Sexual dysfunction in women includes pain during intercourse, involuntary painful contractions (spasms) of the muscles around the vagina (vaginismus), lack of interest in sex (low libido), and problems with arousal or orgasm. For a sexual dysfunction disorder to be diagnosed, these problems must cause distress to the woman.
Sexual problems in women may have physical causes, psychological causes, or often a combination, with each impacting the other.
To diagnose sexual issues, doctors often talk with the woman and, sometimes, her partner; a pelvic examination is often necessary when the woman has pain or problems with orgasm.
Treatment of sexual problems in women varies by cause but may include education about sexual function, medications, pelvic physical therapy, or psychotherapy or sex therapy.
Women commonly have concerns about sexual function. If the problems are severe enough to cause distress, they may be considered sexual dysfunction. Approximately 12% of women in the United States have sexual dysfunction.
Sexual dysfunction can be described and diagnosed in terms of specific problems, such as the following:
Lack of interest in sexual activity and/or difficulty becoming aroused (called sexual interest/arousal disorder)
Involuntary tightening of the muscles around the vagina or pain during sexual activity (called genito-pelvic pain/penetration disorder)
Difficulty reaching orgasm despite normal interest in sexual activity (called female orgasmic disorder)
Substance/medication–induced sexual dysfunction
Other sexual dysfunction (doctors refer to this as "other specified and unspecified sexual dysfunction")
In substance/medication–induced sexual dysfunction, sexual dysfunction is related to initiation, change in dose, or stopping of a substance (including illicit drugs) or medication.
Other sexual dysfunction includes sexual dysfunction that does not fit in the other categories. It includes sexual dysfunction that has no identifiable cause or that does not precisely meet the criteria for a specific sexual dysfunction disorder.
Persistent genital arousal disorder is a rare disorder that can occur in both men and women but does not have specific criteria for diagnosis. Women with persistent genital arousal disorder experience excess physical arousal (indicated by increased blood flow to the genital organs and increased vaginal secretion), but sexual desire is absent. No cause for the arousal is identified, and arousal does not usually resolve after orgasm.
Often, women with sexual dysfunction have features of more than one specific issue. For example, women who have pain during sex or have difficulty becoming aroused usually enjoy sex less and may have difficulty reaching orgasm.
A woman’s sexual response is strongly influenced by her mental health and by the quality of her relationship with her partner. Initial desire typically lessens with age but increases with a new partner at any age.
Normal Sexual Function
Sexual function and responses involve mind (thoughts and emotions) and body (including the nervous, circulatory, and hormonal systems). Sexual response includes
Desire, also called interest or libido
Arousal
Orgasm
Resolution
Desire (libido)
Desire is the wish to engage in or continue sexual activity. Sexual interest or desire may be triggered by thoughts, words, sights, smells, or touch. Desire may be obvious at the outset or may build once sexual activity and stimulation begin.
For women, sexual desire and arousal are often closely related. Sexual stimulation can trigger excitement and pleasure and physical responses (including increased blood flow to the genital area). Desire for sexual satisfaction builds as sexual activity and intimacy continue.
Arousal
Arousal has a subjective element—sexual excitement that is felt and thought about. It also has a physical element—an increase in blood flow to the genital area. Blood flow may increase without the woman being aware of it and without her feeling aroused. In women, the increased blood flow causes the clitoris and vaginal walls to swell (a process called engorgement). The increased blood flow also causes vaginal secretions (which provide lubrication) to increase.
This reflexive response that causes engorgement and lubrication occurs within seconds of a sexual stimulus. The brain sensing something sexual, not necessarily as erotic or subjectively arousing, triggers this response. During this response, genital tingling and throbbing are more typically reported by younger women. As women age, the genital blood flow from sexual stimuli decreases, but lubrication in response to sexual stimuli may not.
Orgasm
Orgasm is the peak or climax of sexual excitement. Just before orgasm, muscle tension throughout the body increases. As orgasm begins, the muscles around the vagina contract rhythmically. Women may have several orgasms. Hormones released at orgasm may contribute to the sense of well-being, relaxation, or fatigue that follows (resolution).
Resolution
Resolution is a sense of well-being and widespread muscular relaxation. Resolution typically follows orgasm. However, resolution can occur slowly after highly arousing sexual activity without orgasm. Some women can respond to additional stimulation almost immediately after resolution.
Causes
Many factors cause or contribute to the various types of sexual dysfunction. Traditionally, causes are considered physical or psychological. However, the two types of causes cannot be separated. Psychological factors can cause physical changes in the brain, nerves, hormones, and, eventually, the genital organs. Physical changes can have psychological effects, which, in turn, have more physical effects. Some factors are related more to the situation than to the woman. Also, the cause of sexual dysfunction is often unclear.
Psychological factors
Depression and anxiety commonly contribute to sexual dysfunction. Sometimes, when the depression is effectively treated, the sexual dysfunction improves also. However, some types of antidepressants (selective serotonin reuptake inhibitors) may also cause sexual dysfunction.
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Various fears—of letting go, of being rejected, or of losing control—and low self-esteem can contribute to sexual dysfunction.
Previous experiences can affect a woman’s psychological and sexual development, causing problems, as in the following:
Negative sexual or other experiences, including sexual trauma, may lead to low self-esteem, shame, or guilt.
Emotional, physical, or sexual abuse during childhood or adolescence can teach children to control and hide emotions—a useful defense mechanism. However, women who control and hide emotions may have difficulty expressing sexual feelings.
If women lose a parent or another loved one during childhood, they may have difficulty becoming intimate with a sex partner because they are afraid of a similar loss—sometimes without being aware of it.
Various sexual worries can impair sexual function. For example, women may be worried about unwanted consequences of sex (such as pregnancy or a sexually transmitted infections) or about their or their partner’s sexual performance.
Factors related to a woman’s current situation (called contextual factors) that may impact sexual function include
Self-image: For example, women may have a low sexual self-image if they have a negative body image, urinary incontinence, are having fertility problems or have had surgery to remove a breast, the uterus, or another body part associated with sex.
Relationship: Women may not trust or may have negative feelings about their partner. They may feel less attracted to their partner than earlier in their relationship.
Surroundings: The setting may not be erotic, private, or safe enough for sexual expression.
Culture: Women may come from a culture that restricts sexual expression or activity. Cultures sometimes make women feel ashamed or guilty about sexuality. Women and their partners may come from cultures that view certain sexual practices differently.
Distractions or emotional stress: Family, work, finances, or other things can preoccupy women and thus interfere with sexual arousal.
Physical factors
Various physical conditions, hormones, medications, and illicit drugs may lead or contribute to sexual dysfunction. Hormonal changes, which may occur with aging or result from a disorder, can interfere.
After menopause, changes in the vagina and urinary tract (called genitourinary syndrome of menopause) can affect sexual function. For example, the tissues of the vagina can become thin, dry, and inelastic after menopause because estrogen levels decrease. This condition, called vulvovaginal atrophy (or atrophic vaginitis), can make intercourse painful. Urinary symptoms that can occur at menopause include a compelling need to urinate (urinary urgency) and frequent urinary tract infections.
Similar symptoms can also result from removal of both ovaries and hormonal changes that occur after a baby is delivered (postpartum).
Selective serotonin reuptake inhibitors (SSRIs), a type of antidepressant, commonly cause problems with sexual function. These medications may contribute to several types of sexual dysfunction.
Alcohol can also cause problems with sexual function.
What Affects Sexual Function in Women?
Type | Factor |
|---|---|
Psychological factors | Abuse (emotional, physical, or sexual) during childhood or adolescence Anxiety Depression Fear of intimacy Fear of losing control Fear of losing the partner High self-expectations Low self-esteem Worry about inability to have an orgasm or about sexual performance in a partner Worry about unwanted consequences of sex (such as unwanted pregnancy or sexually transmitted infections) |
Situational factors | A low sexual self-image, as may result from having a negative body image, urinary incontinence, fertility problems or having had surgery to remove a breast, the uterus, or another body part associated with sex Cultural background that restricts sexual expression or activity Distractions or emotional stress Relationship problems Surroundings that are not conducive to sexual activity |
Physical factors | Abnormalities in genital organs (such as birth defects or scarring after surgery or radiation therapy) Breastfeeding Changes in the skin around the opening of the vagina area (such as lichen sclerosus) Genital mutilation Genitourinary syndrome of menopause (changes in the vagina and urinary tract that can occur at menopause, including thinning of tissues of the vagina and a compelling need to urinate) Infections of the genital area (such as genital herpes) or infections of the vagina Fatigue Hyperprolactinemia (high levels of prolactin, a hormone produced by the pituitary gland) Nerve damage (as may result from diabetes, multiple sclerosis, peripheral neuropathy, or spinal cord disorders) Pelvic organ prolapse (dropping down of a pelvic organ such as the vagina or uterus) Physical disability Poor health Premature menopause (ovarian insufficiency) Sexually transmitted infections Some brain and spinal cord disorders, such as multiple sclerosis Substance use disorder (continuing to use a substance despite having problems caused by its use) Surgical removal of both ovaries in premenopausal women |
Medications and other substances | Alcohol Certain antidepressants, particularly selective serotonin reuptake inhibitors Antihistamines Beta-blockers (used to treat high blood pressure or heart disorders) and other medications used to treat high blood pressure Gonadotropin-releasing hormone agonists (used to treat infertility) |
Diagnosis
Interview with the woman and, sometimes, her partner
Pelvic examination
A sexual dysfunction disorder is typically diagnosed when symptoms have been present for at least 6 months and cause significant distress. Some women may not be distressed or bothered by decreased or absent sexual desire, interest, arousal, or orgasm. In such cases, a disorder is not diagnosed.
Female sexual dysfunction can be characterized by at least one of the following:
Pain during sexual activities
Loss of sexual desire
Impaired arousal
Inability to achieve orgasm
Diagnosis of sexual dysfunction disorders involves detailed questioning of the woman and, sometimes, her partner. Doctors first ask the woman to describe the problem in her own words. Then doctors ask about the following:
Symptoms
Other disorders
Gynecologic and obstetric procedures done
Injuries to the pelvic area
Sexual trauma
Illicit drug use
Relationship with her partner
Sexual function problems in her partner
Mood
Self-esteem
Childhood relationships
Past sexual experiences
Personality traits (such as her ability to trust, tendency to be anxious, and need to feel in control)
Doctors do a pelvic examination to look for abnormalities in the external and internal genital organs, including the vulva, vagina, and cervix. Doctors can often identify where pain is coming from. Some women with sexual pain or a history of sexual trauma find it difficult to have a pelvic examination. This can be discussed with the doctor before the examination. Some strategies for making a pelvic examination more tolerable are as follows:
A woman and her doctor can discuss the examination before it begins and agree on how to communicate during the examination.
A woman can hold a mirror to be able to see what the doctor sees during the examination and allow the doctor to show her any issues that are detected.
A woman can place her hand on the doctor’s hand to have a greater sense of control during the examination.
However, if doctors suspect a sexually transmitted infection or another infection (such as a yeast infection or bacterial vaginosis), they may insert a speculum (instrument) into the vagina to be able to see the vagina and cervix (as done during a Papanicolaou, or Pap, test) and take a sample of fluids from the vagina or cervix and send it to a laboratory to be tested.
Treatment
Treatment of causes of sexual pain
Medications, including hormone therapy
Pelvic physical therapy
Sometimes, personal or couple's psychotherapy or sex therapy
Certain treatments depend on the cause of sexual dysfunction. However, some general measures can help regardless of the cause:
For both partners, learning about the woman's anatomy and ways to increase libido or arouse her
Improving communication, including about sex, between the woman and her partner
Encouraging trust, respect, and emotional intimacy between partners: These qualities should be cultivated with or without professional help. Couples may need help learning to resolve conflicts, which can interfere with their relationship.
Setting aside time together that does not involve sexual activity: Couples who talk to each other regularly are more likely to want and enjoy sexual activity together.
Making time and space for sexual activity: Women may be preoccupied with or distracted by other activities (involving work, household chores, or children). Making sure the place is private can help if the woman is afraid of discovery or interruption. Enough time should be allowed, and a setting that encourages sexual feelings may help.
Engaging in many types of sexual activities: For example, stroking and kissing responsive parts of the body and touching each other’s genitals enough before initiating intercourse may enhance intimacy and lessen anxiety.
Taking steps to prevent unwanted consequences: Such measures are particularly useful when fear of pregnancy or sexually transmitted infections inhibits desire.
Practicing mindfulness: Mindfulness involves learning to focus on what is happening in the moment, without making judgments about or monitoring what is happening. Being mindful helps free women from distractions and enables them to pay attention to sensations during sexual activity by staying in the moment. Resources for learning how to practice mindfulness are available on the Internet.
Just becoming aware of what is required for a healthy sexual response may be enough to help women change their thinking and behavior. However, more than one treatment is often required because many women have more than one type of sexual dysfunction. Sometimes a multidisciplinary team, including primary care physicians, gynecologists, pain specialists, psychotherapists, sex therapists, and/or physical therapists, is needed.
Medications
Estrogen therapy can be used to treat sexual dysfunction in women with genitourinary syndrome of menopause. When women have only vaginal and urinary symptoms, doctors usually prescribe forms of estrogen that are inserted into the vagina as a cream (with a plastic applicator), as a tablet, or in a ring. Estrogen cream may also be applied externally to the vulva. These treatments can effectively treat symptoms that affect the vagina (such as dryness and thinning of the vagina, an urgent need to urinate, and frequent urinary tract infections), but they do not help with moodiness, hot flashes, or sleep problems.
Prasterone (a synthetic form of dehydroepiandrosterone [DHEA]) inserted as a suppository into the vagina, can also relieve vaginal dryness and make sex less painful for postmenopausal women.
(a selective estrogen receptor modulator) can be used to treat genitourinary syndrome of menopause in women who cannot apply vaginal hormone therapy.
Because selective serotonin reuptake inhibitors
For postmenopausal women who are taking a full-body dose of estrogen and a progestogen, adding testosterone, doctors must regularly check for side effects such as acne, excess hair growth (hirsutism), and development of masculine characteristics (virilization).
Psychological therapies
Psychological therapies may help women with sexual problems. For example, cognitive-behavioral therapy can help women recognize a negative self-view that results from illness or infertility. Mindfulness-based cognitive therapy combines cognitive-behavioral therapy with the practice of mindfulness. As in cognitive-behavioral therapy, women are encouraged to identify negative thoughts. Women are then encouraged to simply observe these thoughts and to recognize that they are just thoughts and may not reflect reality. This approach can make such thoughts less distracting and disruptive. Mindfulness-based cognitive therapy can be used to treat sexual interest/arousal disorder and pain that occurs whenever pressure is put on the opening to the vagina (called provoked vestibulodynia, a type of genito-pelvic pain/penetration disorder).
More in-depth psychotherapy may be needed when issues from childhood (such as sexual trauma) are interfering with sexual function.
Couples therapy may be helpful to improve communication or address relationship issues. Sex therapy often helps women and their partner deal with issues that affect their sexual life, such as specific sexual problems and their relationship with each other.
Other treatments
Several types of physical therapy may be useful in women with genito-pelvic pain/penetration disorder.
Physical therapists can use several techniques to stretch and relax tight pelvic muscles:
Soft-tissue mobilization and myofascial release: Using various movements (such as rhythmic pushing or massage) to apply pressure on and stretch the affected muscles or the tissues that cover muscles (myofasciae)
Trigger-point pressure: Applying pressure to very sensitive areas of the affected muscles, which may be where the pain starts (trigger points)
Electrical stimulation: Applying gentle electric current through a device positioned at the opening of the vagina
Bladder training and bowel retraining: Having women follow a strict regimen for urination and recommending exercises to strengthen the muscles around the urethra and anus, sometimes with biofeedback
Therapeutic ultrasonography: Applying energy (produced by high-frequency sound waves) to the affected muscles (increasing blood flow to the area, enhancing healing, and relaxing tight muscles)
If tight pelvic muscles are making sexual activity painful, women can insert self-dilation devices, available by prescription and over the counter, to stretch and to make the vagina less sensitive. Sexual activity may then be more comfortable.
Vaginal lubricants and moisturizers can reduce vaginal dryness, which causes pain during intercourse. These treatments include food-based oils (such as coconut oil), silicone-based lubricants, and water-based products. Water-based lubricants dry out quickly and may have to be reapplied, but they are preferred over petroleum jelly and other oil-based lubricants. Food-based oils can damage latex contraceptive devices such as condoms and diaphragms. They should not be used with condoms. Silicone-based lubricants can be used with condoms and diaphragms, as can water-based lubricants. Women can ask their doctor which type of lubricant would be best for them.
Depending on the type of dysfunction, sexual skills training (for example, instruction in masturbation) and exercises to facilitate communication with a partner about sexual needs and preferences can be implemented.
Devices such as vibrators or clitoral suction devices may be used by women with sexual interest/arousal or orgasmic disorder, but there is little evidence to support their effectiveness. Many of these products are available over the counter.
Spotlight on Aging: Sexual Dysfunction in Older Women
A major reason older women give up on sex is lack of a sexually functional partner. However, age-related changes, particularly those due to menopause, can make women more likely to experience sexual dysfunction. Also, medical conditions that can interfere with sexual function, such as diabetes, atherosclerosis, urinary tract infections, and arthritis, become more common as women age. However, these changes need not end sexual activity and pleasure, and not all sexual dysfunction in older women is caused by age-related changes. In older women as in younger women, the most common problem is lack of interest in sex. After menopause, less estrogen is produced.
Less and less testosterone is produced starting when women are in their 30s, and testosterone production stops by about age 70. Whether this decrease leads to decreased sexual interest and response is unclear. Other problems may interfere with sexual function. For example, older women may be distressed by changes in their body caused by medical conditions, surgery, or aging itself. They may have cultural views that sexual desire and fantasy are improper or shameful at an older age. They may be worried about the general health or sexual function of their partner. Many older women are interested in sex. Older women should not assume that sexual dysfunction is normal for older age. If sexual dysfunction is bothering them, they should talk to their doctor. In many cases, treating a health condition (including depression), stopping or substituting a medication, learning more about sexual function, or talking to a health care professional or counselor can help. Vaginal dryness or painful sex due to menopause can be treated with vaginal hormone therapy, including low-dose estrogen (as a cream, tablet, or ring) or dehydroepiandrosterone (DHEA, as a suppository). Estrogen may be taken by mouth or applied to the skin in a patch or gel, but these forms of estrogen affect the whole body and are usually only used if a woman also has other symptoms of menopause (such as hot flashes) and are usually not given to women older than 60 years. Estrogen has potential risks (including blood clots and a slightly increased risk of breast cancer) as well as benefits, so women should talk to their doctor about its risks and benefits before starting to take it. |
