Patient information: Sexual problems in women

SEXUAL PROBLEMS OVERVIEW

Sexual problems are common and can occur in women of any age. In the United States, approximately 40 percent of women have sexual concerns and 12 percent report distressing sexual problems [1].

Sexual dysfunction is a term used to describe difficulties in libido (sex drive), arousal, orgasm, or pain with sex that is 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, and tissues of the vagina can affect a woman's sexuality, relationship difficulties and feeling poorly about yourself 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 information: Sexual problems in men".)

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 response to a partner's desire is more typical of long-term relationships.

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 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.

Although desire, arousal, and orgasm describe the typical sexual response, the goal of sexual activity is satisfaction for both partners, which may or may not 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 women's sexual satisfaction. In addition, even good relationships can become less exciting sexually over time.

Male sexual problems — For women with a male sexual partner, midlife changes 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.

Gynecologic issues

Childbirth — After childbirth, physical recovery and breastfeeding, as well as the demands of parenting, may decrease sexual desire or result in vaginal pain during intercourse. In most cases, these issues improve with time.

Menopause — Estrogen is a female 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 interruptions, and fatigue may also contribute to sexual problems. (See "Patient information: Postmenopausal hormone therapy".)

In addition, some women experience vaginal narrowing, dryness, and a decrease in elasticity of the vaginal wall after menopause, which can lead to discomfort or pain during sex. (See "Patient information: Vaginal dryness".)

Hysterectomy — In general, hysterectomy 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. 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 reduces estrogen and androgen levels, which may impact sexual function for some women. (See "Patient information: Vaginal hysterectomy".)

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 information: Chronic pelvic pain in women".)

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 information: Urinary incontinence in women".)

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 cause of sexual inactivity in the United States.

Women with cancer experience can discomfort and fatigue, due to both the disease and its treatments, which impacts 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:

• Beta blockers (used to treat high blood pressure)
• Many antidepressants (especially selective serotonin reuptake inhibitors)
• Some antipsychotic medications (used for psychiatric problems as well as sleep disorders and other conditions)

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. However, some women experience sexual problems after both ovaries are removed due to decreased estrogen levels. (See 'Hysterectomy' above.)

TREATMENT OF SEXUAL PROBLEMS

A number of treatments are available for women with sexual dysfunction. In many cases, a combination of treatments is most effective. (See "Sexual dysfunction in women: Management".)

Deal with relationship issues — Difficulties with communication and understanding are a significant cause of decreased sexual desire and response in men and women. Working with a professional counselor or sex therapist can help couples deal with stress, fatigue, lack of privacy, personal values, and religious beliefs, all of which can impact sexuality.

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.

For premenopausal women, 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. If there are underlying physical problems (eg, pelvic pain), getting these problems under control may also help to improve sexual difficulties. (See 'Where to get more information' below.)

Treat vaginal dryness — Women with vaginal dryness or discomfort may be advised to use topical (vaginal) estrogen or a non-hormonal vaginal moisturizer. Lubricant use with intercourse also increases comfort and pleasure. Postmenopausal women generally will benefit for use of low dose vaginal estrogen therapy. Treatment of vaginal dryness is discussed in detail in a separate topic. (See "Patient information: Vaginal dryness".)

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 or eliminating this problem.

Options for women who have side effects from an antidepressant medication include trying a reduced dose or change in type of antidepressant medication. Bupropion (Wellbutrin®), Nefazodone (Serzone®), mirtazapine (Remeron®), or duloxetine (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 women who took testosterone treatment have shown that select women have small, but significant improvements in sexual desire and response. Despite these findings, no androgen products are approved for the treatment of women with sexual dysfunction in the United States due to 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. 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.

Testosterone skin patches designed for women are available in Europe for postmenopausal women with decreased sexual desire. Studies of the testosterone patch have been completed in the United States, although further study of long-term safety will be required before these products are approved.

Women who are considering use of testosterone should discuss the possible side effects of this treatment with their healthcare provider. (See 'Androgen side effects' below.)

DHEA — Studies on the use of DHEA (dehydroepiandrosterone), available as a nutritional supplement in the United States, have shown that DHEA can improve sexual interest and satisfaction in some women whose adrenal glands no longer function (adrenal insufficiency). (See "Patient information: Adrenal insufficiency (Addison's disease)".)

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, and the amount of hormone may vary from one pill or bottle to another.

Androgen side effects — Side effects of testosterone treatment are a concern; androgens can increase body hair growth 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 and coronary heart disease. Women who take androgens should be monitored closely for side effects.

Erectile dysfunction medications — Medications commonly used for men with erectile problems, including sildenafil (Viagra®), tadalafil (Cialis®), or vardenafil (Levitra®), have not been shown to improve sexual function in women 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 recommended 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 ensure herbal therapies are safe and effective. 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 with abnormalities of the vagina, 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, 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. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Sexual problems in men
Patient information: Postmenopausal hormone therapy
Patient information: Vaginal dryness
Patient information: Vaginal hysterectomy
Patient information: Chronic pelvic pain in women
Patient information: Urinary incontinence in women
Patient information: Adrenal insufficiency (Addison's disease)

Professional Level Information:
Approach to the woman with a sexual pain disorder
Causes and treatment of sexual pain disorders
Chronic complications of spinal cord injury
Clinical manifestations of adrenal insufficiency in adults
Comorbid problems associated with multiple sclerosis in adults
Evaluation of male sexual dysfunction
Overview of male sexual dysfunction
Sexual dysfunction associated with selective serotonin reuptake inhibitor (SSRI) antidepressants
Sexual dysfunction in women: Epidemiology, risk factors, and evaluation
The sexual history and approach to the patient with sexual dysfunction
Treatment of male sexual dysfunction
Sexual dysfunction in women: Management

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• American Association of Sex Educators, Counselors, and Therapists

      (www.aasect.org)

• American Association for Marriage and Family Therapy

      (www.aamft.org)

• Sexuality Information and Education Council of the United States

      (www.siecus.org)

• Society for Sex Therapy and Research

      (www.sstarnet.org)

• The Women's Sexual Health Foundation

      (www.twshf.org)

• The North American Menopause Society

      (www.menopause.org)

Patient Support — There are a number of online forums where patients can find information and support from other people with similar conditions.

• About.com Sexuality Forum

      (http://sexuality.about.com/forum)

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