Female Sexual Dysfunction
What Is Sexual Dysfunction in Women?
Sexual problems in women are very common and can occur at any age. Female sexual dysfunction is defined as a persistent and distressful problem for the woman, and may present in different forms:
- Lack of sexual desire (libido or sex drive)
- Lowered arousal (excitement)
- Inability to achieve orgasm
- Pain during intercourse (dyspareunia)
- Any combination of these effects
Roughly 35 to 40 percent of women may report sexual dysfunction issues, and 10 to 15 percent may consider it as a cause of significant stress or upset in their lives. Women most commonly report low sexual desire and inability to achieve orgasm as the top sexual problems. The prevalence of a sexual problem leading to significant distress is reported highest in the age group of 45 to 64 years. However, sexual problems can be a long term condition or may develop later in life after having a previously satisfying sex life.
Risk Factors for Female Sexual Dysfunction
The factors that increase the risk of sexual difficulties can be physical, psychological, or both. In most women, a combination of risk factors can lead to difficulties with intimacy, libido, or orgasm.
Physical factors contributing to sexual problems may include:
- Medications such as certain blood pressure treatments (beta-blockers), antihistamines, antipsychotics, antidepressants (SSRIs), benzodiazepines, antiepileptics
- Incontinence (fecal or urine)
- Drug, alcohol abuse
- Chronic medical diseases, such as: cancer, diabetes, multiple sclerosis, Parkinson’s disease, severe arthritis, heart disease
- Physical gynecologic issues: pelvic floor dysfunction, uterine fibroids, excessive bleeding, endometriosis, pain during intercourse (dyspareunia), vaginal dryness (atrophic vaginitis)
- Injuries to the back, nerve damage
- Endocrine (hormonal) disorders (thyroid, pituitary, or adrenal gland problems)
- Menopause and estrogen/testosterone deficiencies (hot flashes, night sweats, insomnia)
- Mastectomy, alopecia, or other physical scarring
- Stress, fatigue
- Lack of privacy
Psychological issues that may affect sexual function include:
- Chronic mental health conditions, such as: depression, anxiety, bipolar disorder
- Poor body image
- Physical or sexual abuse
- Sexual dysfunction in male partner (i.e., erectile dysfunction)
- Marital or relationship difficulties
- Lack of trust and open communication between partners
- Personal psychological problems including sexual fears or guilt, past sexual trauma
Types of Sexual Problems
Sexual dysfunction disorders are generally classified into 4 categories:
- Sexual desire disorders
- Sexual arousal disorders
- Orgasm disorders
- Sexual pain disorders
Sexual desire is libido or sex drive: in other words, the desire to have sexual activity which may involve sexual thoughts and images. Sexual desire disorders (decreased libido) may be caused by a decrease in the normal production of estrogen (in women) or testosterone (in both men and women). Other causes may be aging, fatigue, pregnancy, and medications -- the SSRI antidepressants which include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) are well known for reducing desire in both men and women. Psychiatric conditions, such as depression and anxiety, can also cause decreased libido.
Sexual arousal is another word for excitement, or sexual pleasure that may involve increased blood flow to the genitals, lubrication in women, and increased breathing, heart rate and blood pressure. These conditions may appear as an aversion to, and avoidance of, sexual contact with a partner.
Orgasm is defined as a climax of sexual arousal and pleasure centered in the genital area. Orgasm disorders are a persistent delay or absence of orgasm following a normal sexual excitement phase. The disorder occurs in both women and men. The SSRI antidepressants can interfere with orgasm.
Sexual pain disorders affect women almost exclusively, and are known as dyspareunia (painful intercourse) and vaginismus (an involuntary spasm of the muscles of the vaginal wall, which interferes with intercourse). Dyspareunia may be caused by insufficient lubrication (vaginal dryness) as a result of thinner and drier vaginal tissues due to reduced levels of estrogen that occur during menopause. Poor lubrication may result from insufficient excitement and stimulation, or from hormonal changes caused by menopause, pregnancy, or breastfeeding.
Symptoms of Female Sexual Dysfunction
- Lack of interest in sex (loss of libido)
- Inability to feel aroused
- Pain with intercourse
- Inability to relax vaginal muscles enough to allow intercourse
- Inadequate vaginal lubrication before and during intercourse
- Inability to attain orgasm
- Burning pain on the vulva or in the vagina with contact to those areas
Diagnosis of Female Sexual Dysfunction
Specific physical findings and testing procedures depend on the form of sexual dysfunction being investigated. A complete history is usually taken and a complete physical examination performed to:
- Identify predisposing illnesses or physical conditions
- Highlight possible fears, anxieties, or guilt specific to sexual behaviors or performance
- Uncover any history of prior sexual trauma
- Change a drug treatment or class if sexual dysfunction thought to be due to a medication
Treatment Options for Sexual Problems
Treatment depends on the cause of the sexual dysfunction. Before any treatment is started, all underlying causes linked to the sexual dysfunction should be assessed and treated (eg, depression, anxiety, pelvic pain). It is preferable to try available non-drug therapies before taking medications for sexual dysfunction; however, a combination of options may be used, as well.
Treatments may involve many different techniques to treat problems associated with sexual arousal disorders and orgasm.
Focus of treatment should be directed towards optimal physical and mental health, as well as partner interactions. A licensed counselor or sex therapist may be recommended, and communication with the partner should be discussed. Simple, open, accurate, and supportive education about sex and sexual behaviors or responses may be all that is needed in many cases. Psychotherapy may be required to address anxieties, fears, inhibitions, or poor body image. Stress in a woman’s life, such as stress due to a partner relationship or added burden due to the caretaker role for children or elderly parents should be addressed.
Pelvic floor physical therapy, strengthening physical therapy, and mechanical aids such as vaginal dilators may prove helpful for some people experiencing sexual dysfunction due to physical illnesses, conditions, or disabilities. Vaginal dilators may be placed in the vagina for 5 to 10 minutes each night. Over time, the dilator will stretch the vagina until intercourse is comfortable. Your physician or a specially trained physical therapist can guide these exercises.
Sexual arousal in women can be enhanced with clitoral stimulation by using a vibrator. Using devices can add novelty and excitement and may enhance the overall sexual experience for both partners.
Vaginal Lubricants and Moisturizers
Over-the-counter, nonhormonal, water-based vaginal lubricating gels may be helpful for vaginal dryness or discomfort. Vaginal dryness due to vaginal atrophy is a very common symptom in women who are going through menopause (perimenopause) or who have had a hysterectomy, and can lead to painful sex (dyspareunia). Vaginal gels and lubricants have very few if any side effects. Water-based vaginal lubricants such as:
- K-Y Touch
are helpful to use right before and during sex, and can be applied to either man or woman. If your partner is using a condom, be sure to use a water-based lubricant. Petroleum-based lubricants, such as Vaseline, will damage condoms and can interfere with protection from pregnancy and sexually transmitted diseases. Avoid glycerin-based products if they cause irritation.
Vaginal moisturizers are formulated to allow water to be retained in the vaginal tissues over a longer period of time. Non-prescription products such as:
- Vagisil Feminine Moisturizer
are typically applied vaginally every 3 days to reduce vaginal dryness; they are not used during sex as they can be irritating. These products must be used consistently as directed to maintain their effectiveness.
Low Dose Vaginal Estrogen
Loss of estrogen leads to vaginal dryness and vaginal atrophy (thinning of tissues). Lower amounts of estrogen leading to vaginal dryness can occur:
- During perimenopause and menopause
- After surgical removal of the ovaries
- After certain cancer treatments of the ovary (radiation, chemotherapy, endocrine therapy)
- After childbirth
- During breastfeeding
- Due to certain medications, such as danazol, medroxyprogesterone, leuprolide (Lupron), or nafarelin, often used for endometriosis or uterine leiomyomata
Women with vaginal dryness who are not helped with over-the-counter lubricating gels or moisturizers might ask their doctor about low-dose prescription vaginal estrogen or estradiol, a very effective treatment. Only small amounts of estrogen are absorbed into the bloodstream when used vaginally. However, vaginal estrogen products will not treat hot flashes as the dose is too low to be absorbed. Vaginal estrogen usually relieves dryness within 2 to 3 weeks.
There is a smaller risk of serious side effects with low dose vaginal estrogens, such as breast cancer, blood clots, or a heart attack compared to taking estrogen orally. However, if you have a history of breast cancer, talk to your doctor about your risks. The safety of vaginal estrogen in women with a past history of breast cancer is unknown. The added use of a progestin is not usually required with vaginal estrogen used in a low dose.; however, this should always be discussed with your healthcare provider.
Examples of vaginal estrogen products and dosing:
- Premarin (conjugated estrogens) - vaginal cream: inserted at bedtime into the vagina with an applicator; used nightly for 1-3 weeks at first, then 1-3 times per week thereafter.
- Vagifem (estradiol vaginal) - vaginal tablet: use the applicator to insert the vaginal tablet following package directions; initially insert one tablet vaginally once a day for two weeks, then one tablet inserted into the vagina twice weekly.
- Estrace (estradiol topical) - vaginal cream: usual initial dose range is 2 to 4 grams (marked on the application) daily for 1 or 2 weeks; then gradually reduce to one-half the initial dose for the same time period. A maintenance dose of 1 gram, one to three times per week, may be used after restoration of vaginal symptoms.
- Estring (estradiol vaginal) - vaginal ring: one vaginal ring should be inserted into the upper third of the vagina either by you or your doctor. Each Estring ring lasts for 90 days and does not need to be removed prior to sex.
Some women prefer to use an oral tablet for vaginal atrophy and pain during sex rather than a vaginally-administered product. In February 2013, the FDA approved:
- Osphena (ospemifene), an estrogen-like product called a selective estrogen receptor modifier (SERM) to treat women experiencing moderate to severe pain during sexual intercourse. Osphena comes in a 60 mg tablet and is taken once daily with food. Osphena does not directly increase sex drive but may make sex more comfortable and enjoyable.
SERMs bind to estrogen receptors but act either as agonists (activates the receptor) or antagonists (blocks the receptor) in different tissues. On some tissues, Osphena acts like an estrogen and on other tissues it acts like an anti-estrogen. Osphena has estrogenic-like activity to build vaginal tissues and reduce pain during sex.
Common side effects with Osphena may include hot flashes, vaginal discharge, and vaginal bleeding. Osphena may increase the risk of stroke, heart disease, blood clots, endometrial cancer, and breast cancer. Usually estrogen products used in women with an intact uterus are given with a progestin; however, this is not a requirement with Osphena. Women should see their health care professional if they experience any unusual bleeding.
The medication may cause hot flashes as a side effect. This type of medication may increase the risk of blood clots or uterine cancer.
- Intrarosa (prasterone) is a once-daily vaginal insert approved in November 2016 to treat postmenopausal women experiencing moderate to severe pain during sexual intercourse (dyspareunia) as a symptom of vulvar and vaginal atrophy (VVA) due to reduced estrogen levels.
Intrarosa is the first FDA approved product containing the active ingredient prasterone, also known as dehydroepiandrosterone (DHEA). The most common side effects include vaginal discharge and abnormal Pap smear. In two 12-week placebo-controlled clinical studies in 406 postmenopausal women, Intrarosa, when compared to placebo was shown to reduce the severity of pain experienced during sexual intercourse.
In August 2015, Addyi (flibanserin) was approved for the treatment of acquired, generalized hypoactive sexual desire disorder (HSDD) in premenopausal women. It is meant to be used in premenopausal women who have a low libido that causes distress in their life.
Addyi, a multifunctional serotonin agonist antagonist (MSAA), is the first approved medication for HSDD. While the drug showed modest benefit in clinical trials, it’s side effects, including fainting with alcohol use, prompted many labeling restrictions: a Boxed Warning, a REMS plan, required certification for providers and pharmacies, and a Patient-Provider Agreement Form. Women will need to discuss these issues with their doctor prior to starting Addyi.
Addyi is given daily as a 100 milligram (mg) tablet taken by mouth at bedtime. Addyi should not be used in patients with liver disease, with alcohol, and with many prescription drugs. The most common side effects with Addyi are dizziness, sleepiness, nausea, fatigue, insomnia and dry mouth.
- Androgens such as testosterone are not commonly recommended for treatment of sexual side effects in women.
These treatments are not FDA approved due to lack of effectiveness and studies on long-term safety are lacking. Androgen side effects in women may include facial hair growth, hair loss (alopecia), acne, voice deepening, elevated cholesterol, liver problems, blood clots, and increased risk for breast cancer.
Estroven is an over-the-counter (OTC) dietary supplement that contains phytoestrogens and has been available since 1997. Phytoestrogens are naturally occurring compounds found in plants including soybeans, whole grain cereals, seeds, nuts and many herbs. Phytoestrogens have a structure similar to natural estrogen and is promoted to support hormonal balance.
Estroven is marketed to reduce physical and psychological effects of hormonal imbalance associated with perimenopause, menopause and postmenopause. This can include night sweats, hot flashes, memory lapses, weight issues, sleeplessness, and mood changes, However, these statements have not been verified by the FDA. The usual dose for Estroven is one caplet daily taken by mouth a few hours before bedtime with food.
According to the manufacturer, Estroven does not contain synthetic, animal or human-derived hormones. The two main ingredients in all Estroven brand supplement products are soy isoflavones and black cohosh. While both of these dietary supplements have been available for many years, usually without significant concerns, there can be important drug interactions with these products, so it's important to have a drug interaction screen with all OTC products, prescription drugs and other dietary supplements.
The primary ingredients in Estroven include:
- Black Cohosh Root (Cimicifuga racemosa, a North American herb)
- Soy isoflavones
- Magnolia bark
- Ginkgo Biloba
- Cissus quadrangularis (Synetrim CQ, perennial plant of the grape family)
Sexual Side Effects from Antidepressants
Sexual dysfunction, such as decreased libido (sexual drive), inhibited orgasm, erectile dysfunction, and ejaculatory failure, is a common side effect of many antidepressants, especially the selective serotonin reuptake inhibitors (SSRIs).
If you are being treated with an antidepressant and encounter any of these side effects, speak with your doctor about a medication change. Options may be to lower your dose, change your medication, or add a medication -- such as bupropion -- to counteract sexual dysfunction. Do not change or stop your medicine unless directed to do so by your doctor.
Antidepressants that may have lower or no sexual side effects include:
- Wellbutrin (bupropion)
- Serzone (nefazodone)
- Remeron (mirtazapine)
- Cymbalta (duloxetine)
Prevention of Sexual Dysfunction
Open, informative, and accurate communication regarding sexual issues and body image between parents and their children may prevent children from developing anxiety or guilt about sex and may help them develop healthy sexual relationships.
Review all medications, both prescription and over-the-counter, for possible side effects that relate to sexual dysfunction. Antihistamines that led to drowsiness (e.g., Benadryl) and drugs with anticholinergic properties can aggravate vaginal dryness.
Maintaining a healthy lifestyle, with regular physical activity, stress reduction, and healthy eating habits. Avoiding drug and alcohol abuse will also help prevent sexual dysfunction.
People who are victims of sexual trauma, such as sexual abuse or rape at any age, are urged to seek psychiatric advice. Individual counseling with an expert in trauma may prove beneficial in allowing sexual abuse victims to overcome sexual difficulties.
- Memos on Menopause: What Every Woman Needs to Know
- Melatonin: Worth Losing Sleep Over?
- Ladies A Moment: 10 Health Screenings That All Women Need
- Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol. 2008;112(5):970.
- Shifren JL. Patient education: Sexual problems in women (Beyond the Basics). UptoDate. 09/2015. Accessed 12/16/2016 at https://www.uptodate.com/contents/sexual-problems-in-women-beyond-the-basics?source=related_link
- Vaginal atrophy. Drugs.com. Disease Reference. Accessed 12/16/2016 at https://www.drugs.com/mcd/vaginal-atrophy
- Estring (estradiol ring) [package insert]. Revised: 3/2016. Pharmacia and Upjohn. Accessed December 31, 2016 at http://www.estring.com/.
- Estrace (estradiol vaginal cream 0.01%). [package insert]. Revised: 12/2011. Warner Chillcott. Accessed December 31, 2016 at https://www.estracecream.com/
- Shifren JL, Barbieri RL, Falk SJ. Sexual dysfunction in women: management. UptoDate. May 2016. Accessed December 31, 2106 at https://www.uptodate.com/contents/sexual-dysfunction-in-women-management