Introduction

Women's sexual problems are not nearly as well understood as men's. The main difficulty reported by men is that they cannot get or keep an erection going; once an erection is produced, their orgasm usually follow without difficulty. In women, on the other hand, there are three stages that must be completed before orgasm can occur - desire (or libido), excitement (or arousal), and wetness (lubrication) of the genitals. We'll consider each of these in turn.

Up to two-thirds of women in relationships are unable to reach arousal or orgasm, at least on some occasions. Women can have these problems throughout their sex life, though they are reported less frequently as they get older - just the opposite of the case in men.

Desire

A recently published survey showed that "lack of interest in sex" was the top sexual problem in women - it was reported in about a third of those aged 40-60 with sexual difficulties¹ It was less common than in the younger women surveyed, which suggests that interest returns a little once the childbearing years are over. Of course, interest in sex depends somewhat on the availability of a partner, which can be a particular problem in older women.

Lack of desire or interest in sex responds to various measures, provided there are no obvious difficulties, such as illness, worry, 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 - these are discussed by Dr Verne elsewhere on this site ( Aging and Sexuality">). Sometimes hormone supplements (estrogen and/or testosterone) or a trained sexual therapist are required; however, the woman should see her family physician or gynecologist first.

Arousal and lubrication

Arousal can occur once desire is present. It involves increased blood flow to the pelvis, producing congestion in the vagina, uterus and clitoris. The vagina expands and enlarges, and the clitoris has a mini-erection, similar to that in man, though on a small scale, of course. The increased blood flow to the vagina causes the secretion of clear mucous fluid, which makes intercourse easier and painless. If the woman's partner rushes things, he may attempt penetration before her organs are "prepared" in this way, which can lead to pain and then even more conspicuous lack of arousal.

The most common cause of sexual problems in women after the menopause is not having adequate lubrication. With age, the vaginal wall becomes thinner and less elastic. The difficulty can be worsened by disorders such as diabetes, high blood pressure, radiation treatment for pelvic tumors, or the use of anti-estrogen drugs in the treatment of breast cancer. Saliva is the most natural lubricant that can be used, but Vaseline and K-Y jelly are good substitutes. However, it's better to treat the cause of vaginal dryness. This may involve using estrogen or testosterone vaginal creams, or even oral estrogen. Sometimes vitamin E vaginal suppositories are effective. Vaginal dryness and loss of elasticity in older women is less severe if intercourse is frequent - another example of "use it or lose it".

Recently there has been interest in the use of medications in women to increase arousal, and several products are undergoing clinical trials. Even though results are not yet available, it seems likely that drugs that work in treating erectile dysfunction (ED) in men will also help arousal and lubrication in women. As with men, there are several means to increase the blood flow to the pelvic organs, so it's likely that one or more of the newer drugs will prove helpful in older women.

Orgasm

Orgasm is a fairly automatic event for men - once a certain point of stimulation is reached, orgasm and ejaculation cannot easily be held back. However, about 1 in 4 of women with sexual problems said in the survey that they didn't have orgasms. Obviously, if desire is absent and arousal doesn't occur, orgasm won't follow. Even with successful completion of the first stages, some women still can't have an orgasm. While it can be reached by clitoral or vaginal stimulation during intercourse, oral sex, or masturbation, the actual climax is the much the same, and failure to get there is distressing. Quite a common cause in the USA is the use of anti-depressant medications, including the newer drugs in this class. (The role of medications in causing sexual problems is will be dealt with in a later article.) Another cause is pain on intercourse (called dyspareunia), which may itself have various causes - lack of adequate arousal and lubrication, vaginal infection, and so on.

Most women learn to reach orgasm after they have started to become sexually active, often by masturbation at first. Sex therapists treating older women who cannot have an orgasm believe the person 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 can then show her partner exactly what she needs in order to "make her come". This requires the full cooperation of her partner, who should carry her through the stages of desire, arousal, lubrication, and finally, orgasm.

Two rare problems

Vaginismus is the term given to a rare but troublesome condition when the muscles around the opening of the vagina contract tightly if any object - e.g. penis, finger, or tampon - is inserted. It is usually seen in younger women, and is often associated with psychiatric conditions. Sex therapy is often successful in treating vaginismus.

Another rare condition, which may affect women who have undergone forced sex, rape or incest, is called sexual aversion disorder; it's an extreme form of frigidity. The patient will go to great lengths to avoid any form of sexual contact. Treatment usually requires intense psychotherapy and sex therapy.

Summary

Sexual problems in women at all ages are far more often "psychological" than "physical". However, the liberal climate today allows open discussion of ways to realize sex fantasies to help improve desire, and get things started on the right path. The woman's partner has an important role to play in seeing that desire, followed by arousal, is produced in an unhurried atmosphere of intimacy, mutual trust, and caring. Difficulties with arousal will probably be helped in the near future by one or other of the medications now under development.

After recognizing that they have difficulty in achieving orgasm, women should first consult their family physician or gynecologist to make sure there is no physical problem. Hormone treatment may be prescribed. Ultimately, expert sex therapy may be needed, in order to provide effective advice to both partners on how to get things back on track.

Click here to read the article "Sex Problems in Men"