Sexual Problems in Women

Robert W. Griffith, MD
June 7, 2000 (Reviewed: December 8, 2002)

Introduction

The problems women face in sexual function are not nearly as well understood as those that face men. The main difficulty reported by men is the inability to get and/or maintain an erection - now termed erectile dysfunction (ED) - and if this can be accomplished orgasm usually follows. In women, there are three stages that must be passed through before orgasm can occur - libido (or desire), arousal, and lubrication of the genitalia. It's been estimated that as many as 64% of women in a relationship are unable to reach arousal or orgasm on at least some occasions. Unlike men, women can have these problems throughout their sexual lifetime - indeed, they are more common in younger women.
Traditionally, sexual problems in women have been ascribed to psychological or emotional causes, rather than physical conditions. The availability of effective treatment for ED in men moved male sexual problems from the psychological to the physical arena about ten years ago; not surprisingly, the possibility of treating female sexual dysfunction as a physical disorder is now being actively explored.

Libido

A recently published report of a U.S. 1992 survey showed that lack of interest in sex was the commonest problem encountered - it was described in about 30% of the women aged 40-60 with sexual dysfunction. This was a lower incidence than that in the younger women surveyed, suggesting that interest in sex returns a little once the childbearing years are past. Of course, interest in sex is related to an extent to the availability of a partner, which may be a particular problem in older women.

Lack of desire or interest in sex is responsive to a variety of measures, provided there are no obvious barriers, such as illness, worry, severe stress, exhaustion, or substance abuse. If a woman has lost (or never had) the ability to conjure up sexual fantasies or desires, her partner may be able to help in various ways, by providing the appropriate environment (romance, fantasy, etc), with the help of suitable media (books, music, videos, costumes etc). Hormone supplements may be useful in some older women, although they are more likely to help in dysfunction involving arousal. Sexual counseling and/or group therapy can improve problems of diminished sexual desire.

Arousal and lubrication

Arousal involves increased blood flow to the pelvic area, producing congestion and engorgement of the vagina, uterus and clitoris. The vagina expands and enlarges, and the clitoris has a mini-erection, similar to that in man. The increased blood flow to the vagina causes the formation of serous fluid, which is necessary to lubricate the genitalia and facilitate painless intercourse and clitoral stimulation.

Lack of adequate lubrication is the most common cause of sexual dysfunction in women after their menopause. It is related to declining hormone levels (estrogen and testosterone), and may be due to conditions such as diabetes, high blood pressure, radiation treatment for pelvic tumors, or the use of anti-estrogens in the treatment of breast cancer. Vaginal dryness and loss of elasticity in older women is less pronounced if intercourse is common - an example of the adage "use it or lose it". Treating the cause - estrogen or testosterone vaginal cream, or oral estrogen - is probably the most satisfactory approach. Saliva is the most physiologically compatible external remedy, but K-Y jelly or Vaseline is also helpful. Vitamin E vaginal suppositories have been reported to be effective.

Recently, with the availability of Viagra, there has been interest in the use of oral medication in women to increase blood flow to the genitalia once libido is active. Clinical trials in women of this drug, and others, are in progress. Even though results are not yet available, it seems quite possible that drugs that are effective in treating erectile dysfunction in men will also be effective in improving arousal and lubrication in women. As with men, there are several mechanisms that can increase the blood flow to women's pelvic organs, suggesting the possible use of vasodilators other than Viagra, prostaglandins, or morphine derivatives; it's likely that one or more will prove helpful.

Orgasm

Orgasm is largely an automatic event for men - once a certain point of stimulation is reached, orgasm and ejaculation cannot readily be inhibited. In women, however, about 25% of those with sexual problems report an absence of orgasms, even after passage of the libido/arousal/lubrication stages. An orgasmic climax can be achieved by clitoral or vaginal stimulation, using masturbation, oral or other stimulation. While the actual climax is much the same, the intensity (or "quality") of the orgasm varies.

Failure to achieve orgasm is distressing. One of the commonest causes today is the use of anti-depressant medication, including the newer selective-serotonin-reuptake-inhibitors (SSRI). Another common reason is dyspareunia (pain on intercourse), which almost always has a physical cause - lack of lubrication, vaginal infections, and so on. The treating physician must exclude such causes before considering other therapeutic approaches.

Most women learn to reach orgasm after they start to become sexually active, often first by masturbation. Sex therapists treating older women who cannot have an orgasm commonly recommend that the subject should start by practicing on her own. Masturbating helps her to learn which pressures and rhythms are needed to bring her to orgasm. Once she has learned to climax easily, she shows her partner exactly what she needs in order to reach orgasm. This requires the full cooperation of her partner, who should carry her through the stages of libido, arousal and finally, orgasm.

Other problems

Vaginismus is a rare but troublesome condition when there is contraction of the muscles around the vagina if any object - e.g. penis, finger, or tampon - is inserted. It is commonly associated with psychiatric conditions, and is usually encountered in younger women. Sexual therapy is often successful in treating this condition.

Another condition, which may affect women who have undergone forced sex, rape or incest, is termed sexual aversion disorder. The patient will go to great lengths to avoid any form of genital contact. Treatment usually requires intense psychotherapy and sexual therapy.

Summary

Sexual problems in women at all ages are, indeed, far more "psychological" than physical". Fortunately, the fairly liberal climate that exists today allows more open discussion of ways to realize sex fantasies to help improve libido. Problems of arousal will probably be helped in the near future by one or other of the medications now in development. Women having difficulty in achieving orgasm should first consult their physician to make sure there is no physical problem. If all is well physically, a well-trained sex therapist can often be invoked to provide effective advice to both partners.

The Internet has found good acceptance by older people, and this site has developed several articles aimed at the older visitor who may have questions about sex and aging. These can be found at "Aging and Sexuality". You may wish to direct your patients to this site.

Source

• Sexuality in Old Age in Brocklehurst's Textbook of Geriatric Medicine and Gerontology MI.  Lewis, Churchill Livingston, NY. 5th edition, 1998, vol. 103, pp. 1439--1444

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