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Patient education: Sexual problems in females (Beyond the Basics)

Patient education: Sexual problems in females (Beyond the Basics)
Author:
Jan L Shifren, MD
Section Editor:
Robert L Barbieri, MD
Deputy Editor:
Alana Chakrabarti, MD
Literature review current through: Nov 2022. | This topic last updated: Oct 07, 2022.

INTRODUCTION — Sexual problems are common in both females and males and can occur at any age. In the United States, approximately 40 percent of females 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 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.

In general, females 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. People who are not in a partnered relationship also may experience sexual problems. Although a host of changes in hormones, blood vessels, the brain, and vaginal area can affect sexuality, relationship difficulties and poor physical or psychological well-being contribute to many sexual problems.

This article will discuss causes as well as treatments that are available to help with sexual problems in females. Sexual problems in males 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 after sexual activity has started (in response to a partner, thoughts, events, or sensory cues; this is called "responsive desire"). Spontaneous desire is more common in new relationships while responsive desire is more typical of long-term relationships. A person can experience difficulties with either spontaneous or responsive desire.

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 frequently 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. It is possible to experience sexual pleasure without orgasm; absence of orgasm does not necessarily mean there is a problem unless the woman is bothered by this.

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. It is often the cause of other sexual problems, including low libido.

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

Personal well-being — Your sense of personal well-being is important to sexual interest and activity. Diet and exercise habits can affect body image. Not feeling your best physically or emotionally may contribute to a decrease in sexual interest or response.

Fatigue and stress — It is common to feel less interested in sex and experience reduced sexual pleasure when you are tired or under stress. Fatigue can result from an underlying medical problem, poor sleep, or simply not getting enough rest due to the demands of family, work, and other commitments and obligations.

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 with your partner(s), and limited communication can negatively influence your sexual desire and response. Current or past emotional, physical, or sexual abuse or trauma often contribute to sexual problems. In addition, it is normal for even healthy relationships to become less exciting sexually over time.

Partner health or sexual problems — Sexual dysfunction in a partner can affect your sexual response. If you have 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, females tend to live longer than males, resulting in fewer healthy, sexually functional male partners over time. If you have a female partner, they can also experience sexual problems that may impact your sexual satisfaction.

Gynecologic issues

Childbirth — After childbirth, it is common to experience decreased sexual desire. Contributing factors may include physical recovery and breastfeeding as well as fatigue and the demands of parenting. This can happen whether you gave birth vaginally or had a cesarean delivery ("c-section"). 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 (when monthly periods stop), estrogen levels begin to fluctuate. After menopause, estrogen levels decline dramatically. This may contribute to changes in your libido and ability to become aroused. Hot flashes, night sweats, sleep disruption, and fatigue, which commonly occur with menopause, also may contribute to sexual problems. There are treatments that can help with these symptoms. (See "Patient education: Menopausal hormone therapy (Beyond the Basics)".)

In addition, many people 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 activities that involve vaginal penetration) is infrequent. Although hot flashes and most menopausal symptoms improve with time, vaginal dryness and resulting painful sex generally worsen with time, if not treated. (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 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 people. (See "Patient education: Hysterectomy (The Basics)".)

Vaginal or pelvic pain — Vaginal or pelvic pain is a common cause of sexual dysfunction. 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. (See "Patient education: Chronic pelvic pain in females (Beyond the Basics)".)

Pain may be caused by endometriosis, vaginal or pelvic surgery, infection, or scar tissue. In people who have gone through menopause, a lack of estrogen often causes discomfort with intercourse and other forms of sexual activity. (See 'Menopause' above.)

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. (See "Patient education: Urinary incontinence in women (Beyond the Basics)".)

Medical issues — Almost any serious or chronic medical problem can impact sexual desire and responsiveness. Problems such as heart disease, arthritis, and obesity can affect a person's physical ability to have sex.

People with cancer can experience discomfort and fatigue, due to both the disease and its treatments, which often impact sexual function. Changes in body image, especially after surgery involving the breasts, vagina, or pelvis, can also contribute to sexual problems.

Other conditions, such as Parkinson disease, diabetes, or substance use disorders (involving alcohol, marijuana, pain medications, or other drugs), can impair libido, 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 females. 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:

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)

Gonadotropin-releasing hormone agonists and antagonists (used to treat endometriosis or fibroids)

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 females.

Surgery — Certain surgeries can affect a person's sexual response. In particular, surgeries involving the breast, vagina, uterus, or ovaries can change how a person feels about their 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 people 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 females 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. If possible, adjusting work schedules and obtaining help with childcare and household responsibilities can often improve quality of life and sexual satisfaction. Prioritizing sleep and trying to find other ways to reduce fatigue may also improve sexual interest.

Working with a professional counselor can help you to reduce stress and strengthen your relationships. Sex therapists are professionals with special expertise in helping individuals and couples address sexual problems by providing information, improving communication, and giving instruction 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 time alone together can reduce sexual problems. While this can be challenging to do given competing demands from work, family, and other priorities, it can help your sex life to have time set aside for just you and your partner.

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. (See 'Where to get more information' below.)

Novelty — Increasing novelty often sparks sexual desire and enhances sexual response. Try sensual massage, sharing a bath, experimenting with different sexual positions or activities, using candles and music, or having sex in the middle of the day or outside of the bedroom. Books, films, vibrators or other sex toys, 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 — People with vaginal dryness that makes sex uncomfortable may benefit from the use of a lubricant. These products are designed to reduce friction during intercourse and may result in greater comfort and pleasure. In addition, using a long-acting, nonhormonal vaginal moisturizer on a regular basis (several times weekly) reduces vaginal dryness. Both lubricants and moisturizers are available over-the-counter and do not require a prescription. It's best to use products without color, scents, or other additives in order to minimize vaginal irritation. People who have been through menopause generally will benefit from the use of low-dose vaginal estrogen therapy to treat vaginal dryness and painful sex associated with menopause (brand names: Vagifem, Yuvafem, Estring, Estrace cream, Premarin cream). Treatment of vaginal dryness is discussed in detail in a separate topic. (See "Patient education: Vaginal dryness (Beyond the Basics)".)

Improving painful sex — Many people 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 pelvis and vagina, 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 into the vagina several times for approximately five minutes daily. 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 people 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. Depression also is a common cause of sexual problems, so it is important that the depression is managed effectively.

Carefully considering androgens — Androgens, such as testosterone, are sex hormones that are produced in the testes and adrenal glands in males and the ovaries and adrenal glands in females. 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 less clear. Androgen levels decline with aging, so anyone who has been through menopause has lower blood levels of androgens. Studies of postmenopausal females 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 females demonstrates the importance of nonhormonal factors in sexual function. No androgen products are approved for the treatment of females with sexual dysfunction in the United States due to limited efficacy and the lack of data regarding long-term safety. (See 'Androgen side effects and risks' below.)

Testosterone — Testosterone products are sometimes used "off-label" to treat sexual problems in females. 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 much too high for females, increasing the likelihood of side effects. Testosterone products approved for males can be used at a much lower dose (approximately one-tenth) in females. 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 females.

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 females 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 in other situations, 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 females.

Androgen side effects and risks — Testosterone treatment can cause bothersome side effects. 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 female's body, there may be an increased risk of breast cancer, coronary heart disease, leg and lung clots, and stroke. Females who take androgens should be monitored closely for side effects. They also must be aware that long-term safety is unknown.

If you are considering use of androgens (testosterone or DHEA), it's important to discuss the possible side effects and risks of this treatment with your health care provider.

Medications and devices — In the United States, two medications have been approved for treating low sexual desire in premenopausal females with low desire for sex that is causing them distress (called "hypoactive sexual desire disorder"). Both must be prescribed by a health care provider. While they may slightly improve sexual desire, there can be serious side effects.

In most cases, health care providers recommend trying other things to improve your relationship and sex life before trying androgen therapy or either of these medications. Medication options include:

Flibanserin (brand name: Addyi) – This medication comes in a pill that you take every day. Some people who take it have problems with tiredness, nausea, dizziness, or headaches. Alcohol, as well as certain other medications, can increase the risk of side effects. If you have one or two alcoholic drinks, you should wait at least two hours before taking flibanserin. If you have three or more drinks, you should not take flibanserin at all that day.

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). Darkening of areas of skin can occur, including on the face, which may be permanent. A few people might have a rise in blood pressure. People with high blood pressure or heart problems cannot take bremelanotide.

Medications commonly used to treat erectile problems in males, including sildenafil (brand name: Viagra), tadalafil (brand name: Cialis), or vardenafil (brand name: Levitra), generally have not been shown to improve sexual function in females more than would a placebo and are not usually recommended. The only females 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 people 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. People born with abnormalities of the vagina, those who have had female genital cutting, and those with traumatic injuries from childbirth may benefit from surgical treatment performed by a surgeon with expertise in these procedures.

It's important to be wary of advertisements for "vaginal rejuvenation surgery." These procedures can be costly and uncomfortable, and may result in vaginal scarring and painful sex, which can be permanent. They 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; however, this is not generally recommended. Vaginal laser treatments are very expensive and not covered by health insurance. Injuries and scarring may occur, resulting in increased pain with sex. Studies of long-term safety and efficacy are lacking.

WHERE TO GET MORE INFORMATION — Your health care 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 health care 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 females (The Basics)
Patient education: Recovery after coronary artery bypass graft surgery (CABG) (The Basics)
Patient education: Vaginal dryness (The Basics)
Patient education: Paraplegia and quadriplegia (The Basics)
Patient education: Dyspareunia (painful sex) (The Basics)
Patient education: Vaginismus (The Basics)
Patient education: Bartholin 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 females (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.

Female sexual pain: Evaluation
Female sexual pain: Differential diagnosis
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
Epidemiology and etiologies of male sexual dysfunction
Sexual dysfunction caused by selective serotonin reuptake inhibitors (SSRIs): Management
Overview of sexual dysfunction in females: Epidemiology, risk factors, and evaluation
Treatment of male sexual dysfunction
Overview of sexual dysfunction in females: Management

The following organizations also provide reliable health information.

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)

International Society for the Study of Women's Sexual Health

(www.isswsh.org)

The North American Menopause Society (module on Sexual Health and Menopause, MenoNote on Vaginal Dryness)

     (www.menopause.org)

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