Sexual dysfunction in women includes pain during intercourse, increased tension of the muscles around the vagina (vaginismus), lack of interest in sex (low libido), and problems with arousal or orgasm.
Sexual problems in women may have physical, social, or psychological causes, and often a combination, with each impacting the other.
To diagnose sexual issues, doctors often talk with a woman and, sometimes, her partner; a pelvic examination is often necessary when a 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.
People initiate or engage in sexual activity for many reasons, including to share sexual excitement and physical pleasure; experience affection, love, or romance; and procreate. Women are more likely than men to report emotional motivations for sexual activity, such as to:
Experience and encourage emotional intimacy
Increase their sense of well-being
Confirm their desirability
Please or placate a partner
Sexual function is an important part of quality of life and overall health. Women commonly have concerns about sexual function. (See Normal Female 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)
Physical changes of sexual arousal (fullness, swelling, increased sensitivity) that occur without feeling desire and that are not relieved with orgasm (called persistent genital arousal disorder)
Involuntary tightening of the muscles that surround 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)
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.
Another major contributor to sexual dysfunction in women who are menopausal is genitourinary syndrome of menopause. (See sidebar Spotlight on Aging: Sexual Dysfunction in Older Women.)
Often, women with sexual dysfunction have features of more than 1 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.
Female Sexual Function Cycle
Sexual function and responses involve the mind (thoughts and emotions), interpersonal and social factors (relationships, sources of stress), and the body (including the nervous, circulatory, and hormonal systems). Traditionally, sexual response has been thought to consist of a sequence of events, as follows:
Desire, also called sexual interest or libido
Arousal
Orgasm
Resolution
However, for many women, sexual desire does not start spontaneously. Instead, it may develop in response to physical touch, intimacy, or emotional closeness. Desire and arousal often happen together and can be hard to separate. Feeling physically comfortable and emotionally satisfied can motivate people to seek out and enjoy sexual experiences.
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 a 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, though 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 of Sexual Dysfunction in Women
Many factors cause or contribute to the various types of sexual dysfunction. Traditionally, causes are considered physical or psychological. However, the 2 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 a situation or context than to the woman alone. 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 intimacy, or of losing control—and issues with body image or a sense of oneself as a sexual person 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 or intimate partner violence, 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.
Negative or difficult interpersonal experiences, such as loss of a loved one during childhood or previous relationship problems may result in difficulty becoming intimate with a sex partner.
Various sexual worries can impair sexual function. For example, women may be worried about unwanted consequences of sex (such as pregnancy or sexually transmitted infections) or about their or their partner’s sexual function.
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 changes to other body parts (eg, limb amputation, colostomy).
Relationship: Women may not trust or may have negative feelings about their partner. They may feel less attracted to their partner than they did 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, 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.
Similar symptoms can also result from removal of both ovaries or during breastfeeding.
Selective serotonin reuptake inhibitors (SSRIs), a type of antidepressant, commonly cause problems with sexual function. These medications may contribute to decreased libido or changes in the ability to have an orgasm.
Alcohol can also cause problems with sexual function.
What Affects Sexual Function in Women?
Type | Factor |
|---|---|
Psychological factors | Anxiety or stress Depression Fear of intimacy Fear of losing control Cultural background or education that results in limits on sexual activity or a feeling that sex is negative or shameful Issues with body image Issues with a sense of oneself as a sexual person Changes in body image or sexual self-image as a result of a physical issue, such as urinary incontinence, pelvic organ prolapse, or having had surgery to remove a breast, the uterus, or changes to other body parts (such as a limb amputation or having a colostomy) Worry about having sexual function issues during sexual activity (eg, inability to have an orgasm, sexual pain, ability to please a partner) Worry about unwanted consequences of sex (such as unwanted pregnancy or sexually transmitted infections) Relationship problems Abuse or trauma (emotional, physical, or sexual) during childhood, adolescence, or adulthood) |
Situational factors | Periods of time with increased stress or lack of private time with a partner (eg, due to long work hours, child care responsibilities, grieving the loss of a loved one) Surroundings that are not conducive to sexual activity, such as living situations with limited privacy or with noise or other interruptions or distractions Illness (some illnesses are temporary; chronic illness may cause ongoing disruption of sexual function) Partner's sexual function issues (eg, erectile dysfunction) |
Physical factors | Irritation or inflammation of the labia or vagina (eg, due heat, moisture, friction, or an allergic reaction) Genitourinary syndrome of menopause (changes in the vagina and urinary tract that can occur at menopause, including thinning of tissues of the vagina, resulting in dryness and pain) Sexually transmitted infections or other infections of the reproductive system (eg, yeast infection) Unexplained pain of the vulva (vulvodynia) that is constant or occurs with touch or pressure Changes in the skin of the labia (such as lichen sclerosus) Pelvic organ prolapse (dropping down of a pelvic organ such as the vagina or uterus) Changes in libido, arousal, or orgasm after menopause or premature menopause (ovarian insufficiency) Abnormalities in genital organs (such as birth defects, surgical changes, or scarring after radiation therapy) History of having a female genital mutilation procedure (female circumcision) Breastfeeding Fatigue Poor health Physical disability Nerve damage (as may result from diabetes, multiple sclerosis, peripheral neuropathy, or spinal cord disorders) |
Medications and substances | Alcohol Substance use disorder (continuing to use a substance despite having problems caused by its use) 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, endometriosis, or certain cancers) |
Diagnosis of Sexual Dysfunction in Women
Discussion with a 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 1 of the following:
Pain during sexual activities
Loss of sexual desire
Impaired arousal
Inability to achieve orgasm
Diagnosis of sexual dysfunction disorders involves detailed interviewing of a woman and, sometimes, her partner. Doctors first ask a woman to describe the problem in a 2-step approach: first they start with a statement that helps normalize any potential concerns a woman may have (for example, "Many women with endometriosis experience issues with sexual function."); then they follow up a closed-ended question that invites a woman to describe her issue in her own words (for example, "Do you have pain with sex or any other sexual concerns?"). Doctors ask about the following in this comprehensive interview:
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 evaluate for abnormalities (such as lesions, infections, pelvic organ prolapse) in the external and internal organs, including the vulva, vagina, cervix, uterus, fallopian tubes, and ovaries.
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 if something is too painful.
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.
Treatment of Sexual Dysfunction in Women
Treatment of causes
Prescribing medications to treat sexual dysfunction, or adjusting or discontinuing medications with sexual side effects
Pelvic physical therapy
Personal or couple's psychotherapy or sex therapy
Treatment for sexual problems in women depends on the type of problem (for example, low desire or difficulty having an orgasm), whether there is a clear medical or psychological cause or contributing factors, and what a woman's treatment goals are. Doctors usually consider many different aspects of sexual health, including physical, emotional, and relationship factors.
Doctors first address any medical or mental health conditions that may affect sexual function. Some medications can affect sexual desire or response. Changing or stopping a medication may help, but this decision is made carefully, weighing the benefits of the medication against the sexual side effects.
For many women, treatment begins with basic approaches, which may include using vaginal lubricants or moisturizers and/or making lifestyle changes (such as reducing stress or improving communication with a partner).
Vaginal lubricants and moisturizers can reduce vaginal dryness, which causes pain during intercourse. Lubricants are used during sexual activity. Vaginal moisturizers are used 3 or more times per week. These treatments include food-based oils (such as coconut oil), silicone-based lubricants, and water-based products. Water-based lubricants dry quickly and may have to be reapplied, but they are preferred over petroleum jelly and other oil-based lubricants, which can damage latex prophylactic and contraceptive devices such as condoms and diaphragms. Silicone-based lubricants can be used with condoms and diaphragms, as can water-based lubricants.
If needed, medications may be used, and doctors explain their risks and benefits. Many women also benefit from psychotherapy or sex therapy, either individually or with a partner. If there is pain during sex, or if problems like urinary leakage or pelvic organ prolapse interfere with sexual activity, pelvic physical therapy may be helpful.
Some general measures can help regardless of the cause:
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.
Improving communication between a woman and her partner, particularly about sex: This can lead to an open exploration of options for improving the satisfaction of both the woman and her partner.
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: A woman or her partner may be preoccupied with or distracted by other activities (involving work, household chores, or children). Making sure the place is private can help if a woman is afraid of lack of privacy or interruption. Enough time should be allowed, and a setting that encourages sexual feelings may help.
Learning about a woman's anatomy and how it relates to normal sexual response: This one step may help change both people's perceptions about the ways in which women are more likely to achieve sexual satisfaction (for example, nonpenetrative sex may be more likely to increase the woman's arousal than penetrative sex, and sexual activity without orgasm can be pleasurable and satisfying to many women).
Requiring that both partners consent to all acts of intimacy: Using explicit verbal communications about what each person desires and needs from sexual intimacy may be needed to lessen anxiety, reduce the risk of nonconsensual acts that involve coercion and submission, and enhance overall intimacy. Stroking and kissing responsive parts of the body before touching each other's genitals enough before initiating intercourse may also enhance arousal and intimacy by giving the woman's body time enough to respond.
Learning and communicating with her partner before and during sex about which activities she finds sexually exciting and satisfying: This allows the woman to both set and enjoy the pace and sequence of sexual activities.
Taking steps to prevent unwanted consequences: Fear of becoming pregnant or of contracting 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 may be helpful if a woman feels distracted or anxious and enables her to experience sensations during sexual activity by staying in the moment.
Just becoming aware of what is required for a healthy sexual response may be enough to support a woman in identifying sexual function issues and taking actions to address them.
Medications
Vaginal hormone therapy can be used to treat sexual dysfunction in women with genitourinary syndrome of menopause (vaginal atrophy). When estrogen levels decrease due to menopause (or sometimes other causes, such as certain cancer treatments), the vulvar and vaginal tissues can become thin and fragile. This may result in vaginal dryness and pain during sex. When women have only vaginal and urinary symptoms (and don't have other menopausal symptoms, such as hot flashes), doctors usually prescribe forms of hormone therapy that are low-dose and are applied directly to the vagina. Vaginal estrogen therapy comes in a few different forms. It can be inserted into the vagina as a cream (with a plastic applicator), as a tablet, or in a vaginal ring. Estrogen cream may also be applied externally to the vulva. Another type of vaginal hormone therapy is prasterone (a synthetic form of dehydroepiandrosterone [DHEA]), which is inserted as a suppository into the vagina.
An oral medication, ospemifene (a selective estrogen receptor modulator), is available for treatment of genitourinary syndrome of menopause in women who cannot apply vaginal hormone therapy.
For sexual interest/arousal disorder, 2 medications are available, flibanserin and bremelanotide. Other options that are potentially effective include testosterone, bupropion, and buspirone. However, less is known about use of these medications for sexual function.
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 ultrasound: 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 from a health care professional and over the counter, to stretch and to make the vagina less sensitive. Sexual activity may then be more comfortable.
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
Older women may develop sexual problems for various reasons. 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, lack of interest in sex is common. This may be seen as a problem by a woman or not, depending on whether her lack of libido causes her distress. Another reason older women give up on sex is when a partner has sexual function problems or when they do not have a partner. Or they may be worried about the general health of their partner. After menopause, less estrogen is produced, and this may result in changes in the vaginal tissues called genitourinary syndrome of menopause, which includes the following:
After menopause, some women experience a decrease in sexual interest, arousal, or ability to have an orgasm. The hormonal reasons for this are not clearly understood. When menopause occurs, blood levels of the hormones estrogen and progesterone decrease markedly. However, women's testosterone levels are usually highest in their 20s and then decrease slowly with age. There is no abrupt change with menopause. So, it is unclear what roletestosterone plays in women's sexual function. Other problems may interfere with sexual function. For example, some women may experience negative changes in body image or their sense of themselves as a sexual person as they age. This may also occur if they have illness, physical limitations, or surgeries or other treatments that result in change in their bodies. They may have cultural views that sexual desire and fantasy are improper or shameful at an older age. Older women should not assume that sexual dysfunction is normal for older age. If they have sexual function concerns, 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. For vaginal dryness or painful sex due to menopause, treatment with vaginal lubricants and moisturizers is used first. If this does not help, many women can be treated with vaginal hormone therapy, including low-dose estrogen (as a cream, tablet, or ring) or dehydroepiandrosterone (DHEA, as a suppository). Estrogen can also 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 if hormone therapy does not have too high a risk of complications for them, depending on health status and age. 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. |
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