Female sexual dysfunction

Persistent, recurrent problems with sexual response, desire, orgasm or pain — that distress you or strain your relationship with your partner — are known medically as sexual dysfunction.

Many women experience problems with sexual function at some point, and some have difficulties throughout their lives. Female sexual dysfunction can occur at any stage of 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.

Symptoms

Symptoms vary depending on what type of sexual dysfunction you're experiencing:

• 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.

When to see a doctor

If sexual problems affect your relationship or worry you, make an appointment with your doctor for evaluation.

Causes

Sexual problems often develop when your hormones are in flux, such as after having a baby or during menopause. Major illness, such as cancer, diabetes, or heart and blood vessel (cardiovascular) disease, can also contribute to sexual dysfunction.

Factors — often interrelated — that contribute to sexual dissatisfaction or dysfunction include:

• Physical. Any number of medical conditions, including cancer, kidney failure, multiple sclerosis, heart disease and bladder problems, can lead to sexual dysfunction. Certain medications, including some antidepressants, blood pressure medications, antihistamines and chemotherapy drugs, can decrease your sexual desire and your body's ability to experience orgasm.

• Hormonal. Lower estrogen levels after menopause may lead to changes in your genital tissues and sexual responsiveness. A decrease in estrogen leads to decreased blood flow to the pelvic region, which can result in less genital sensation, as well as needing more time to build arousal and reach orgasm.

  The vaginal lining also becomes thinner and less elastic, particularly if you're not sexually active. These factors can lead to painful intercourse (dyspareunia). Sexual desire also decreases when hormonal levels decrease.

  Your body's hormone levels also shift after giving birth and during breast-feeding, which can lead to vaginal dryness and can affect your desire to have sex.

• Psychological and social. Untreated anxiety or depression can cause or contribute to sexual dysfunction, as can long-term stress and a history of sexual abuse. The worries of pregnancy and demands of being a new mother may have similar effects.

  Long-standing conflicts with your partner — about sex or other aspects of your relationship — can diminish your sexual responsiveness as well. Cultural and religious issues and problems with body image also can contribute.

Risk factors

Some factors may increase your risk of sexual dysfunction:

• Depression or anxiety
• Heart and blood vessel disease
• Neurological conditions, such as spinal cord injury or multiple sclerosis
• Gynecological conditions, such as vulvovaginal atrophy, infections or lichen sclerosus
• Certain medications, such as antidepressants or high blood pressure medications
• Emotional or psychological stress, especially with regard to your relationship with your partner
• A history of sexual abuse

Diagnosis

To diagnose female sexual dysfunction, your doctor may:

• Discuss your sexual and medical history. You might be uneasy talking with your doctor about such personal matters, but your sexuality is a key part of your well-being. The more upfront you can be about your sexual history and current problems, the better your chances of finding an effective way to treat them.
• Perform a pelvic exam. During the exam, your doctor checks for physical changes that affect your sexual enjoyment, such as thinning of your genital tissues, decreased skin elasticity, scarring or pain.
• Order blood tests. Your doctor may recommend blood tests to check for underlying health conditions that might contribute to sexual dysfunction.

Your doctor may also refer you to a counselor or therapist specializing in sexual and relationship problems.

Treatment

Keep in mind that sexual dysfunction is a problem only if it bothers you. If it doesn't bother you, there's no need for treatment.

Because female sexual dysfunction has many possible symptoms and causes, treatment varies. It's important for you to communicate your concerns, as well as to understand your body and its normal sexual response. Also, your goals for your sex life are important for choosing a treatment and evaluating whether or not it's working for you.

Women with sexual concerns most often benefit from a combined treatment approach that addresses medical as well as relationship and emotional issues.

Nonmedical treatment for female sexual dysfunction

To treat sexual dysfunction, your doctor might recommend that you start with these strategies:

• Talk and listen. Open communication with your partner makes a world of difference in your sexual satisfaction. Even if you're not used to talking about your likes and dislikes, learning to do so and providing feedback in a nonthreatening way sets the stage for greater intimacy.
• Practice healthy lifestyle habits. Limit alcohol — drinking too much can blunt your sexual responsiveness. Be physically active — regular physical activity can increase your stamina and elevate your mood, enhancing romantic feelings. Learn ways to decrease stress so you can focus on and enjoy sexual experiences.
• Seek counseling. Talk with a counselor or therapist who specializes in sexual and relationship problems. Therapy often includes education about how to optimize your body's sexual response, ways to enhance intimacy with your partner, and recommendations for reading materials or couples exercises.
• Use a lubricant. A vaginal lubricant may be helpful during intercourse if you have vaginal dryness or pain during sex.
• Try a device. Arousal may be enhanced with stimulation of the clitoris. Use a vibrator to provide clitoral stimulation.

Medical treatment for female sexual dysfunction

Effective treatment for sexual dysfunction often requires addressing an underlying medical condition or hormonal change. Your doctor may suggest changing a medication you're taking or prescribing a new one.

Possible treatments for female sexual dysfunction might include:

• Estrogen therapy. Localized estrogen therapy comes in the form of a vaginal ring, cream or tablet. This therapy benefits sexual function by improving vaginal tone and elasticity, increasing vaginal blood flow and enhancing lubrication.

  The risks of hormone therapy may vary depending on your age, your risk of other health issues such as heart and blood vessel disease and cancer, the dose and type of hormone and whether estrogen is given alone or with a progestin.

  Talk with your doctor about benefits and risks. In some cases, hormonal therapy might require close monitoring by your doctor.

• Ospemifene (Osphena). This medication is a selective estrogen receptor modulator. It helps reduce pain during sex for women with vulvovaginal atrophy.

• Androgen therapy. Androgens include testosterone. Testosterone plays a role in healthy sexual function in women as well as men, although women have much lower levels of testosterone.

  Androgen therapy for sexual dysfunction is controversial. Some studies show a benefit for women who have low testosterone levels and develop sexual dysfunction; other studies show little or no benefit.

• Flibanserin (Addyi). Originally developed as an antidepressant, flibanserin is approved by the Food and Drug Administration (FDA) as a treatment for low sexual desire in premenopausal women.

  A daily pill, Addyi may boost sex drive in women who experience low sexual desire and find it distressing. Potentially serious side effects include low blood pressure, sleepiness, nausea, fatigue, dizziness and fainting, particularly if the drug is mixed with alcohol. Experts recommend that you stop taking the drug if you don't notice an improvement in your sex drive after eight weeks.

• Bremelanotide (Vyleesi). Bremelanotide is another FDA-approved treatment for low sexual desire in premenopausal women. This medication is an injection you give yourself just under the skin in the belly or thigh before anticipated sexual activity.

  Some women experience nausea, which is more common after the first injection but tends to improve with the second injection. Other side effects include vomiting, flushing, headache and a skin reaction at the site of the injection.

Potential treatments that need more research

More research is needed before these agents might be recommended for treatment of female sexual dysfunction:

• Tibolone. Tibolone is a synthetic steroid drug used in Europe and Australia for treatment of postmenopausal osteoporosis. Due to concerns over increased risk of breast cancer and stroke in women taking tibolone, the drug isn't approved by the FDA for use in the U.S.

• Phosphodiesterase inhibitors. This group of medications has proved successful in treating erectile dysfunction in men, but the drugs don't work nearly as well in treating female sexual dysfunction. Studies looking into the effectiveness of these drugs in women show inconsistent results.

  One drug, sildenafil (Revatio, Viagra), may prove beneficial for some women who have sexual dysfunction as a result of taking selective serotonin reuptake inhibitors (SSRIs), a class of drugs used to treat depression. Don't take sildenafil if you use nitroglycerin for angina — a type of chest pain caused by reduced blood flow to the heart.

Issues surrounding female sexual dysfunction are usually complex, so even the best medications aren't likely to work if other emotional or social factors remain unresolved.

Lifestyle and home remedies

To boost your sexual health, find ways to be comfortable with your sexuality, improve your self-esteem and accept your body. Try practicing these healthy lifestyle habits:

• Avoid excessive alcohol. Drinking too much blunts sexual responsiveness.
• Don't smoke. Cigarette smoking restricts blood flow throughout your body. Less blood reaches your sexual organs, which means you could experience decreased sexual arousal and orgasmic response.
• Be physically active. Regular aerobic exercise increases your stamina, improves your body image and elevates your mood. This can help you feel more romantic, more often.
• Make time for leisure and relaxation. Learn ways to decrease stress, and allow yourself to relax amid the stresses of your daily life. Being relaxed can enhance your ability to focus on your sexual experiences and may help you attain more satisfying arousal and orgasm.

Alternative medicine

More research is needed, but therapies that may help improve sexual satisfaction include:

• Mindfulness. This type of meditation is based on having an increased awareness and acceptance of living in the present moment. You focus on what you experience during meditation, such as the flow of your breath. You can observe your thoughts and emotions, but let them pass without judgment.
• Acupuncture. Acupuncture involves the insertion of extremely thin needles into your skin at strategic points on your body. Acupuncture may have positive effects on low libido and lubrication difficulties, especially if these problems are related to the use of some antidepressant medications.
• Yoga. During yoga, you perform a series of postures and controlled breathing exercises to promote a flexible body and a calm mind. Certain subsets of yoga aim to channel the body's sexual energy and improve sexual functioning.

There are also some herbal supplements and topical oils marketed to increase libido and sexual pleasure. However, these products haven't been well-studied. One product has estrogen-like properties and may encourage the growth of breast tumors that need estrogen to grow. Talk to your doctor before trying any herbal or topical oil formulations.

Coping and support

At each stage of your life, your level of sexual desire, arousal and satisfaction can change. To better adapt:

• Understand your body and what makes for a healthy sexual response. The more you and your partner know about the physical aspects of your body and how it functions, the better able you'll be to find ways to ease sexual difficulties.
• Gather information. Ask your doctor or look for educational materials to learn how issues such as aging, illnesses, pregnancy, menopause and medicines might affect your sex life.
• Communicate openly with your partner. Be flexible in your approach to intimacy with your partner. Continue to engage in the areas of intimacy that are working well for the two of you.
• Accept changes that occur. Explore new aspects of your sexuality during times of transition to improve your sexual experiences.

Sexual response often has as much to do with your feelings for your partner as it does with physical sexual stimuli. Rediscover each other and reconnect.

Preparing for an appointment

If you have ongoing sexual difficulties that distress you, make an appointment with your doctor. You may feel embarrassed to talk about sex with your doctor, but this topic is perfectly appropriate. A satisfying sex life is important to a woman's well-being at every age.

You might have a treatable, underlying condition, or you might benefit from lifestyle changes, therapy or a combination of treatments. Your primary doctor will either diagnose and treat the problem or refer you to a specialist.

Here's some information to help you prepare for your appointment.

What you can do

Gather information about:

• Your symptoms. Take note of any sexual difficulties you're having, including when and how often they occur.
• Your sexual history. Your doctor likely will ask about your relationships and experiences since you became sexually active. He or she also might ask about any history of sexual trauma or abuse.
• Your medical history. Write down any medical conditions you have, including mental health conditions. Jot down the names and doses of medications you take or have recently taken, including prescription and over-the-counter drugs.
• Questions to ask your doctor. Create a list of questions to make the most of your time with your doctor.

Some basic questions to ask your doctor about your sexual concerns include:

• What might be causing my sexual difficulties?
• Do I need medical tests?
• What treatment do you recommend?
• If you're prescribing medication, are there possible side effects?
• How much improvement can I reasonably expect with treatment?
• Are there lifestyle changes or self-care steps that might help?
• Do you recommend therapy?
• Should my partner be involved in treatment?
• Do you have printed material you can give me? What websites do you recommend?

Don't hesitate to ask other questions that occur to you.

What to expect from your doctor

Your doctor might ask a number of personal questions and might want to include your partner in the interview. To help determine the cause of your problem and the best course of treatment, be ready to answer questions such as:

• What problems are you having?
• How much do these problems bother you?
• How satisfied are you with your relationship?
• Do you become aroused during sexual interactions with your partner?
• Do you have orgasms?
• If you've had orgasms in the past but no longer can, what's different?
• Do you have pain with intercourse?
• What form of birth control, if any, do you use?
• Do you use alcohol or recreational drugs? How much?
• Have you ever had surgery that involved your reproductive system?
• Have you been diagnosed with other medical conditions, including mental health conditions?
• Have you ever had an unwanted sexual experience?

What you can do in the meantime

Keep the lines of communication open with your partner. Be honest about your dissatisfaction or the problem you have. Consider alternatives for intimacy and engage in sexual activities that are rewarding for both of you.

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