Dr. Sanjay Shah

If you have persistent, recurrent problems with sexual response or desire — and if these problems are making you distressed or straining your relationship with your partner — what you're experiencing is known medically as female sexual dysfunction.

Female sexual dysfunction isn't uncommon — many women experience problems with sexual function at some point in their lives. Female sexual dysfunction can be a lifelong problem, or it can happen later in life after you've experienced a period of satisfactory functioning.

Female sexual dysfunction has many possible symptoms and causes. Fortunately, they're almost all treatable. Communicating your concerns and understanding your body and its normal response to sexual activity are important steps toward gaining sexual satisfaction.

Symptoms

You can develop female sexual dysfunction at any age, but sexual problems often happen when your hormones are in flux — for example, after having a baby or during menopause. Sexual concerns may also occur with major illness, such as cancer or cardiovascular disease.

Your problems might be classified as female sexual dysfunction if you experience one or more of the following and you're distressed about it:

Your desire to have sex is low or absent.
You can't maintain arousal during sexual activity, or you don't become aroused despite a desire to have sex.
You cannot experience an orgasm.
You have pain during sexual contact.

When to see a doctor

If sexual problems are undermining your relationship or disrupting your peace of mind, make an appointment with your doctor for evaluation.

Causes

Several factors may contribute to sexual dissatisfaction or dysfunction. These factors tend to be interrelated.

Physical. Physical conditions that may cause or contribute to sexual problems include arthritis, urinary or bowel difficulties, pelvic surgery, fatigue, headaches, other pain problems, and neurological disorders such as multiple sclerosis. Certain medications, including some antidepressants, blood pressure medications, antihistamines and chemotherapy drugs, can decrease your sex drive and your body's ability to experience orgasm.

· Hormonal. Lower estrogen levels after the menopausal transition may lead to changes in your genital tissues and your sexual responsiveness. The folds of skin that cover your genital region (labia) become thinner, exposing more of the clitoris. This increased exposure sometimes reduces the sensitivity of the clitoris, or may cause an unpleasant tingling or prickling sensation.

In addition, the vaginal lining becomes thinner and less elastic, particularly if you're not sexually active. At the same time, the vagina requires more stimulation to relax and lubricate before intercourse. These factors can lead to painful intercourse (dyspareunia), and experiencing orgasm may take longer.

Your body's hormone levels also shift after giving birth and during breast-feeding, which can lead to vaginal dryness and can affect your desire to have sex.

· Psychological and social. Untreated anxiety or depression can cause or contribute to sexual dysfunction, as can long-term stress. The worries of pregnancy and demands of being a new mother may have similar effects. Longstanding conflicts with your partner — about sex or any other aspect of your relationship — can diminish your sexual responsiveness as well. Cultural and religious issues and problems with your own body image also may contribute.

Emotional distress can be both a cause and a result of sexual dysfunction. Regardless of where the cycle began, you usually need to address relationship issues for treatment to be effective.

Risk factors

Some factors may increase your risk of sexual dysfunction:

Depression or anxiety
Cardiovascular disease
Neurologic conditions, such as spinal cord injury or multiple sclerosis
Liver or kidney failure
Certain medications, such as antidepressants or high blood pressure medications
Emotional or psychological stress, especially with regard to your relationship with your partner
A history of sexual abuse

Preparing for your appointment

If you're experiencing ongoing sexual difficulties, such as low desire or lack of arousal, and it's causing you distress, make an appointment with your doctor. You may feel embarrassed to talk about sex with your doctor, but this topic is perfectly appropriate. Your doctor knows that a satisfying sex life is very important to a woman's well-being at every age and stage of life.

You may have a treatable, underlying condition, or your may benefit from lifestyle changes, therapy or a combination of treatments. Your regular doctor may diagnose and treat the problem or refer you to a specialist who can.

Here's some information to help you prepare for your appointment, and what to expect from your doctor.

Information to gather in advance

Your symptoms. Take note of any sexual difficulties you're having, including when and how often you usually experience them.
Your sexual history. Your doctor likely will ask about your relationships and experiences since you first became sexually active. He or she also may ask about any history of sexual trauma or abuse.
Your medical history. Write down any medical conditions with which you've been diagnosed, including mental health conditions. Also note the names and strengths of all medications you're currently taking or have recently taken, including prescription and over-the-counter drugs.
Questions to ask your doctor. Creating a list of questions in advance can help you make the most of your time with your doctor.

Basic questions to ask your doctor

The list below suggests questions to raise with your doctor about your sexual difficulties. Don't hesitate to ask more questions during your appointment if you don't understand something.

What may be causing my sexual difficulties?
Do I need any medical tests?
What treatment approach do you recommend?
If you're prescribing medication, are there any possible side effects?
How much improvement can I reasonably expect with treatment?
Are there any lifestyle changes or self-care steps that may help me?
Do you recommend therapy?
Should my partner be involved in treatment?
Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?

What to expect from your doctor

Your doctor may ask a number of very personal questions and may want to include your partner in the interview. To help your doctor determine the cause of your problem and the best course of treatment, be ready to answer questions such as:

What problems are you currently experiencing?
How much do these problems bother you?
How satisfied are you with your current relationship?
When did you first become sexually active?
Do you become aroused during sexual interactions with your partner?
Are you able to experience orgasm?
If you've had orgasms in the past, what were the circumstances?
Do you experience any pain with intercourse?
Are you using any form of birth control? If yes, what form?
What medications are you taking, including prescription and over-the-counter drugs as well as vitamins and supplements?
Do you use alcohol or recreational drugs? How much?
Have you ever had surgery that involved your reproductive system?
Have you been diagnosed with any other medical conditions, including mental health conditions?
Have you ever been the victim of sexual violence?

What you can do in the meantime

Keep the lines of communication open with your partner. Be honest about your dissatisfaction or the problem you're experiencing. Consider alternatives for intimacy and engage in sexual activities that are relaxing and rewarding for both of you. In this way, you can sustain your intimacy and ease the stress of the situation.

Tests and diagnosis

You might be reluctant to consult your doctor about sexual concerns, but your sexuality is integral to your well-being — and it’s standard practice during general medical visits for doctors to ask about sexual health. The more forthcoming you can be about your sexual history and current problems, the better your chances of finding an effective approach to treating them.

You may need a pelvic exam, during which your doctor will check for any physical changes that may be diminishing your sexual enjoyment, such as thinning of your genital tissues, decreased skin elasticity, scarring or pain.

Your doctor may also refer you to a counselor or therapist specializing in sexual and relationship problems.

Female sexual dysfunction often is divided into the following categories, which are not mutually exclusive:

Low sexual desire. You have diminished libido, or lack of sex drive.
Sexual arousal disorder. Your desire for sex might be intact, but you have difficulty or are unable to become aroused or maintain arousal during sexual activity.
Orgasmic disorder. You have persistent or recurrent difficulty in achieving orgasm after sufficient sexual arousal and ongoing stimulation.
Sexual pain disorder. You have pain associated with sexual stimulation or vaginal contact.

Sexual response is a complex interaction of many components, including physiology, emotions, experiences, beliefs, lifestyle and relationships. If any one of these components is disrupted, sexual drive, arousal or satisfaction may be affected.

Treatments and drugs

Women with sexual concerns most often benefit from a combined treatment approach that addresses medical as well as emotional issues. Occasionally, there's a specific medical solution — using vaginal estrogen therapy, for example, or switching from one antidepressant medication to another. More often, behavioral treatments — such as couples therapy and stress management — are needed to address the cause of female sexual dysfunction. And sometimes, a combination approach works best.

Nonmedical treatment for female sexual dysfunction

You can improve your sexual health by enhancing communication with your partner and making healthy lifestyle choices.

Talk and listen. Some couples never talk about sex, but open and honest communication with your partner can make a world of difference in your sexual satisfaction. Even if you're not used to communicating about your likes and dislikes, learning to do so and providing feedback in a nonthreatening manner can set the stage for greater sexual intimacy.
Practice healthy lifestyle habits. Avoid excessive alcohol. Drinking too much will blunt your sexual responsiveness. Also, stop smoking and start exercising. Cigarette smoking restricts blood flow throughout your body, and less blood reaching your sexual organs means decreased sexual arousal and orgasmic response. Regular aerobic exercise can increase your stamina, improve your body image and elevate your mood, helping you feel more romantic, more often. Finally, don't forget to make time for leisure and relaxation. Learning to relax amid the stresses of your daily life can enhance your ability to focus on the sexual experience and attain better arousal and orgasm.
Seek counseling. Talk with a counselor or therapist specializing in sexual and relationship problems. Therapy often includes education about how to optimize your body's sexual response, ways to enhance intimacy with your partner, and recommendations for reading materials or couples exercises. With a therapist's help, you may gain a better understanding of your sexual identity, beliefs and attitudes; relationship factors including intimacy and attachment; communication and coping styles; and your overall emotional health.

Medical treatment for female sexual dysfunction

Effectively treating sexual dysfunction often requires addressing an underlying medical condition or hormonal change that's affecting your sexuality.

Treating female sexual dysfunction tied to an underlying medical condition might include:

Adjusting or changing medications that have sexual side effects
Treating thyroid problems or other hormonal conditions
Optimizing treatment for depression or anxiety
Trying strategies recommended by your doctor to help with pelvic pain or other pain problems

Treating female sexual dysfunction linked to a hormonal cause might include:

Estrogen therapy. Localized estrogen therapy — in the form of a vaginal ring, cream or tablet — can improve sexual function in a number of ways, including improving vaginal tone and elasticity, increasing vaginal blood flow, enhancing lubrication, and having a positive effect on brain function and mood factors that impact sexual response.

· Androgen therapy. Androgens include male hormones, such as testosterone. Testosterone is important for sexual function in women as well as men, although testosterone occurs in much lower amounts in a woman. Androgen therapy for sexual dysfunction is controversial. Some studies show a benefit for women who have low testosterone levels and develop sexual dysfunction; other studies show little or no benefit.

Testosterone may be given as a cream that you apply to your skin. Sometimes, testosterone is given as a pill in combination with estrogen. Side effects, such as acne, excess body hair (hirsutism), enlargement of the clitoris, and mood or personality changes, are possible. Because long-term effects of testosterone therapy in women aren't known, you should be closely monitored by your doctor.

Hormonal therapies won't resolve sexual problems that have causes unrelated to hormones. Because the issues surrounding female sexual dysfunction are usually complex and multifaceted, even the best medications are unlikely to work if other emotional or social factors remain unresolved.

Other possible medical treatments

More research is needed before these agents might be recommended for treatment of female sexual dysfunction:

Tibolone. Tibolone is a synthetic steroid drug currently used in Europe and Australia for treatment of postmenopausal osteoporosis. In one randomized trial, postmenopausal women taking the drug experienced an improvement in overall sexual function and a reduction in personal distress compared with postmenopausal women taking estrogen, but the effect was small. Due to concerns over increased risk of breast cancer and stroke in women taking tibolone, the drug isn't approved by the Food and Drug Administration (FDA) for use in the U.S.
Phosphodiesterase inhibitors. This group of medications has proven successful in treating erectile dysfunction in men, but the drugs don't work nearly as well in treating female sexual dysfunction. At best, studies looking into the effectiveness of these drugs in women have yielded inconsistent results. One drug, sildenafil (Viagra) may prove beneficial for some women who experience sexual dysfunction as a result of taking selective serotonin reuptake inhibitors, a class of drugs used to treat depression.

Alternative medicine

More research is needed, but promising alternatives to traditional therapies for improving sexual satisfaction include these Eastern approaches:

Mindfulness. This type of meditation is based on being mindful, or having an increased awareness and acceptance of living in the present moment. You focus on what you experience during meditation, such as the flow of your breath. You can observe your thoughts and emotions but let them pass without judgment. Some research shows that mindfulness practiced during the course of group therapy improved many aspects of sexual response and reduced personal distress in women with desire and arousal disorders.
Acupuncture. Acupuncture involves the insertion of extremely thin needles in your skin at strategic points on your body. Traditional Chinese theory explains acupuncture as a technique for balancing the flow of energy or life force — known as qi or chi (chee) — believed to flow through pathways (meridians) in your body. By inserting needles into specific points along these meridians, acupuncture practitioners believe that your energy flow will rebalance. Acupuncture may have positive effects on women with sexual pain disorders. Another possible therapy is acupuncture to improve libido in women with low desire, although this area has yet to be rigorously studied.
Yoga. During yoga, you perform a series of postures and controlled breathing exercises to promote a more flexible body and a calm mind. Certain subsets of yoga aim to channel the body's sexual energy and improve sexual functioning. Very little data exist on the benefits of yoga on sexual functioning. However, the practice of yoga is associated with improved psychological well-being and overall health.

Coping and support

At each stage of your life, you may experience changes in sexual desire, arousal and satisfaction. Accepting these changes and exploring new aspects of your sexuality during times of transition contribute to positive sexual experiences.

Understanding your body and what makes for a healthy sexual response can help, too. The more you and your partner know about the physical aspects of your body and how it functions, the better able you'll be to find ways to ease sexual difficulties. Ask your doctor about how things like aging, illnesses, pregnancy, menopause and medicines might affect your sex life.

Sexual response often has as much to do with your feelings for your partner as it does with physical sexual stimuli. For women, emotional intimacy tends to be an essential prelude to sexual intimacy. Show affection and communicate openly with your partner about your feelings — it can help you reconnect and discover each other again.

To learn more about your body and how to communicate with your partner, check out these books:

"Resurrecting Sex: Solving Sexual Problems & Revolutionizing Your Relationship," by David Schnarch, Ph.D.
"What Your Mother Never Told You about Sex," by Hilda Hutcherson, M.D.
"The Elusive Orgasm: A Woman's Guide to Why She Can't and How She Can Orgasm," by Vivienne Cass, Ph.D.