Sexual Problems

Sex is a normal, healthy and usually pleasurable part of life.

The female sexual response is fairly complex though, and it is not uncommon for many women to experience sexual problems from time to time during their life.

Almost every gynecologic condition, for example, can affect sex for women, whether it is a hormonal imbalance, changes in lubrication, conditions that cause pain with sex, conditions that cause a lot of bleeding, problems with vaginal laxity and relaxation, abnormal discharge and vaginitis, pelvic floor spasm, STDs or fear of STDs, contraceptive method. Helping improve a sexual problem is sometimes as simple as improving the underlying medical condition. General medical conditions such as depression, certain medications, cancer, and other chronic disease, can affect sex as well.

Sometimes however, even in the absence of any gynecologic condition or concern, sexual problems still exist. If you are experiencing a problem with sex that is worrying or upsetting, you may wish to bring it up to your provider at Women's Health Connection. Often we can help, although we do not always have an immediate solution.

Differences in the Male and Female Sexual Response Cycles

It is important to realize first of all, that although the male sexual response is fairly straightforward (ie desire, arousal, orgasm, resolution), the female sexual response does not necessarily follow that nice neat pattern. For starters, for men, sex is often stress relief. Not so for many women (although for some it is). Often women need their lives to fairly stress-free, or at least feel stress is well controlled, before they are receptive to the idea of initiating in or participating in sexual activity. For some women, particularly with gynecologic problems, or issues with body image and perception, sex may actually be a source of stress.

For some women, the sexual response begins with desire ("libido"). This is particularly true for women seeking or establishing a relationship, or desiring pregnancy. Desire (libido) is often different throughout the menstrual cycle, being highest at ovulation. Libido varies throughout life, however, and is highly tied in with stress and with hormones.

For many women, especially those in a long term relationship, the sexual response cycle does not begin with desire and this “desire” is not the starting point for many women. It is not uncommon in long term relationships and with aging, for women to be motivated to have sex in order to feel closer to her partner or express feelings, rather than from physical desire, and not to be motivated at all in the absence of such feelings. As such, the first response is often "arousal" rather than "desire", ie sex is initiated for a reason other than sexual desire, but once initiated, the physical desire is present.

A decreasing libido is part of the normal aging process for both men and for women. Sometimes women notice an abrupt change however, with a stressful event in their lives, or with a surgery (particularly one in which the ovaries are removed), or with menopause, or depression. Changes in one's self esteem and perception of body image can also play a role. For some women, the changes in their body after childbirth, or after a weight gain, can cause trouble with desire, and sometimes arousal as well. Anticipating pain with sex can also have a crushing effect on both desire and arousal.

During the arousal phase, a number of physical changes happen: Lubrication increases, bloodflow to the vulva and vagina increases, heartbeat, breathing and body temperature increase, the nipples, clitoris and vagina become more sensitive, and the vagina expands. An aroused vagina can accommodate and easily stretch in an elastic way to twice its non-aroused size. Typically with arousal, the upper two thirds of the vagina expands, and the lower third contracts. Thus gynecologists who do pelvic floor repairs and vaginal rejuvenation procedures, typically leave the upper part of the vagina free to expand, and focus on the lower part of the vagina, where tightening typically occurs, but may not be because of the muscle and fascia tears that often occur with childbirth.

Sometimes the situation may not feel right, and arousal and desire do not occur even after the initiation of sexual activity. Feeling unsafe, or anticipating pain are two common reasons this happens, and the lack of response may be a healthy response in these situations.

Orgasm is the peak of sexual arousal when all the muscles that were tightened during arousal relax then spasm rhythmically, causing a pleasurable feeling that often involves the whole body. Heart rate goes up even higher, breathing is quicker and blood pressure is higher. Chemicals called endorphins are released that cause pleasant sensations, and may make women feel happy, flushed, warm, giddy or sleepy.

While orgasm is part of the male sexual response cycle, it is not necessarily part of the female sexual response cycle, and many women report feeling very satisfied even without orgasm. Some women have several waves of heightened pleasure, without actually experiencing orgasm. Some women experience more than one actual orgasm during a sexual encounter. Many women do not achieve orgasm with intercourse alone, and need more stimulation than intercourse provides. This is particularly true when vaginal relaxation or prolapse are present. Foreplay that includes kissing, caressing and oral sex, and stimulation of the clitoris or nipples is important for achieving orgasm. Imagining fantasy situations may be part of achieving orgasm for some women. Both partners need to understand that sexual intercourse alone may not be enough, and that the definition of sex can include many other activities (no matter what any former president may tell you).

Unlike the male sexual response cycle, where rapid resolution occurs after orgasm, this may not necessarily be the case either for women, and the resolution phase may be highly variable from woman to woman, and from time to time for the same woman.

Common Causes of Sexual Problems

1. Aging

   It is normal for both desire and arousal and intensity of orgasms to decrease with age, in both men and women. With aging comes atrophy (loss of elasticity and lubrication) of the vagina. However, with or without the use of extra hormones or medications, many women enjoy sex well into their eighties and nineties.

2. Hormone problems

   Both estrogen and testosterone play major roles in the female sexual response. Testosterone tends to cause an increase in desire, where estrogen causes the physical capacity that allows arousal to occur. It is also becoming more and more apparent that stress hormones play a role in sexual response. Your stress hormones put your body into a "survival" state, physically, psychologically and emotionally, and activities that your body considers "extra" such as sexual pleasure, are suppressed. Stress may be physical stress from an illness, or emotional stress (work, family, etc).

   Menopause has direct effects on levels of estrogen, less so on testosterone. Declining progesterone levels play a role to, since the proteins that bind and inactivate estrogen and testosterone increase as progesterone decreases. Menopause can also have indirect hormonal effects since it induces a state of sleep deprived physical stress which can cause increased production of stress hormones. The oral contraceptive pill can also affect libido negatively for many women, since it increases these protein levels as well.

   Many women with perceived low sexual desire request extra testosterone. In fact, when testosterone levels are measured, they are most often normal. If they are “low normal” there may be some benefit in working within the normal range to increase the testosterone levels. Levels in excess of the physiologic range may indeed increase libido, but can have side effects such as hair growth on the face, male pattern scalp hair

3. Vaginal relaxation and prolapse

   - often from childbirth but sometimes from other causes. Vaginal relaxation and a perception of looseness can affect both body image, and hence desire, and can affect arousal as well, particularly with sexual intercourse itself. Sometimes, this can be resolved with position changes, or with Kegal exercises or pelvic floor prolapse. Sometimes, surgically correcting vaginal relaxation and prolapse can improve this situation for many women. For some women, very sensitive area(s) of the vagina ("G-spot") exist and their position may be changed when vaginal relaxation occurs. Not everyone agrees that these sensitive spots exist, but many women feel they do, and educating your partner on where they are and how best to access them can be helpful.

4. Other Body Image Issues

   Weight gain is the most common issue that makes women self conscious and thus decreases desire, and occasionally arousal. Sometimes elongated labia minora (the "inner lips") can cause discomfort or embarrassment. Sometimes the fear of urinary or fecal leaking, or gas leaking (all known as "incontinence") may cause embarrassment or fear of embarrassment and negatively affect the whole female sexual response cycle. Fear of STDs, pregnancy or a urinary tract infection or vaginitis from sex may adversely affect physical desire.

5. Relationship Problems

   Because sex begins with arousal rather than with desire for many women, sex is initiated or permitted to start for other reasons, typically the desire to be closer to one's partner. If that desire for an emotional connection isn't there because of relationship issues, such as lack of trust, power and control issues, feeling of being taken advantage of in ways that do not involve sex (for example, money and financial issues, or a feeling that one does all the supportive work in childcare or cleaning, etc ), or generally feels unappreciated, then sexual relationships are often affected, since the desire to feel close, which leads to a receptivity for sex to begin, simply isn't there.

6. Bad memories

   Childhood sexual abuse can have a serious and lasting effect on enjoyment of sexual activity. Problems with desire, arousal, a sense of guilt and a poor body image and perception are common problems. Pelvic floor spasm, resulting in pain with sex, occurs more commonly in women with this history, and typically there is a lower trigger threshold where this starts to occur. Depression and body image perception problems are more common.

7. Pain with Sex

   Pain with sex has a crushing effect on all parts of the female response cycle. Your provider at Women's Health Connection will ask you some pretty specific questions about exactly when and where the pain occurs, the nature of the pain (superficial, burning, pain on entry or deep visceral pain), whether or not it is positional, and if it persists afterwards. Pain that occurs during intercourse is called dyspareunia.

   • "Superfical dyspareunia" is a burning raw stinging feeling in the vagina. It is often the result of either an infection, such as a yeast infection, or atrophy (after menopause the vagina reverts back to a prepubertal state unless a little extra estrogen is used locally in the vagina on an ongoing basis). Sometimes atrophy makes people more prone to vaginitis. Sometimes an imbalance of the normal bacteria can cause this pain. Herpes simplex can sometimes cause superficial dyspareunia, even though there may be no obvious lesions. Treatment is aimed at correcting the infection or skin disorder.

   • "Entry dyspareunia" is pain with or shortly after, the penis enters the vagina. It is caused by spasm of the levator ani muscle, a large sling like muscle that forms the pelvic floor, looks like a hammock between the pubic bone in front and the tail bone in the back. Pelvic pain of any kind (ie from the bladder, the vagina, the uterus, the peritoneal lining of the pelvis, or the rectum) can trigger pelvic floor spasm in people who are susceptible to it. Typically, intercourse is still possible, but usually painful and not pleasurable. In its most severe form, it is called "vaginismus". With vaginismus, the spasm is so severe, that intercourse is not possible (in fact, even tampon use can be difficult or impossible). Some women with vaginismus have presented to our clinic with many years of an unconsummated marriage because of vaginismus. Treatment is aimed at techniques that release spasm from the muscle. Recently, studies using Botox to relax the muscles of the pelvis have shown promise.

   • "Deep dyspareunia" usually has a gynecologic cause. Most often it occurs because there is endometriosis in the pelvis, just above the top of the vagina, causing inflammation, or embedded in the uterus itself (a condition called "adenomyosis"). Sometimes degenerating fibroids can cause deep dyspareunia, or any condition in which the lining of the uterus or cervix is inflamed (typically with infection). Bladder or bowel inflammations may also cause deep dyspareunia. Adhesions (scar tissue) from previous surgeries can cause deep dyspareunia. Most of the time, there is a medically or surgically treatable gyencologic condition when deep dyspareunia is present. Sometimes, there is simply a size issue, with a particularly large penis and small vagina, but this is uncommon, and usually means there is a problem with the arousal process, because an aroused vagina can accommodate easily to two to three times its normal relaxed size. (In fact, you will recall that the vagina can stretch to accommodate a 10 pound baby passing through it, although typically not without some degree of injury). Treatment is aimed at correcting the gynecologic conditions.

Addressing the underlying medical or gynecologic condition causing the dyspareunia is important. Limiting sex to non-penetrating activities can help, as can carefully trying different positions, emptying your bladder and using a high quality lubricant such as Astroglide or Replens.

Problems with the Specific Parts of the Sexual Response Cycle

• Lack of desire

  As discussed above, this is common, so common that during many parts of women’s lives it is more common than not to report a lack of desire until after sex begins. It is considered a “disorder” if a women:

  • Does not have a desire to engage in ANY sexual activity, including masturbation
  • Does not have any sexual fantasies or erotic dreams AND
  • Is bothered by this lack of libido

  What can be done?

  Educating yourself about sex and getting more comfortable with the idea, can be helpful, focusing less on the act and more on intimacy can help, non-sexual but sensual activities like massage can help, adding oral sex, manual stimulation and time for lubrication and for adequate arousal can help increase desire and make sex more pleasurable, addressing issues that are causing stress, talking to your partner about likes and dislikes, resolving other aspects of the relationship that are causing stress outside of sex can all be part of resolution. Changing medications or birth control methods can sometimes help, as can adding a small amount of testosterone, within the normal range.

• Lack of Arousal

  There is a large overlap between lack of arousal and lack of desire. The most common cause of not achieving physical arousal include medical conditions, vaginal relaxation, prolapse or looseness, exhaustion, smoking, drugs, fear of pain, fear of embarrassment, negative past sexual experiences, boredom. More time with sensual activities and foreplay, adequate sleep and stress management, using lubricants as needed, treating underlying medical conditions, doing Kegals to increase tone can help with sensation. More recently, some women have found that vaginal rejuvenation procedures, tightening procedures and if necessary, surgical prolapse repairs, can help with the arousal phase. G-spot injections have been recently introduced to help the more sensitive areas of the vagina protrude further into the vagina to increase pleasure and arousal.

• Lack of orgasm or lack of intensity of orgasm

  It is normal for the intensity and frequency of orgasms to decrease with age. Many women thoroughly enjoy sex without ever having a specific climax. Lack of orgasm is only a problem if it is causing personal distress. Not uncommonly, women can achieve orgasm with masturbation but not with their partner. Communicating with your partner what activities lead to orgasm can be helpful. Sometimes introducing something new, such as a sex toy, or a different setting or circumstance or time of day, can heighten pleasure and allow orgasm. Anxiety and depression can diminish ability to orgasm as can negative body image and fear of pain or embarrassment. All of the techniques above that increase arousal, also have potential to increase the likelihood and intensity of orgasm. These include lubricants, sex toys, G-spot injections, vaginal tightening or rejuvenation procedures, Kegals to increase vaginal muscle tone. Increasing sexual stimulation, by whatever means chosen (as long as it is safe), using fantasy and imagery, role playing can all increase likelihood, frequency and intensity of orgasm. Treating any underlying medical or gynecologic condition that may be causing discomfort of embarrassment can be helpful.

Approaching your Healthcare Provider about this Topic

You are in a safe place at Women’s Health Connection – do not be afraid to bring this topic up. It is an important part of quality of life for many women.