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    Sexual Problems in Women

    Sexual Problems in Women

    Topic Overview

    What are sexual problems?

    A sexual problem is something that keeps sex from being satisfying or positive.

    Most women have symptoms of a sexual problem at one time or another. For some women, the symptoms are ongoing. But your symptoms are only a sexual problem if they bother you or cause problems in your relationship.

    There is no "normal" level of sexual response because it's different for every woman. You may also find that what is normal at one stage of your life changes at another stage. For example, it's common for an exhausted mother of a baby to have little interest in sex. And it's common for both women and men to have lower sex drives as they age.

    What are some causes of sexual problems in women?

    Female sexuality is complicated. At its core is a need for closeness and intimacy. Women also have physical needs. When there is a problem in either the emotional or physical part of your life, you can have sexual problems.

    Some common causes include:

    • Emotional causes, such as stress, relationship problems, depression or anxiety, a memory of sexual abuse or rape, and unhappiness with your body.
    • Physical causes, such as hormone problems, pain from an injury or other problem, and certain conditions such as diabetes or arthritis.
    • Aging, which can cause changes in the vagina , such as dryness.
    • Taking certain medicines. Some medicines for depression, blood pressure, and diabetes may cause sexual problems.

    What are the symptoms?

    Symptoms of sexual problems can include:

    • Having less desire for sex.
    • Having trouble feeling aroused.
    • Not being able to have an orgasm.
    • Having pain during sex.

    How are sexual problems in women diagnosed?

    You may notice a change in desire or sexual satisfaction. When this happens, it helps to look at what is and isn't working in your body and in your life. For example:

    • Are you ill, or do you take a medicine that can lower your sexual desire or response?
    • Are you stressed or often very tired?
    • Do you have a caring, respectful connection with a partner?
    • Do you and your partner have the time and privacy to relax together?
    • Do you have painful memories about sex or intimacy?

    Your doctor can help you decide what to do. He or she will ask questions, do a physical exam, and talk to you about possible causes.

    It can be hard or embarrassing to talk to your doctor about this. Sometimes it helps to write out what you want to say before you go. For example, you could say something like, "For the past few months, I haven't enjoyed sex as much as I used to." Or you could say, "Ever since I started taking that medicine, I haven't felt like having sex."

    How are they treated?

    Treatment for a sexual problem depends on the cause. It may include treating a health problem, learning how to talk openly with your partner, and learning about things you can do at home. For example, you might take a warm bath to relax, have plenty of foreplay before sex, or try different positions during sex.

    It's important to feel comfortable talking with your doctor. The more you can tell your doctor, the more he or she will be able to help you.

    Frequently Asked Questions

    Learning about sexual problems in women:

    Being diagnosed:

    Getting treatment:

    Cause

    Your sexuality is a mixture of mental, emotional, and physical signals. A problem in one area can grow to involve other areas.

    Mental and emotional causes: These include stress, depression, relationship problems, fear, a history of sexual abuse or rape, and being unhappy about your body.

    Physical causes: These include natural hormonal changes, such as those related to your menstrual cycle, birth control pills, or pregnancy. Physical causes also include injuries, pain during sex, and certain health problems, such as diabetes, endometriosis, or arthritis.

    Medical treatments: Sometimes treatments for other illnesses or conditions-such as past surgeries or cancer treatments-cause changes that result in pain during sex or other problems. For example, it's common for a woman who has had her breast removed or has had her uterus and ovaries removed to have less sexual desire.

    Medicines: Some medicines may lower sexual desire and arousal. These include certain medicines for high blood pressure, diabetes, depression, and allergies.

    Getting older: As a woman ages, she may have a decrease in sexual desire. She may need more time to feel sexually aroused. And aging can cause physical changes. Vaginal walls may grow thinner. The vagina itself may narrow or shorten. There may be less lubrication. These changes can cause pain during sex.

    Alcohol and drug abuse: Drinking too much or continually using illegal drugs like cocaine or amphetamines will eventually cause problems with orgasm and sexual desire.

    Symptoms

    Symptoms of sexual problems can include:

    • Less desire. You may have fewer sexual fantasies or thoughts. You may not want to have sex.
    • Less arousal. You may notice that you're not interested when a partner makes sexual suggestions. You may not be able to feel or maintain sexual excitement.
    • Being unable to reach orgasm .
    • Pain during sex.

    These symptoms are problems only if they bother you or cause problems in your relationship with a partner.

    What Happens

    Many things in a woman's life can lead to a sexual problem. Over time, an untreated sexual problem can have a growing impact on your quality of life. If the problem makes you feel uncomfortable and/or unsatisfied, sex can become a tense and unwelcome experience.

    Physical influences

    Women normally experience a physical change during sexual arousal, as blood swells areas of the vulva . If those areas aren't stimulated enough, a woman may not feel as much sexual pleasure.

    Chronic (ongoing) illnesses, such as diabetes and arthritis, can affect sexual desire, enjoyment, and performance. Medicines for many medical conditions also affect desire and arousal.

    Pain during sex

    Any history of pain during sex may cause a woman to avoid sex or find it unpleasant.

    Pain during sex may result from:

    • Vaginal dryness. Lack of lubrication in the vagina is the most common cause of pain with sex.
    • Vaginismus (say "vadj-uh-NIZ-mus"). This is an involuntary contraction of the vagina. It's often related to a lack of experience with sex. 1 Sometimes it stems from a trauma such as rape or sexual abuse. But there can also be a medical cause, such as:
      • Scars in the vaginal opening from injury, surgery, or childbirth.
      • Pelvic infections, such as vaginitis or Bartholin glands infections.
      • Chronic pain conditions, such as vulvodynia .
      • Skin conditions, such as lichen sclerosus or lichen planus .
      • Irritation from douches, spermicides, or latex condoms.
    • Dyspareunia (say "dis-puh-ROO-nee-uh"). This is physical pain that occurs during entry into the vagina, during deep thrusting, or after sexual intercourse.

    Partner and emotional influences

    Living situations that give couples very little privacy can interfere with feelings of arousal.

    Your partner's level of sexual skill and attention can play a big part in your sexual enjoyment. A positive, respectful connection between partners sets the stage for sexual interest and arousal.

    Positive sexual experiences help build a healthy sexuality. On the other hand, a woman who has had a forced sexual experience is likely to have mixed feelings about sex. In one study, 1 out of 5 women reported having been forced to do something sexual. This was most often done by someone they were close to. 2

    Some women feel guilty, embarrassed, ashamed, or self-conscious during sex.

    A woman may avoid sex because she's afraid that an illness (such as cancer) or surgery (such as mastectomy or hysterectomy) will make sexual activity unpleasant for one or both partners.

    Or she may be afraid of spreading a sexually transmitted infection , such as genital herpes .

    Age-related influences

    As a woman ages, she may have sex less often because she no longer has a partner or her partner has lost interest in or is no longer able to have sex. Many older women also report problems with lubrication.

    Women may notice less desire for sex after menopause.

    It may take longer to feel sexually aroused, and orgasms may be briefer. But orgasms still will offer mental and physical pleasure to most women.

    Women can feel sexual pleasure throughout their lives. But those who stop having sex after menopause have more shrinking and drying of the vagina than women who continue to have sex. 2

    What Increases Your Risk

    A risk factor is anything that increases your chances of having a problem. The main risk factors for sexual problems are:

    • Having poor mental and emotional health.
    • Having problems with your sexual relationship.
    • Having a partner who has problems with sexual function.

    Other risk factors include:

    • Exhaustion, often from round-the-clock care of a baby or small children and/or parenting and having a job.
    • Normal hormonal changes linked to pregnancy, recovery from pregnancy, menopause, or aging.
    • Taking certain medicines that decrease your desire for sex.
    • Health problems that cause pain during sex or make it harder for you to engage in and enjoy sex. Such health problems include:
      • Nervous system problems such as stroke, spinal cord injury, and Parkinson's disease.
      • Surgery that affects the pelvic organs or genitals.
      • Diseases such as diabetes or liver disease.
      • Peripheral arterial disease .

    Sexual problems are common

    Most women have a sexual problem at one time or another. For some women, the problem is long-term.

    Surveys of the general population in the United States found that many women occasionally have sexual problems and worries. These may include: 2

    • Concerns about sexuality (6 out of 10 women).
    • Lack of interest in sex (3 out of 10 women).
    • Sex not always being pleasurable (2 out of 10 women).
    • Pain with sex (1 to 2 out of 10 women).
    • Difficulty becoming aroused (5 out of 10 women).
    • Difficulty reaching orgasm (5 out of 10 women).
    • Not being able to have an orgasm (2 to 3 out of 10 women).

    When To Call a Doctor

    Call a doctor for immediate care if you have sudden, severe pelvic pain.

    Call a doctor for an appointment if you feel pain or discomfort in your vaginal area. You may have a vaginal infection or a sexually transmitted infection .

    Watchful waiting

    Watchful waiting is a wait-and-see approach. If you improve on your own, you won't need treatment. If you don't improve, you and your doctor will decide what to do next.

    If you are having pain with sex, you need to see a doctor. For other sexual problems, it may help to talk with your doctor before trying watchful waiting.

    During watchful waiting, you might try home treatment, such as lubrication and exercises to stimulate sexual desire.

    Maintaining honest and frequent communications with your doctor will help you decide whether medical treatment is needed.

    Who to see

    Health professionals who can help you evaluate your symptoms and treat a sexual problem include:

    To prepare for your appointment, see the topic Making the Most of Your Appointment.

    Exams and Tests

    Your doctor will work with you to identify your symptoms. He or she will:

    • Ask questions about your medical history and the medicines you're taking.
    • Ask questions about your sexual history.
    • Have you answer a set of written questions that will give your doctor more details about your sexual problem.
    • Do a physical exam, in some cases. This may include a pelvic exam if you are having pain during sex.
    • Order tests, if they are needed. For example, blood tests can check hormone levels and thyroid function.

    It can be embarrassing to talk about sexual problems. It may help to remember that a sexual problem is no different than any other health problem. There is usually a treatment that will help.

    Treatment Overview

    Treatment will depend on the type of sexual problem you're having. Treatment may include:

    • Treatment of any physical causes.
    • Education about your body, your sexual signals and receptors, and changes in sexuality as you get older.
    • Counseling for you and your partner.
    • Psychological therapy. Therapy for sexual problems often involves cognitive-behavioral therapy .
    • Sex therapy.

    Treatment for decreased sexual desire

    Treatment for physical causes of this problem can include:

    • Changing a medicine that has been lowering your interest in sex.
    • Relieving pain, illness, or sleep problems that are lowering your interest in sex.
    • Low-dose estrogen. After menopause, low levels of estrogen in the body cause vaginal dryness. Estrogen reverses this.
    • Testosterone. Testosterone is sometimes used after natural or surgical menopause to improve sex drive. But long-term use of testosterone has not been shown to be effective in increasing sexual desire. 3
    • Exercise, to improve your mood and increase natural testosterone levels.

    Getting counseling as a couple can help strengthen your emotional connection with your partner. Improving a stressed relationship is likely to improve your sexual relationship.

    There are also steps you can take at home that may raise your sexual desire. To learn more, see Home Treatment.

    Having a partner you feel comfortable and nonstressed with plays a big part in your desire level. It's normal to lack desire for a partner who forces sex or is verbally abusive or physically violent.

    Treatment for decreased sexual arousal

    Treatment for decreased sexual excitement may include learning about the role emotions play and about how a woman's arousal sometimes depends on stimulating other parts of her body, especially her breasts.

    Treatment may also include:

    • Changing treatment for certain illnesses, if that treatment has side effects that lower your arousal.
    • Counseling, to help adjust expectations of sexual activity. If too much pressure is put on partners to perform, it can affect arousal.
    • Steps you can take at home, such as use of vaginal lubricants or masturbation.

    Treatment for inability to reach orgasm

    Treatment usually begins with changing any medicine that is known to affect orgasm. But don't stop taking your medicine without talking to your doctor first.

    If you're having trouble with orgasm or it takes much longer than it used to, you can try a number of things at home, such as self-stimulation and fantasy.

    It may also help to find out more about sexual response . For example, most women find it easier to have an orgasm from direct clitoral stimulation. And most couples do not have orgasms at the same time.

    Treatment for pain

    If pain is caused by a physical problem, treating that problem may get rid of the pain. But pain during intercourse may have more than one cause, including psychological causes such as anxiety or the memory of sexual assault. 2

    Pain when penis enters the vagina

    Pain that occurs when the penis first enters the vagina may be caused by involuntary contractions of the vagina (vaginismus). This is sometimes related to a lack of experience with sex. 1

    Treatment may include a program of progressive muscle relaxation and gradual vaginal dilation, possibly including psychotherapy.

    But pain during initial penetration also may be caused by vaginal irritation or another physical problem. If so, getting rid of the pain will require treating the physical reason.

    Other pain during intercourse

    If the pain is caused by the deep thrusting of the penis, the cause may be a pelvic disease. But it may also be caused by not being able to relax. Being able to talk openly with your doctor will help you explore the cause of the pain and decide on treatment.

    Treatment for aging and menopause-related sexual problems

    Vaginal dryness after menopause can sometimes be treated at home with lubrication.

    If home treatment doesn't work as well as you need it to, talk to your doctor about using estrogen. This hormone can be used in several forms to help menopause-related problems. To learn more, see Medications.

    Prevention

    You can take the following steps to help prevent sexual problems.

    • Look after your overall health-both your physical health and your emotional health.
    • Talk regularly to your partner about your needs and desires.
    • Become familiar with your own patterns and methods of sexual arousal, perhaps through masturbation.
    • Understand that many women do not always have orgasms during sex and that mutual pleasure can be a satisfying way to have sexual intimacy.
    • Use plenty of lubrication for your vagina to avoid dryness. This is the most common cause of painful sex.
    • Enjoy tenderness and closeness. And avoid expectations of great sexual performance.

    Being sexually active with a partner or through masturbation helps maintain vaginal health. And having regular sexual intercourse helps preserve vaginal elasticity and keeps vaginal tissues from shrinking.

    Home Treatment

    You can try a number of things at home that may help your sexual problems.

    Working with your partner

    • Increase the level of intimacy and foreplay with your partner before penetration.
    • Experiment with different sex positions to find the most comfortable ones.
    • Think about changing your setting and routine to improve your time together. Do you have enough privacy and time? Are you interested in trying something new?
    • Try talking and listening to each other more. This includes talking openly about sex, what each of you needs, and what you want to do differently together.

    Foreplay and relaxation

    You may be able to increase your sexual desire and arousal with:

    • Masturbation, possibly with the aid of a vibrator and/or with your partner.
    • Sensual massage and other pleasurable physical activities without sexual intercourse.
    • Fantasies, distractions, music, or erotic videos or books.
    • Reducing anxieties before sexual activity, perhaps by taking a warm bath.

    Vaginal lubricants

    Lack of lubrication in the vagina is the most common cause of pain with sex.

    Nonprescription water-based products that provide vaginal lubrication can help. You can typically find these products, such as Astroglide and K-Y Jelly, at pharmacies, usually near the condoms.

    Vaginal moisturizers, such as Replens, are not for use right before sexual intercourse. But when used regularly, they can help with vaginal dryness.

    Exercises for pelvic muscles

    Exercises can help you develop muscular control of contraction and relaxation of the pelvic muscles. This can increase sexual arousal and improve orgasm. You can improve pelvic floor muscle strength using Kegel exercises or vaginal weights.

    Vaginal weights usually come in five sizes. You start with the smallest weight, and work up to the largest over time. Insert a weight into your vagina, then hold it in place while standing upright for 15 minutes. Your muscles will feel the urge to tighten and hold it in.

    After a few days, the vaginal muscles become strong enough that they no longer feel an urge to hold the weight. This is when you use the next larger weight. When you've used all five weights, keep your muscles toned by using the largest weight for 5 to 7 days in a row each month.

    Medications

    Medicines may be used in treating certain conditions that contribute to sexual problems.

    Lidocaine gel

    For women who have pain in the area around the opening of the vagina (vulvodynia), putting on lidocaine gel shortly before sex may be helpful. Talk to your doctor about how to use the gel safely.

    Estrogen for postmenopausal women

    If you only have vaginal dryness and irritation (and not other symptoms such as hot flashes), you can use a limited amount of estrogen in a cream, tablet, or ring in the vagina. The daily estrogen makes your vaginal lining thicker. Many women find that using a cream or tablet twice a week is enough. This may increase vaginal tone and lubrication, which will decrease vulvar dryness, irritation, and shrinkage (atrophy).

    If you also have other menopausal symptoms that affect physical and mental well-being, talk to your doctor about taking daily estrogen. Estrogen can increase the blood flow in the vagina and reduce hot flashes and other symptoms of menopause.

    Estrogen therapy or estrogen-progestin therapy can be oral (pills), vaginal, or transdermal (with a patch). In a small number of women, hormone therapy can cause heart disease, breast cancer, ovarian cancer, dangerous blood clots, stroke, and dementia. Talk to your doctor about whether this therapy is right for you.

    Testosterone

    This hormone may play a part in a woman's sex drive and satisfaction. Your ovaries make testosterone throughout your life. Women have the most testosterone in early adulthood. Testosterone levels drop by half between the early 20s and the early 40s.

    A woman who has had surgery to remove her uterus (hysterectomy) and ovaries (oophorectomy) will suddenly be in menopause. She will have an immediate drop in both estrogen and testosterone. She may then have a problem with sexual desire. If so, her doctor may suggest hormone therapy.

    Other medicines

    Ospemifene (Osphena) is used to reduce vaginal changes that can make sex painful.

    Sildenafil (Viagra), which is used to treat erectile dysfunction in men, is being studied for use in women who have arousal problems but has not been shown to work. 3

    Surgery

    Surgery isn't used to treat sexual problems unless pain is caused by endometriosis or another medical condition.

    There are advertised procedures, such as "vaginal rejuvenation" surgeries, that promise to increase sexual pleasure. But such surgeries may not provide any benefit. And they may cause harm. They also may be costly and painful.

    Other Treatment

    Researchers continue to look for treatments for raising sexual desire, arousal, and satisfaction. The research includes both devices and herbal supplements.

    Some products, such as different vitamins and herbs, are promoted as natural treatments for sexual problems. But most of these products have not been subject to the same kind of testing for safety and effectiveness that standard medical treatments must go through before they are approved in the United States.

    If you decide to use an alternative medicine or supplement, follow these precautions:

    • Talk with your doctor first, especially if you are pregnant or trying to become pregnant, if you take prescription medicines, or if you have another health problem.
    • Follow the directions on the label, and don't take more than the recommended dose.

    DHEA

    Like testosterone, DHEA (dehydroepiandrosterone) is an androgen made in the body. Over-the-counter DHEA: 4

    • Is not known to improve sexual well-being in healthy women.
    • When taken by mouth, has the same risks of liver damage and negative effects on your cholesterol levels as oral testosterone. It also has the same unwanted hair-growth and acne side effects. This is because the body turns DHEA into testosterone.
    • Is not regulated by the government, so you cannot know for sure how much you are taking. Some DHEA supplements contain less DHEA than the labels claim. Others contain more than the labels claim.

    Eros Therapy device

    This is a small battery-operated device used to stimulate engorgement of the clitoris. It was cleared by the U.S. Food and Drug Administration (FDA) for sale in the U.S. in 2000.

    Using this device is said to increase lubrication and clitoral sensation, to help with achieving orgasm, and to improve women's sexual satisfaction.

    Initial studies have shown good results in women reporting sexual problems and also in women recovering from cervical cancer treatment. 4

    Other Places To Get Help

    Organizations

    American Congress of Obstetricians and Gynecologists (ACOG)
    Web Address: www.acog.org

    North American Menopause Society (NAMS)
    5900 Landerbrook Drive
    Suite 390
    Mayfield Heights, OH 44124
    Phone: (440) 442-7550
    Fax: (440) 442-2660
    Email: info@menopause.org
    Web Address: www.menopause.org
     

    The North American Menopause Society (NAMS) is a nonprofit organization that promotes the understanding of menopause and thereby improves the health of women as they approach menopause and beyond. NAMS members include experts from medicine, nursing, sociology, psychology, nutrition, anthropology, epidemiology, pharmacy, and education. The NAMS website has information on perimenopause, early menopause, menopause symptoms and long-term health effects of estrogen loss, and a variety of therapies.


    References

    Citations

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    2. Baram DA (2007). Sexuality, sexual dysfunction, and sexual assault. In JS Berek, ed., Berek and Novak's Gynecology, 14th ed., pp. 313-349. Philadelphia: Lippincott Williams and Wilkins.
    3. Drugs for female sexual dysfunction (2010). Medical Letter on Drugs and Therapeutics, 52(1353/1354): 100-102.
    4. American College of Obstetricians and Gynecologists (2011). Female sexual dysfunction. ACOG Practice Bulletin No. 119. Obstetrics and Gynecology, 117(4): 996-1007.

    Other Works Consulted

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    • Goldstein I (2007). Urological management of women with sexual health concerns. In AJ Wein et al., eds., Campbell-Walsh Urology, 9th ed., vol. 1, pp. 863-889. Philadelphia: Saunders Elsevier.
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    Credits

    By Healthwise Staff
    Sarah Marshall, MD - Family Medicine
    Kirtly Jones, MD - Obstetrics and Gynecology
    Last Revised April 30, 2013

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