Patient education: Sexual problems in women (Beyond the Basics)
- Jan L Shifren, MD
Jan L Shifren, MD
- Associate Professor of Obstetrics, Gynecology, and Reproductive Biology
- Harvard Medical School
SEXUAL PROBLEMS OVERVIEW
Sexual problems are common in both women and men and can occur at any age. In the United States, approximately 40 percent of women have sexual concerns and 12 percent report distressing sexual problems .
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 are the most common causes of sexual problems.
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. (See "Patient education: Sexual problems in men (Beyond the Basics)".)
SEXUAL PROBLEMS TERMINOLOGY
It 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, or images. Spontaneous desire is more common in new relationships while desire in response to an erotic stimulus is more typical of long-term relationships. Responsive desire may occur after sexual activity has started.
Sexual 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).
RISK FACTORS FOR SEXUAL PROBLEMS
There 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. (See "Sexual dysfunction in women: Epidemiology, risk factors, and evaluation".)
Personal well-being — A woman's sense of personal well being is important to sexual interest and activity. A woman who does not feel her best physically or emotionally may experience a decrease in sexual interest or response.
Relationship issues — An emotionally healthy relationship with current and past sexual partners is the most important factor in sexual satisfaction. Stress or conflict between a woman and her partner, and current or past emotional, physical, or sexual abuse often influence a woman's sexual desire and response. In addition, even good relationships can become less exciting sexually over time.
Male sexual problems — For women with a male sexual partner, sexual dysfunction in the partner can affect her sexual response. Male sexual problems, (erectile dysfunction, diminished libido, or 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.
Childbirth — After childbirth, 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 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. (See "Patient education: Menopausal hormone therapy (Beyond the Basics)".)
In addition, some women experience vaginal narrowing, dryness, and a decrease in elasticity of the vagina after menopause, especially if intercourse is infrequent, which can lead to discomfort or pain during sex. (See "Patient education: Vaginal dryness (Beyond the Basics)".)
Hysterectomy — In general, hysterectomy (removal of the uterus) does not cause sexual dysfunction. Most studies actually show in improvement in sexual function after hysterectomy, likely due to an improvement in 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. (See "Patient education: Hysterectomy (The Basics)".)
Vaginal or pelvic pain — Women who have vaginal or pelvic pain often have difficulty with sexual activity. Pain may lead to fear of further pain during sex and can diminish lubrication and cause involuntary tightening of the vaginal muscles, causing further pain.
Pain may be caused by endometriosis, prior surgeries, infection, or scar tissue. In postmenopausal women, a lack of estrogen often causes discomfort with intercourse. (See "Patient education: Chronic pelvic pain in women (Beyond the Basics)".)
Bladder and pelvic support issues — Changes in the bladder or loss of pelvic support (pelvic organ prolapse) can lead to loss of urine (incontinence) or sensations of vaginal pressure. These symptoms may interfere with sexual desire or activity in some women. (See "Patient education: Urinary incontinence in women (Beyond the Basics)".)
Medical issues — Almost any serious or chronic medical problem can impact a woman's sexual desire and responsiveness. Problems such as coronary artery disease and arthritis can affect a woman's physical ability to have sex. Indeed, arthritis has been identified in some studies as a common contributor to sexual inactivity.
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, complications of diabetes, or alcohol and drug abuse can impair arousal and ability to experience orgasm.
Psychiatric or emotional problems may also 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.
Medications — Both prescription and nonprescription medications can alter sexual desire, arousal, and orgasm. 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)
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 who take hormonal medications.
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. (See 'Hysterectomy' above.)
TREATMENT OF SEXUAL PROBLEMS
A number of treatments are available for women with sexual problems. In many cases, a combination of treatments is most effective. (See "Sexual dysfunction in women: Management".)
Manage stress and relationship issues — Stress, fatigue, lack of privacy, personal values, and religious beliefs can all impact sexuality. Conflict in a relationship and difficulties with communication also are a significant cause of decreased sexual desire and response for women. Working with a professional counselor or sex therapist can help individuals and couples reduce stress and strengthen their relationships.
Most 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 have more fun in the bedroom, so establishing a regular "date night" and increasing the frequency of special outings and vacations is an effective treatment for many sexual problems.
Counseling, books, and web sites help couples communicate better about their sexual needs and differences, understand the causes of their difficulties, and provide treatment suggestions. (See 'Where to get more information' below.)
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 zesty lubricants can also add excitement.
Treat vaginal dryness — Women with vaginal dryness or discomfort may benefit from using a long-acting non-hormonal vaginal moisturizer several times weekly. Lubricant use with intercourse also increases comfort and pleasure. Postmenopausal women generally will benefit from the use of low dose vaginal estrogen therapy. Treatment of vaginal dryness is discussed in detail in a separate topic. (See "Patient education: Vaginal dryness (Beyond the Basics)".)
Treat 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 help to decrease tightness in these muscles. This type of PT is quite different from physical therapy intended to treat a knee injury or back pain, which usually works to increase muscle strength.
With pelvic floor PT, the physical therapist works on your body to manually "release" the tightness and tender points of the connective tissues and muscles. This includes the muscles and tissues of the vagina or rectum, abdomen, hips, thighs, and lower back. Physical therapists who perform this type of PT must be specially trained in pelvic soft tissue manipulation and rehabilitation.
Often painful sex is due to involuntary tightening of the muscles of the vaginal wall, called “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 should be placed in the vagina several times for 5 to 10 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.
Deal with sexual side effects of medications — If you have sexual side effects from a medication, speak with your healthcare 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 healthcare provider before making any changes in your medications.
Carefully consider androgens — Androgens, such as testosterone, are sex hormones that are produced in the testes and adrenal glands in men and the ovaries and adrenal glands in women. In men, androgens are responsible for producing typical male characteristics, such as facial hair, as well as feelings of desire and arousal.
However, the role of androgens in female sexuality is not 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 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 non-hormonal 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. (See 'Androgen side effects' below.)
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. Testosterone doses provided by these formulations are often too high for women, increasing the likelihood of side effects. 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). (See "Patient education: Adrenal insufficiency (Addison's disease) (Beyond the Basics)".)
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.
Androgen side effects — 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 healthcare provider.
Medications — In 2015, flibanserin (brand name: Addyi) was approved in the United States to treat sexual problems in certain women. It is intended only for use in premenopausal women who have a low desire for sex that is causing them distress. It is available by prescription only, as a pill that is taken every night at bedtime. While it can help increase sexual desire in some women, it can also cause potentially serious side effects such as low blood pressure or fainting or bothersome side effects such as nausea, dizziness, or headache. Women taking flibanserin must avoid alcohol, which can increase the risk of these side effects. Certain other medications can also increase the risk of side effects.
Medications commonly used for men with erectile problems, including sildenafil (brand name: Viagra), tadalafil (brand name: Cialis), or vardenafil (brand name: Levitra), have not been shown to improve sexual function in women more than would a placebo and are not usually recommended. The only exception to this is in women who take certain antidepressant medications who have difficulty achieving orgasm and who cannot switch to another antidepressant medication; an erectile dysfunction medication may be helpful in this situation.
Treatments that are unproven
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 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 circumcision (also known as female genital mutilation), 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 painful, may result in painful intercourse, are permanent, and are unlikely to improve a woman's or her partner's sexual enjoyment.
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Uterine cancer (The Basics)
Patient education: Menopause (The Basics)
Patient education: Sex problems in women (The Basics)
Patient education: Recovery after coronary artery bypass graft surgery (CABG) (The Basics)
Patient education: Atrophic vaginitis (The Basics)
Patient education: Paraplegia and quadriplegia (The Basics)
Patient education: Dyspareunia (painful sex) (The Basics)
Patient education: Vaginismus (The Basics)
Patient education: Bartholin's gland cyst (The Basics)
Patient education: Sex as you get older (The Basics)
Patient education: Vulvar pain (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Sexual problems in men (Beyond the Basics)
Patient education: Menopausal hormone therapy (Beyond the Basics)
Patient education: Vaginal dryness (Beyond the Basics)
Patient education: Vaginal hysterectomy (Beyond the Basics)
Patient education: Chronic pelvic pain in women (Beyond the Basics)
Patient education: Urinary incontinence in women (Beyond the Basics)
Patient education: Adrenal insufficiency (Addison's disease) (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Approach to the woman with sexual pain
Differential diagnosis of sexual pain in women
Chronic complications of spinal cord injury and disease
Clinical manifestations of adrenal insufficiency in adults
Symptom management of multiple sclerosis in adults
Evaluation of male sexual dysfunction
Overview of male sexual dysfunction
Sexual dysfunction caused by selective serotonin reuptake inhibitors (SSRIs): Management
Sexual dysfunction in women: Epidemiology, risk factors, and evaluation
Treatment of male sexual dysfunction
Sexual dysfunction in women: Management
The following organizations also provide reliable health information.
●American Association of Sex Educators, Counselors, and Therapists
●American Association for Marriage and Family Therapy
●Sexuality Information and Education Council of the United States
●Society for Sex Therapy and Research
●The North American Menopause Society (module on Sexual Health and Menopause)
- Shifren JL, Monz BU, Russo PA, et al. Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol 2008; 112:970.
- Basson R. Clinical practice. Sexual desire and arousal disorders in women. N Engl J Med 2006; 354:1497.
- Shifren JL, Davis SR, Moreau M, et al. Testosterone patch for the treatment of hypoactive sexual desire disorder in naturally menopausal women: results from the INTIMATE NM1 Study. Menopause 2006; 13:770.
- Segraves RT, Clayton A, Croft H, et al. Bupropion sustained release for the treatment of hypoactive sexual desire disorder in premenopausal women. J Clin Psychopharmacol 2004; 24:339.
- Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause 2013; 20:888.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.