Sexual Dysfunction. You're not the only one!

Have you ever felt the need to explore the reasons behind your diminished sexual desire? Did you ever think about the causes of a painful intercourse? Do you fantasize about sex, yet when it comes to practice you just cannot do it? Do you enjoy sex but fail to reach a satisfying orgasm?

This article aims to explore the different aspects of sexual dysfunction, and to elaborate the risk factors behind it.

Sexual function is of utmost importance! Some communities label any talks about sexual concerns as “Taboo”, but believe me, one of the most frequently described complaints we encounter in our clinics as gynecologists, is related to sexual function. Actually, studies have shown that sexual complaints are reported by around 40% of women worldwide, and approximately 12% of women report a sexual problem that is negatively impacting their personal and interpersonal lives! Which means that 1 out of 8 women will have a sexual problem that is severe enough to cause her impairment and personal distress.

This sexual dysfunction can take many forms, such as lack of sexual desire, disturbed female arousal, lack of orgasms or simply painful sex! You should keep in mind that it can occur anytime during a woman’s life. Some women experience it since their first sexual relations, whereas others experience it later in their lives after a period of normal sexual functioning.  

The general belief of sexual pleasure stems from a rigid cycle and sequence of events. Traditionally a proper sexual response was expected to follow 4 consecutive phases: the desire (famously known as the Libido), which leads to the arousal or excitement phase, followed by the orgasm, ending with the resolution. However, if we take a closer look at actual cases of women experiencing sexual pleasures, this rigid framework does not properly apply at all times. Some of these mentioned phases recur, overlap, vary in sequence or even fade in some women. For example, desire decreases and sometimes disappears in long term relationships, and this is totally normal as there are other motives leading to the female’s sexual excitement (like love, care, and desire for a strengthened relationship…), and thus sexual activity may precede desire in a subset of women. My point is that women are not meant to follow these rigid frameworks in order to have a satisfying sexual experience (to note that this applies to women who have sex with men, women or both).

According to the American Psychiatric Association (APA), the diagnosis of a female sexual disorder requires that a sexual dysfunction be recurrent or persistent and causes personal distress, lasting for at least 6 months, and not accounted for by a different diagnosis (such as generalized anxiety or depression).

Five major categories have been described:

Female sexual interest/arousal disorder

Women in this category tend to have a lack of sexual desire or excitement which manifests by:

• The absent or reduced interest in sexual activity
• The absent or reduced erotic thoughts or fantasies
• The lack of initiation of sexual activity
• Being not receptive to the partner’s sexual initiations  
• The lack of pleasure during sexual activity
• The lack of interest in any form of sexual cues (visual, auditory, verbal…)
• The reduced or absent genital or non-genital sensations during sex
  
  

Female orgasmic disorder

On the other hand, some women do fantasize about sex and have a desire to engage in sexual activity, but suffer from a marked delay in, infrequency or absence of orgasms. And in some instances, they might have a reduced intensity of orgasmic sensations.

Painful sex

This was previously called “Dyspareunia” and “Vaginismus” in order to describe genito-pelvic pain or penetrative disorder. Women can experience persistence or recurrent difficulty in vaginal penetration during sex, or can have severe fear of penetration in anticipation of pain, and some might describe a sensation of marked tensing or tightening of the pelvic and vaginal muscles during attempted penetration

Substance/medication-induced sexual dysfunction

Some women experience sexual dysfunction secondary to the introduction of a new medication or substance. Be careful, not all medications are capable of causing sexual dysfunction, as sometimes the latter is secondary to the existing medical condition for which you are taking the medication. So, the clinical diagnosis of this entity, is based on a sexual dysfunction that coincides with the initiation of a new medication or substance that is known to cause sexual dysfunction.

Unspecified sexual dysfunction

In some other instances, women have a trouble in their sexual function that does not fit any of the previously mentioned categories, and thus we, as clinicians, classify them as having an unspecific sexual dysfunction.

What about the risk factors that can negatively affect a woman’s sexual life?

Relationship

One of the most commonly reported reasons behind a decline in proper sexual activity is the duration of a relationship. In fact, studies have shown that the longer is the duration of a relationship, the lower is the rate of sexual activity because of a decline in the woman’s sexual desires despite an increase in her desire for tenderness and care! Adding to that, women who were in abusive intimate relationships were twice as likely to have a chronic lack of sexual desire even while being members of other non-abusive relationships.

Fatigue and Stress

Obviously the less relaxed and stress-free the woman is, the lower is her sexual desire. This can be applicable to most women worldwide who become less and less aroused as they become more stressed and tired. The typical improvement in a woman’s libido on vacations is a clear example reflecting the negative impact fatigue has on a woman’s sexual function.

Age

Even though there is a common belief that the older a woman gets, the less important her sexual life becomes. However, this is controversial and not applicable to all women. Indeed, some women grow old and tend to lose their sexual desires, but this might not be secondary only to age, as many factors interplay here, the most important being menopause. Studies have shown that menopause takes precedence over age alone.
As you know, menopause is the age when women lose their periods and start having a hypo-estrogenic state (low estrogen level). This low estrogen has a double effect on a woman’s body; firstly a low estrogen level is associated with a lower libido and desire, secondly, a low estrogenic state can cause vaginal dryness which can lead to painful penetrative sexual intercourse (coitus). So, these two sexual issues have been commonly reported by menopausal women seeking improvement in their sexual lives. One should not forget the other effects of menopause, such as poor sleep, anxiety, depression, hot flushes and irritability, all of which negatively impacting a woman’s sexual life.

Mental health

This goes without saying, many psychological issues have been associated with a higher sexual dysfunction rate. This applies to depression, anxiety, and psychosis. In addition, some of the medications used in the management of these psychiatric illnesses were shown to worsen sexual desire and excitement (such as antidepressants, anxiolytics, and antipsychotics)

Pregnancy and Childbirth

Women have testosterone! Yes, women have all forms of male sex hormones (normally, in lower concentrations than men). These hormones are associated with an increased libido. They can be free or bound to proteins, the free form being the active from of these sex hormones that can have a positive effect on the female’s sexual function. Pregnancy is known to increase the level of bound "inactive" hormones and thus leading to a decrease in the level of the free “active” hormones, resulting in a lower sexual desire in pregnant women. Also after childbirth, the pregnancy changes need time to readjust and thus sexual desire also needs time to go back to normal. Adding to that, after childbirth, most mothers become exhausted, stressed out, and more emotionally labile which causes them to have a lower sexual desire that normal.

Leaking urine

Urinary Incontinence is the involuntary loss of urine. Some women report experiencing it while having penetrative sex or during their orgasms. This can be very distressing and can end up in the development of an aversion to sexual intercourse.

Painful sex

Pain while having sex can be very distressing to women. This pain can either be “external” or “deep”. The external irritative type of pain is mainly seen in women with dry or tight vaginas. As for the deep penetrative pain, it is seen in women with endometriosis (when the endometrial glands of the uterus are present outside the uterus), infections (of the cervix or uterus), adenomyosis (when the endometrial glands of the uterus invade the uterine wall) or fibroids (muscle and connective tissue tumors of the uterus).

Medical conditions

Diabetes, hypertension and neurologic diseases have all been linked to sexual dysfunction in one way or another. This can be related to the disease itself or the medication used in its management.

Body image

Studies have shown that many obese women were more likely to enjoy sex only after weight reducing surgeries or activities, because obese women were shown to be more self-conscious about their body image. But I believe that regardless of your body mass index, if you are not satisfied with your own body, you will not enjoy sharing it with your sex partner. So, before targeting your actual weight and figure, focus on your mental health and practice self-love.

Birth control pills

The data that looked at the potential association between the intake of hormonal birth control pills and sexual dysfunction showed conflicting results. Some studies say that birth control pills negatively impact the woman’s desire, some other studies show no relationship between the two, and other studies have linked hormonal birth control pills intake to an increase in sexual desire.

Substance abuse

This falls in the category of substance abuse related sexual dysfunction, and the most commonly consumed "drug" is nicotine which may inhibit female sexual arousal!
As for alcohol and opioids (morphine, codeine, heroin…), they were shown to impair sexual desire in both males and females.
In addition to the just mentioned physiologic effects that some drugs have on sexual function, studies have always linked substance abuse to other mental and psychologic disorders that further exacerbate sexual problems.

So it should be clear for you by now that sexual problems do exist and are actually highly prevalent in women. If you are not happy with your sexual performance, or you do not seem to enjoy sex, or you do not desire sex in first place or find it to be painful, trust me you're not alone! Instead of "living" with a problematic sex life, I would urge you to seek help and visit your gynecologist/sexologist as treatment exists. 

But what should you expect during your doctor’s visit for such a complaint?

The first and most important thing is for you to feel comfortable with your physician and to have a private discussion about your condition. It is always preferable to have your partner with you in case you have one, as most treatment modalities require both members of the couple to be involved.
Moreover, you should know and set your goals prior to the initiation of therapy! Your physician might ask you to fill some questionnaires that identify your goals and track your improvement. It may be hard to achieve the ideal sexual pleasure (based on prior experiences or cultural images of sexuality) so your clinician might ask you to set realistic expectations.  

You should also keep in mind that sexual problems are often multi-factorial, associated with physical, psychological and relationship qualities. Feel engaged and well informed before boarding any treatment plan. This shared decision-making was proven to enhance patient’s satisfaction, especially when it comes to private matters such as sexual function.

Remember that treatment is not magical, and it needs TIME! Don’t lose hope, as most of the times a period of trial and error will ensue before you start noticing any improvement in your sexual behavior.

I reiterate that if you a have a sexual partner, it is advisable that he/she attend the clinic’s appointment as he/she must be considered in the treatment plan. In some instances, your sexual dysfunction can be secondary to your partner’s dysfunction, however there is no need to neither blame yourself nor blame your partner as it takes two (or more) to enjoy sex!! Acknowledge that communication is key, as it improves intimacy and pleasure.

Finally, your doctor will scrutinize your medical, psychological and social histories. As I have previously mentioned, some medical/psychological conditions are associated with sexual problems and thus addressing them by a specialist might benefit your sexual function as well. In addition, medications and illicit drugs should be put on the table as some can have deleterious effects on your sex life.

Furthermore, expect a full physical examination (general assessment and a pelvic examination) as sometimes the reason behind a sexual dysfunction can be anatomic. 
Again and again, I urge you not to feel ashamed or embarrassed, and trust me when I tell you that gynecologists have seen it all!  

At the end of the day, when your clinician clearly understands your main concerns, recognizes your goals and realizes the barriers hindering you from your optimal sex life, then treatment can begin.

Stay tuned for another article tackling the different treatment modalities.

Until then, stay safe and embrace your sexual lives!

 

Karam