Sexual dysfunction includes painful intercourse, painful contraction (spasm) of the vaginal muscles, or a problem with sexual desire, arousal, or orgasm that causes distress.

• Depression or anxiety, other psychologic factors, disorders, and drugs can contribute to sexual dysfunction, as can the situation.
• To identify a problem, doctors often talk to both partners separately and together, and a pelvic examination is often done to check the woman.
• Improving the relationship, communicating more clearly and openly, and arranging the best circumstances for sexual activities can often help, regardless of the cause of sexual dysfunction.

About 30 to 50% of women have sexual problems at some time during their life. If the problems are severe enough to cause distress, they may be considered sexual dysfunction. Sexual dysfunction can be described and diagnosed in terms of specific problems, such as lack of interest or desire, difficulty becoming aroused or reaching orgasm, pain during sexual activity, or involuntary tightening of the muscles around the vagina. However, these distinctions are not always useful. Almost all women with sexual dysfunction have features of more than one such specific problem. For example, women who have difficulty becoming aroused may enjoy sex less, have difficulty reaching orgasm, or even find sex painful. Women who have pain during sexual activity often understandably lose their interest and desire for sex.

Normal Sexual Function

Sexual function and responses involve mind (thoughts and emotions) and body (including the nervous, circulatory, and endocrine systems). Sexual response consists of the following:

• Desire is the wish to engage in or continue sexual activity. Desire may be triggered by thoughts, words, sights, smells, or touch. Desire may be obvious at the outset or may build once the woman is aroused.
• 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. In women, the increased blood flow causes the clitoris (which corresponds to the penis in men) and vaginal walls to swell (a process called engorgement). The increased blood flow also causes vaginal secretions (which provide lubrication) to increase. As women age, blood flow may increase less. Blood flow also may increase without the woman being aware of it and without her feeling aroused.
• 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.
• 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. Many women can respond to additional stimulation almost immediately after resolution.

Most people—men and women—engage in sexual activity for several reasons. For example, they may be attracted to a person or desire physical pleasure, affection, love, romance, or intimacy. However, women are more likely to have emotional motivations. Many women initiate or agree to sexual activity because they want one or more of the following:

• To experience emotional intimacy
• To increase their sense of well-being
• To confirm their desirability
• To please or placate a partner

Especially after a relationship has lasted a long time, women often have little or no desire for sex before sexual activity (initial desire), but desire can develop once sexual activity and stimulation begin. Desire before sexual activity typically lessens as women age but increases when women, regardless of their age, have a new partner. Some women may feel sexually satisfied whether they have an orgasm or not. Other women have much more sexual satisfaction with an orgasm.

Did You Know... Women in a long-term relationship often have little or no desire for sex until sexual activity and stimulation begin.

Causes

Many factors cause or contribute to various types of sexual dysfunction. Traditionally, causes are considered physical or psychologic. However, this distinction is not strictly accurate. Psychologic factors can cause physical changes in the brain, nerves, hormones, and, eventually, the genital organs. Physical changes can have psychologic effects, which, in turn, have more physical effects. Some factors are related more to the situation than to the woman.

Psychologic Factors: Depression and anxiety commonly contribute. Previous experiences can affect a woman's psychologic and sexual development, causing problems, as in the following:

• Harsh sexual or other experiences 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.

Did You Know... Taking a selective serotonin reuptake inhibitor (a type of antidepressant) can interfere with sexual function, but so can depression.

Various sexual worries can impair sexual function. For example, women may be worried about unwanted consequences of sex or about their or their partner's sexual performance.

Situational Factors: Factors related to the situation may involve the following:

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What Affects Sexual Function in Women? Type Factor Psychologic factors Abuse (emotional, physical, or sexual) during childhood or adolescence Anxiety Depression Fear of intimacy Fear of losing control Fear of losing the partner 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 diseases) Situational factors Cultural background that restricts sexual expression or activity Distractions Relationship problems Surroundings that are not conducive to sexual activity Physical factors Atrophic vaginitis (thinning of tissues of the vagina) Fatigue Hyperprolactinemia (high levels of prolactin, a hormone produced by the pituitary gland) Poor health Surgical removal of both ovaries in premenopausal women Underactive thyroid gland (hypothyroidism) Some nerve disorders, such as multiple sclerosis Drugs Beta-blockers (used to treat hypertension or heart disorders) Drugs that block the production and activity of testosterone (including the diuretic spironolactone) Hormones (such as hormonal contraceptives or oral estrogen therapy) Certain antidepressants, particularly selective serotonin reuptake inhibitors

• The relationship: Women may not trust or have negative feelings about their sex partner. They may feel less attracted to their partner than earlier in their relationship.
• The surroundings: The setting may not be erotic, private, or safe enough for uninhibited sexual expression.
• The 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: Family, work, finances, or other things can preoccupy women and thus interfere with sexual arousal.

Physical Factors: Various physical conditions and drugs may lead or contribute to sexual dysfunction. Hormonal changes, which may occur with aging or result from a disorder, can interfere. For example, the tissues of the vagina can become thin, dry, and inelastic after menopause because estrogen levels decrease. This condition, called atrophic vaginitis, can make intercourse painful. Other conditions, such as the removal of both ovaries, can also cause estrogen levels to decrease and thus contribute to sexual dysfunction.

Selective serotonin reuptake inhibitors, a type of antidepressant, commonly cause problems. Estrogen therapy, if taken by mouth, sometimes used to control symptoms associated with menopause, can cause sexual dysfunction, but not always. In fact, estrogen therapy may enhance sexual function in postmenopausal women.

Diagnosis

Diagnosis often involves detailed questioning of both sex partners, alone and together. Doctors ask about symptoms, other disorders, drug use, the relationship between the partners, mood, self-esteem, childhood relationships, past sexual experiences, and personality traits.

Doctors also often need to do a pelvic examination. Doctors try to do this examination as gently as possible. They move slowly and often explain the examination procedures in detail. If the woman wishes, they may give her a mirror to observe her genitals. If she is fearful of anything entering her vagina, she can place her hand on the doctor's to control the internal examination. Usually, doctors do not need to use an instrument, such as a speculum, to diagnose sexual problems. Such instruments are needed to do a Papanicolaou (Pap) test.

If doctors suspect a sexually transmitted disease, tests are done.

Treatment

Certain treatments depend on the cause of dysfunction. However, some general measures can help regardless of the cause:

• Making time for and learning to focus on sexual activity: Women, who are used to multitasking, may be preoccupied with or distracted by other activities (involving work, household chores, children, and community). Making sexual activity a priority and recognizing how counterproductive distractions are may help. That is, women can concentrate their awareness (be mindful) during sexual activity and thus stay in the moment.
• Improving communication, including about sex, between the woman and her partner
• Choosing a good time and place for sexual activity: For example, late at night—when a woman is ready for sleep—is not a good time. 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.
• Setting aside time together that does not involve sexual activity: Couples who talk to each other regularly are more likely to feel sexual desire.
• Encouraging trust, respect, and emotional intimacy between partners: These qualities should be cultivated with or without professional help. Women need them to respond sexually. Couples may need help learning to resolve conflicts, which can interfere with their relationship.
• Taking steps to prevent unwanted consequences: Such measures are particularly useful when fear of pregnancy or sexually transmitted diseases inhibits desire.

Often, more than one treatment is required because many women have more than one type of sexual dysfunction. Psychotherapy benefits some women, particularly when psychologic factors are prominent. However, just becoming aware of what is required for a healthy sexual response may be enough to help women change their thinking and behavior.

Because selective serotonin reuptake inhibitors (SSRIs) may contribute to several types of sexual dysfunction, substituting another antidepressant that impairs sexual response less may help. Such drugs may include bupropion, moclobemide, mirtazapine, and venlafaxine. Also, taking bupropion with an SSRI may be better for sexual response than taking the SSRI alone. Some evidence suggests that if women stopped having orgasms when they started taking SSRIs, sildenafil may help them have orgasms again.

Last full review/revision November 2008 by Rosemary Basson, MD, FRCP(UK)