought about by the disease and its treatments. For many who undergo changes or stresses that affect sexuality because of disease, it is common for sexuality to take a back seat to fatigue, pain and a fight for survival.

Once the immediate crisis has passed, however, anxiety over resuming sexual activity is normal and natural. The following suggestions may offer relief for specific concerns:

  • Give it time. Many patients experiencing FSD from a medical condition may have unrealistic expectations of how soon normal sexual relations will resume. It is important to realize that an interruption in the patient’s usual ability to experience sexual pleasure is perfectly normal. After treatment for cancer for example, it may be best for a patient and her partner to schedule quiet time together and start slowly.
  • Keep communication open. It is helpful for a woman to communicate her feelings about any physical changes (e.g., loss of a breast due to breast cancer) with her partner. It is best for the couple to be open about how they may work though any anxiety about loss of a body part or gynecologic changes and the remaining scars together. Open communication means letting a partner know what type of physical touching the patient is ready to explore. Remember that poor communication often results in feelings of rejection for the woman and frustration and confusion for her partner. Continuous sharing offers an atmosphere of acceptance and understanding that will help to slowly eliminate any “off-limit” zone. For example, some women may enjoy a partner’s touch at the site of a mastectomy scar, but others will not and may even dislike being touched on the remaining breast and nipple. Experimenting with different visual types of exposure, such as wearing a camisole or even a bra during sex may also help.
  • Try over-the-counter (OTC) remedies for painful intercourse (dyspareunia). To alleviate painful intercourse, many women choose hormone replacement therapy (HRT) or estrogen creams. However, HRT and estrogen-based creams can have serious side effects and health risks and may not be recommended for breast cancer patients as they could lead to a recurrence. There are many OTC creams, gels and lubricants that work well to alleviate vaginal dryness.
  • Reduce medication side effects. Many medications that are commonly prescribed for patients can have sexual side effects, including antidepressants. However, some of the newer antidepressants have fewer sexual side effects. Generic brands that offer fewer sexual side affects include venlafaxine, citalopram and bupropion.
  • Make healthy lifestyle changes. This includes quitting smoking, avoiding or reducing alcohol consumption, exercising regularly and getting plenty of rest and relaxation. Smoking or drinking alcohol can affect not only the prognosis or treatment of a medical condition, but also the patient’s sexual function. The serious side effects of tobacco and alcohol apply to prescribed and OTC medications. Health experts recommend regular aerobic exercisefor increasing stamina, improving body image and elevating mood. Getting proper relaxation and rest also can enhance a woman’s ability to focus on the sexual experience and achieve better arousal and orgasm.
  • Strengthen pelvic muscles. Pelvic floor exercises (e.g., Kegel exercises) can help with some arousal and orgasm problems. Kegel exercises can help strengthen the muscles involved in pleasurable sexual sensations. A physician also may recommend using vaginal weights to strengthen the pelvic muscles.
  • Seek professional help. At times, focusing on the positives are not enough, and the problems that affect sex and intimacy in a relationship require the assistance of a professional. Patients and their partners may find help and the needed support from a sex therapist or counselor who has experience counseling patients with chronic illnesses or gynecologic cancers.

Ongoing research regarding FSD

Studies are currently being done to assess the effectiveness of medications used for treating erectile dysfunction in men (e.g., sildenafil, tadalafil) for treating certain types of female sexual dysfunction (FSD). Although most of these studies have shown little benefit for women, some have reported a benefit for women with sexual dysfunction due to antidepressant or anti-anxiety medication side effects.

Questions for your doctor on sexual dysfunction

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or healthcare professional the following questions about sexual dysfunction:

  1. I have been avoiding sex with my partner because I find intercourse to be painful. Is there something I can do?
  2. I can’t seem to achieve an orgasm with my partner. Could something be wrong with me medically?
  3. I haven’t had any interest in sex for months now. What could the problem be?
  4. I find that now that I’ve started menopause my desire is lower and sex can sometimes be painful. Is this how our love life is going to be from now on?
  5. What treatments are available to improve my sex life?
  6. Are there any side effects involved with this treatment?
  7. How soon before I see improvement in my sexual dysfunction?
  8. Do I need to make any lifestyle changes to improve my sex life?
  9. Can you recommend a sex therapist?
  10. How can I prevent my sexual dysfunction from recurring?
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