Sexual Difficulties for Women
Sexual difficulties are common in women of all ages with reported prevalences ranging from 10-50%.
The diagnostic classifications of female sexual dysfunctions according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition revised (DSM-V revised), are:Sexual interest/arousal disorder
- Orgasmic disorder
- Genito-pelvic pain/penetration disorder
Symptoms may have appeared as soon as the person became sexually active or may begin after a period of normal sexual functioning.
Sexual interest/arousal disorder is defined as the persistent lack or significant reduction of an interest in sexual activity, in sexual fantasies/thoughts and/or receptivity to sexual activity, which causes personal distress. This is believed to be intimately linked to low arousal and sexual responsiveness in women.
Female orgasmic disorder, the second most frequently reported women’s sexual problem, is considered to be the persistent or recurrent delay in, or absence of, orgasm following normal sexual excitement, causing marked distress or interpersonal difficulty. This may also lead to secondary loss of sexual interest and/or interpersonal difficulties.
20-30% of women report an inability to orgasm during sexual intercourse. This can be lifelong (has never achieved orgasm) or acquired (has achieved orgasm in the past but is no longer able), or due to physical, psychological, or combined factors.
Common causes of anorgasmia are:
- Relationship issues
- Past sexual abuse
- Chronic disease such as multiple sclerosis, heart disease, high blood pressure, smoking and diabetes
- Urinary incontinence
- Medications such as antidepressants, antipsychotics and mood stabilizers
- Pelvic disorders- post surgery; irradiation; trauma
Genito-Pelvic Pain/Penetration Disorder is when a woman experiences persistent or recurrent difficulties towards vaginal penetration which causes her significant distress. It occurs with at least one of the following:
- Intense fear/anxiety in anticipation of, during, or as a result of vaginal intercourse
- Actual pain experienced in pelvis or vulvovaginal area during attempted or as a result of vaginal penetration
- Marked tensing or tightening of the lower pelvic/inner-abdominal muscles during attempted vaginal penetration
and is not caused by a nonsexual mental disorder (i.e., post traumatic stress disorder), relationship distress (i.e., domestic violence), other life stressors impacting a person’s sexual desire, or any other medical condition.
How can women be helped ?
Women experiencing sexual function difficulties should speak to their doctor about their problem.
The first step is to identify factors contributing to the problem including:
- relationship issues
- personal circumstances
- concurrent illness
- partner health issues.
Initial management may include counselling, sensate focus, cognitive behavioural therapy and couple therapy, as well as addressing any physical illnesses or medication side effects, such as with antidepressant treatment such as serotonin reuptake inhibiter drugs (SSRI’s).
Counselling can address issues such as poor emotional intimacy and domestic distractions (children, work etc.) and strategies to create a more positive sexual context.
Individual cognitive therapy, which focuses on individual’s thoughts, feelings and behaviour, helps women to be more aware of irrational beliefs, and dysfunctional thoughts and, in doing so, may help women modify their thinking and approach.
The aim of couple therapy is to enhance communication skills between couple, and reduce stress and conflict within the relationship.
Sexual pain disorders are pain disorders that interfere with sexual activity. Conditions resulting in painful sexual intercourse are often complex and respond well to a variety of approaches to treatment. Physiotherapy may include a combination of hands-on techniques, exercises, behavioural approaches, biofeedback, and electrical and heat modalities.
Although issues such as effect on the relationship, and lifelong or acquired low libido and arousal are best addressed in sex therapy, physiotherapists are in a unique position to provide adjunctive treatment for overcoming anxiety related to vaginal penetration. Physiotherapists are vital members of the interdisciplinary team treating female sexual dysfunction.
Oestrogen levels drop precipitously at menopause and this results in thinning of the vaginal wall, loss of vaginal tone and painful sex. These symptoms are best treated with local oestrogen therapy as either oestrogen cream or pessaries used twice weekly long term.
For women experiencing loss of sexual desire and diminished arousal, testosterone therapy may be of benefit.
Whereas oestrogen levels fall at menopause, testosterone levels decline in women steadily with increasing age. Thus by the time women reach their forties their testosterone level may be as low as half of what it was in their late teens-twenties. Several studies have now shown that treatment of women with ‘female’ doses of testosterone, which restore blood levels into the range of young women, improves sexual desire, arousal, orgasm and overall pleasure. Many women are successfully treated with low dose testosterone therapy.
A nonhormonal therapy, called flibanserin, has also been shown to improve sexual desire in premenopausal and postmenopausal women. Flibanserin has been recently approved by the FDA in the United States to treat acquired, generalized hypoactive sexual desire disorder (HSDD) in premenopausal women.
Testosterone or flibanserin are not elixirs of sexual youth, but both can have a meaningful impact on a woman’s sexual interest and equally importantly sexual responsiveness to her partner’s interest.
Phosphodiesterase type 5 inhibitors such as sildenafil (Viagra®) may be of value to women with sexual arousal disorder, but in general these compounds do not benefit the majority of women with sexual dysfunction.
A new approach to treating women who do not experience orgasm
Most recently a novel approach has been developed to potentially treat women who fail to reach orgasm (anorgasmia). Researchers recognised that testosterone therapy not only improved sexual desire, but also resulted in increased vaginal blood flow and increased orgasm frequency. As a result the approach of using testosterone on an “as needs” basis is being studied in centres across Australia and North America, including the Women’s Health Research Program, Monash University.
Female sexual dysfunction impacts adversely on self-esteem, quality of life, mood and relationships with sexual partners. It is associated with significantly lower health-related quality of life in women in general. Furthermore, sexual desire within a relationship is a key determinant of the quality of the nonsexual aspects of the relationship. Both men and women reporting a discrepancy between their own and their partner’s sexual desire have lower relationship satisfaction and individuals in sexually inactive marriages report less marital happiness.
Women with concerns about their sexual life should find a doctor or counsellor with whom they feel comfortable discussing this very personal but important aspect of their life.
Disclaimer: This information aims to inform patients and health professionals about Urinary Incontinence. This website's content is designed to complement, not replace, the relationship between a patient and his/her own doctor.