Clinical Department

Female Problems

Female Problem Solutions

What are some types of sex problems that women might have?Sex problems that women might have include:

Patient education: Sex problems in women

Sometimes problems can come and go, and might not cause distress. But if you have pain or are worried about your problems, there are treatments that can help.

Some women have problems with sex throughout their adult life. Other women develop problems later in life.

What causes sex problems?Sex problems can be caused by many things. For instance, a woman might have sex problems if she has problems with her partner or in her relationship.

Sex problems can also be linked to medical events in a woman's life. For instance, sex can be painful for a woman in the weeks or months after she gives birth. And some women lose interest in sex or have pain with sex as they get older or after they go through menopause. (Menopause is the time in a woman's life when she stops having monthly periods.)

Certain conditions can also lead to sex problems. These include:

Dryness or pain in the vagina

Pain in the lower belly, such as from an infection, past surgery, or a condition called endometriosis (women with this condition often also have painful periods)

Changes in the muscles near and around the vagina

Mood problems, such as depression

Medical problems, such as cancer or heart problems

Sex problems can also be a side effect of certain medicines. For example, medicines to treat depression or heart disease sometimes cause sex problems.

Is there anything I can do on my own to improve my sex problem?

Yes. If you are having relationship problems, you can try to improve your relationship with your partner. For example, you can:

Talk to your partner about how to make sex better

Make an effort to have more fun together by having a regular "date night"

Read books or websites about sex

Go to counseling, either on your own or with your partner

Women with pain or dryness during sex often feel better if they use vaginal lubricants. These are sold without a prescription. Lubricants are used during sex. If using a lubricant is not enough, a woman can also use a vaginal moisturizer. Vaginal moisturizers are used several times a week, but not necessarily during sex.

It is also important to stay as healthy as possible and get treated for any medical problems you have. Women who feel healthy and happy are more likely to be happy with their sex life.

Should I see a doctor or nurse?

If you don't know why you are having sex problems, your doctor or nurse can help you figure it out. He or she will talk with you and do an exam.

How are sex problems treated?

Sex problems can be treated in different ways. These include:

Using vaginal lubricants and moisturizers or a prescription cream (usually estrogen) to treat vaginal dryness

Getting treatment for mood problems, if you have mood problems

Working with your doctor to change any medicines you take that might be causing sex problems

Having physical therapy to work on the muscles around your vagina so that you do not have pain during sex

In addition, some women who have gone through menopause are helped by taking hormone medicines.

You might have heard about medicines that can help some women with "low desire" or "low libido." There are 2 medicines that are approved for this in the United States. Both of them are meant only for certain women who have not yet gone through menopause and who have a low desire for sex that is causing them stress. Both medicines must be prescribed by a doctor. They can help some women want to have sex more, but there can be serious side effects, too.

In most cases, doctors recommend trying other things to improve your relationship and sex life before trying medicine. But if your doctor does suggest medicine, the options might include:

Flibanserin – This medicine comes in a pill that you take every day. Some women who take it have problems with tiredness, nausea, dizziness, or headache. It's also important to limit alcohol if you are taking this medicine. Alcohol and certain other medicines can increase the risk of side effects.

Bremelanotide– This medicine comes as a shot that you give yourself about 45 minutes before you plan to have sex. Side effects can include nausea, vomiting, or flushing (when your skin turns red and hot). A few women might have a rise in blood pressure. Women with high blood pressure or heart problems cannot take this medicine.

Patient education: Sexual problems in women

Sexual dysfunction is a term used to describe difficulties in libido (sex drive), arousal, orgasm, or pain with sex that are bothersome to an individual. Sexual dysfunction may be a lifelong problem or acquired later in life after a period of having no difficulties with sex.

Women are most likely to be satisfied with their sex lives if they are physically and psychologically healthy and have a good relationship with their partner. Although a host of changes in hormones, blood vessels, the brain, and vaginal area can affect a woman's sexuality, relationship difficulties and poor physical or psychological well-being contribute to the majority of sexual problems in women.

This article will discuss causes as well as treatments that are available to help women who have problems with sex. Sexual problems in men are discussed separately.

SEXUAL PROBLEMS TERMINOLOGYIt is important to know the definitions of several terms used to describe the sexual response to understand related sexual problems.

Desire (libido) — Libido, or sex drive, is the desire to have sexual activity, and often involves sexual thoughts, images, and wishes. Desire may occur spontaneously or in response to a partner, thoughts, events, or sensory cues. Spontaneous desire is more common in new relationships

while desire in response to an erotic stimulus or stemming from a wish for greater physical or emotional closeness to a partner is more typical of long-term relationships. Responsive desire describes desire that does not occur until after sexual activity has started. This is common in long-term relationships.

Despite a focus on the importance of sexual desire in the media, desire is not essential to have a satisfactory sex life. In other words, a woman who does not think about or initiate sex does not necessarily have a problem.

Arousal (excitement) — Arousal is a sense of sexual pleasure, often accompanied by an increase in blood flow to the genitals, increased lubrication, and an increased heart rate, blood pressure, and rate of breathing.

Orgasm — Orgasm is defined as a peaking of sexual pleasure and release of sexual tension, usually with contractions of the muscles in the genital area and reproductive organs. A woman who never or rarely experiences an orgasm may still experience pleasure with sex and does not have a sexual problem unless this is bothersome to her.

Although desire, arousal, and orgasm describe the typical sexual response, the goal of sexual activity is satisfaction, which may or may not involve all aspects of the sexual response cycle (desire, arousal, orgasm).

Pain — Painful sex is a common problem with many different causes.

RISK FACTORS FOR SEXUAL PROBLEMSThere are a number of risk factors that may contribute to sexual problems in women. A risk factor is not necessarily the cause of a problem, but rather something that makes the problem more likely.

Personal well-being — A woman's sense of personal well-being is important to sexual interest and activity. An unhealthy diet and limited exercise may result in a poor body image. A woman who does not feel her best physically or emotionally may experience a decrease in sexual interest or response.

Fatigue and stress — Women are often less interested in sex and experience reduced sexual pleasure when they are tired or under stress. Fatigue can result from an underlying medical problem, poor sleep, or simply not getting enough sleep due to the demands of family and work. Many women experience high levels of stress in their daily lives trying to meet the needs of children, partners, parents, and work.

Sociocultural factors — Lack of privacy and personal, religious, and cultural beliefs about sex may contribute to sexual problems.

Relationship issues — An emotionally healthy relationship with current and past sexual partners is a critical factor in sexual satisfaction. Stress in a relationship, conflict between a woman and her partner, and limited communication can negatively influence a woman's sexual desire and response. Current or past emotional, physical, or sexual abuse often contribute to sexual problems. In addition, even good relationships can become less exciting sexually over time.

Partner health or sexual problems — Sexual dysfunction in the partner can affect a woman's sexual response. For women with a male partner, sexual problems, including erectile dysfunction, diminished libido, and abnormal ejaculation, can occur at any time but become more common with advancing age. In addition, women tend to live longer than men, resulting in a shortage of healthy, sexually functional partners for older women.

Gynecologic issues

Childbirth — After childbirth or cesarean section, physical recovery and breastfeeding, as well as fatigue and the demands of parenting, often decrease sexual desire. Low estrogen levels after delivery and local injury to the genital area or abdominal wall at delivery may result in pain with sexual activity. In most cases, these issues improve with time.

Menopause — Estrogen is a hormone produced by the ovaries. During the several years before menopause, estrogen levels begin to fluctuate. After menopause, estrogen levels decline dramatically. This may lead to changes in a woman's libido and ability to become aroused. Hot flashes, night sweats, sleep disruption, and fatigue also may contribute to sexual problems.

In addition, many women experience discomfort or pain during sex after menopause due to vaginal dryness, loss of normal secretions and lubrication, decreased elasticity, and narrowing of the vagina. Menopausal vaginal changes are generally more severe if intercourse or other vaginal penetrative activities are infrequent. Although hot flashes and most menopausal symptoms improve with time, vaginal dryness and resulting painful sex generally worsen with time, if not treated.

Hysterectomy — In general, hysterectomy (removal of the uterus) does not cause sexual dysfunction. Most studies actually show an improvement in sexual function after hysterectomy, likely due to resolution of symptoms that interfere with sex, such as heavy bleeding or pain. Removal of the cervix at the time of hysterectomy also has no negative effect on sexuality. Removal of the ovaries at the time of hysterectomy, typically done to decrease the risk of ovarian cancer, reduces estrogen and androgen levels, which may impact sexual function for some women.

Vaginal or pelvic pain — Vaginal or pelvic pain is a cause of sexual dysfunction for many women. Pain during sex may lead to fear of further pain, which can diminish lubrication and cause involuntary tightening of the pelvic muscles, resulting in further pain.

Pain may be caused by endometriosis, vaginal or pelvic surgery, infection, or scar tissue. In postmenopausal women, a lack of estrogen often causes discomfort with intercourse and other forms of sexual activity. Genitourinary syndrome of menopause describes bothersome symptoms of the genital and urinary tracts due to lack of estrogen after menopause. This is probably the most common cause of painful sex for older women.

Bladder and pelvic support issues — Changes in the bladder or loss of pelvic support (pelvic organ prolapse) can lead to loss of urine or stool (incontinence) or sensations of vaginal pressure. These symptoms may interfere with sexual desire and activity.

Medical issues — Almost any serious or chronic medical problem can impact a woman's sexual desire and responsiveness. Problems such as heart disease and arthritis can affect a woman's physical ability to have sex. Obesity can contribute to sexual problems likely due to effects on exercise tolerance and body image.

Women with cancer can experience discomfort and fatigue, due to both the disease and its treatments, which impact sexual function. Changes in body image, especially after surgery on the breasts or other intimate areas, can contribute to sexual problems in women with cancer.

Other conditions, such as Parkinson disease, diabetes, or substance use disorders (involving alcohol, marijuana, pain medications, or other drugs), can impair arousal and ability to experience orgasm.

Psychiatric or emotional problems may significantly impact sexual function, either due to the disease itself or its treatment (see below). Depression is one of the most common causes of decreased libido and other sexual disorders in women. Anxiety is another common cause of sexual problems.

Medications — Both prescription and nonprescription medications can alter sexual desire, arousal, orgasm, and pain. This may include:

Medications — Both prescription and nonprescription medications can alter sexual desire, arousal, orgasm, and pain. This may include:

Many antidepressants (especially selective serotonin reuptake inhibitors)

Some antipsychotic medications (used for psychiatric problems as well as sleep disorders and other conditions)

Beta blockers (used to treat high blood pressure)

Antiestrogens/aromatase inhibitors (used to treat breast cancer)

It is not clear if hormonal medications, such as birth control pills and menopausal hormone therapy, affect sexuality. Studies have shown mixed results, with some studies showing that hormonal medications have no effect while others showing worsening or improvement of sexual problems in women.

Surgery — Certain surgeries can affect a woman's sexual response. In particular, surgeries of the breast or the reproductive organs can change how a woman feels about her body, particularly if there is an underlying diagnosis such as cancer that led to the surgery.

Hysterectomy, with or without removal of the cervix should not negatively impact sexual function once healing is complete. However, some women experience sexual problems after both ovaries are removed, possibly due to decreased estrogen and/or androgen levels.

TREATMENT OF SEXUAL PROBLEMSA number of treatments are available for women with sexual problems. In many cases, a combination of treatments is most effective.

Managing stress, fatigue, and relationship issues — Strategies to reduce life stress, including exercise, yoga, massage, meditation, and other mind/body techniques, can result in a more satisfying sex life. Optimizing sleep and other interventions to reduce fatigue may improve sexual interest. Working with a professional counselor can help individuals and couples reduce stress and strengthen their relationships. Sex therapists are professionals with special expertise in helping individuals and couples address sexual problems by providing information, improving communication, and instructing couples in specific exercises to improve intimacy and mutual pleasure.

Many couples have better sex while on vacation, demonstrating the importance of reducing stress and fatigue to improve sexual satisfaction. Couples who have more fun together outside of the bedroom typically are more satisfied with their sex lives, so establishing a regular "date night" and increasing the frequency of special outings and vacations can reduce sexual problems.

Counseling, books, and web sites about sexuality help couples communicate better about their sexual needs and differences, understand the causes of their difficulties, and provide treatment suggestions.

Novelty — Increasing novelty often sparks sexual desire and enhances sexual response. Try sensual massage, sharing a bath, different sexual positions or activities, candles and music, or having sex in the middle of the day or outside of the bedroom. Books, films, vibrators, and lubricants can also add excitement. Vibrators are the most effective treatment for orgasm difficulties. They can be used with or without a partner.

Treating vaginal dryness — Women with vaginal dryness or discomfort may benefit from using a long-acting, nonhormonal vaginal moisturizer several times weekly. Lubricant use with intercourse or other penetrative sexual activity reduces friction to increase comfort and pleasure. Postmenopausal women generally will benefit from the use of low-dose vaginal estrogen therapy to treat vaginal dryness and pain associated with menopause (brand name: Vagifem, Yuvafem, Estring, Estrace cream, and Premarin cream). Treatment of vaginal dryness is discussed in detail in a separate topic

Improving painful sex — Many women who have pain with sex have tight and tender muscles and connective tissue in the pelvis, lower belly, thighs, groin, and buttocks.

Pelvic floor physical therapy (PT) can significantly decrease discomfort associated with involuntary tightening of pelvic floor muscles.

Physical therapists who perform this type of PT are specially trained in pelvic manipulation and rehabilitation.

Often, painful sex is due to narrowing and shortening of the vagina after surgery or menopause or involuntary tightening of the muscles of the vaginal wall, called "provoked pelvic floor hypertonus." This is best treated by purchasing a set of vaginal dilators and gently stretching the vagina over several months. A well-lubricated dilator of the appropriate size is placed in the vagina several times for five minutes nightly. The size of the dilator is gradually increased until intercourse is once again comfortable. These exercises are best guided by a gynecologist or pelvic floor physical therapist.

Adjusting medications with sexual side effects — If you have sexual side effects from a medication, speak with your health care provider about options for reducing the dose or finding an effective alternative medication.

Options for women who have side effects from an antidepressant medication include trying a reduced dose or change in type of antidepressant medication. Bupropion (brand name: Wellbutrin), nefazodone (brand name: Serzone), mirtazapine (brand name: Remeron), or duloxetine (brand name: Cymbalta) are antidepressant medications that have few or no sexual side effects, and can sometimes be used in addition to or in place of your current medication. Talk to your health care provider before making any changes in your medications.

However, the role of androgens in female sexuality is less clear. Androgen levels decline with aging, so all postmenopausal women have low blood levels of androgens. Studies of postmenopausal women with low sexual desire associated with distress and no other identifiable cause have shown that testosterone treatment may result in small but significant improvements in sexual desire and response. Although studies of a testosterone patch showed benefit, studies of a similar dose of testosterone gel showed no benefit compared with a placebo gel. The high placebo response seen in studies of testosterone treatment for low sexual desire in women demonstrates the importance of nonhormonal factors in women's sexual function. No androgen products are approved for the treatment of women with sexual dysfunction in the United States due to limited efficacy and the lack of data regarding long-term safety.

Testosterone — Testosterone products are sometimes used "off-label" to treat sexual problems in women. These products include testosterone skin patches, gels, creams or ointments, pills, implants, and injections, often designed and government-approved for men. Testosterone doses provided by these formulations generally are often too high for women, increasing the likelihood of side effects. Low doses of testosterone can be formulated in a topical cream or gel by a compounding pharmacist. Quality, efficacy, and safety of these products are generally untested. Testosterone is not recommended for premenopausal women.

DHEA — DHEA (dehydroepiandrosterone), an androgen-like hormone made in the adrenal glands, is available as a nutritional supplement in the United States. Studies have shown that DHEA can improve sexual interest and satisfaction in some women whose adrenal glands no longer function (adrenal insufficiency).

However, DHEA is not proven to be safe or effective for other women, and it is not generally recommended. In addition, DHEA is produced as a nutritional supplement, so is not closely regulated by the government. The amount of hormone may vary from one pill or bottle to another and it is not possible to be certain that a product is free of potentially dangerous additives.

A nightly vaginal suppository containing a low dose of DHEA (brand name: Intrarosa) is approved by the US Food and Drug Administration for the treatment of painful sex due to menopause. Improvements in sexual function with vaginal DHEA are similar to those seen with the use of low-dose vaginal estrogen therapy in postmenopausal women.

Androgen side effects and risks — Side effects of testosterone treatment are a concern; androgens can increase hair growth on the body and face and cause scalp hair loss, oily skin, acne, irreversible deepening of the voice, liver problems, and high cholesterol levels. In addition, because testosterone is converted to estrogen in a woman's body, there may be an increased risk of breast cancer, coronary heart disease, leg and lung clots, and stroke. Women who take androgens should be monitored closely for side effects. They also must be aware that long-term safety is unknown

Women who are considering use of androgens (testosterone or DHEA) should discuss the possible side effects of this treatment with their health care provider.

Medications and devices — In the United States, two medications have been approved for treating low sexual desire in women. Both are intended for premenopausal women who have a low desire for sex that is causing them stress, and both must be prescribed by a doctor. They can help some women desire sex more, but there can be serious side effects.

In most cases, doctors recommend trying other things to improve your relationship and sex life before trying medication. However, if your health care provider does suggest medication, the options may include:

Flibanserin (brand name: Addyi) – This medication comes in a pill that you take every day. Some women who take it have problems with tiredness, nausea, dizziness, or headache. It is also important to limit alcohol if you are taking this medicine, as alcohol (as well as certain other medications) can increase the risk of side effects.

Bremelanotide (brand name: Vyleesi) – This medication comes in the form of a shot that you give yourself approximately 45 minutes before you plan to have sex. Side effects can include nausea, vomiting, or flushing (when your skin turns red and hot). A few women might have a rise in blood pressure. Women with high blood pressure or heart problems cannot take bremelanotide.

Medications commonly used for men with erectile problems, including sildenafil (brand name: Viagra), tadalafil (brand name: Cialis), or vardenafil (brand name: Levitra), generally have not been shown to improve sexual function in women more than would a placebo and are not usually recommended. The only women who may benefit from use of an erectile dysfunction medication are those who develop orgasmic difficulties secondary to antidepressant medication, especially selective serotonin reuptake inhibitors.

Unproven treatments

Herbal therapies — Many women are interested in trying over-the-counter herbal supplements, which are advertised to increase sexual desire and pleasure. More studies are needed to assess whether herbal therapies are safe and effective. Some herbal supplements may improve sexual function, but no more than would a placebo. The production of herbs is not regulated by the government, and it is not always possible to know that an herbal product contains the type and quantity of ingredient that the label indicates, or that it is free of potentially dangerous additives. People who wish to use herbal therapies are urged to do so with caution.

Surgical and laser treatments — Surgery is very rarely necessary to make the vagina "better" for sex. Women born with abnormalities of the vagina, those who have had female genital cutting, and those with traumatic injuries from childbirth are a few groups that may benefit from careful surgical treatment.

All women should be wary of advertisements for "vaginal rejuvenation surgery." These procedures can be costly and uncomfortable, may result in painful sex, are permanent, and are unlikely to improve a woman's or her partner's sexual enjoyment.

The use of laser therapy to treat vaginal dryness and painful sex after menopause is widely advertised. Vaginal laser treatments are very expensive and not covered by health insurance. Studies of long term safety and efficacy are lacking.