Understanding Female Sexual Problems — Diagnosis and Treatment

How Do I Know If I Have a Sexual Problem?

The most important way for your health care provider to diagnose a sexual problem is to listen carefully to the story you tell, review the medications and substances you use, and try to determine whether difficulties are recent, long-standing, or have been a permanent fixture thus far in your life. It’s also important for your provider to try to understand how much you know about your body and about sexuality. The provider will probably encourage you to talk about the relationship with your partner, past sexual history, any history of trauma, and any other stresses or concerns that may be interfering with the ability to respond sexually. While these topics may seem extraordinarily private, they must be covered to properly evaluate sexual dysfunction and help you have a more satisfying sex life.

A thorough physical exam and basic blood tests will help determine whether a physical ailment could be causing your sexual problems. During a thorough pelvic exam, your health care provider will try to identify any possible physical sources for sexual dysfunction, such as involuntary muscle spasms around the vagina (vaginismus) or prolapse of organs into the vagina. You may be asked to use a mirror to identify the parts of your body, to determine your level of knowledge about and degree of comfort with your own body. It is important to understand that the recognition and treatment of female sexual problems is a relatively new field. Providers vary considerably in their expertise and personal comfort in addressing these issues.



What Are the Treatments for Sexual Problems in Women?

Your health care provider may try to treat any underlying condition that might be interfering with your sexual functioning. For example, vaginal dryness after menopause may be treated with local estrogen creams or an oral estrogen, infections with antibiotics, and some conditions (organ prolapse into the vagina, anatomic defects, or abnormal healing after repair after childbirth) may require surgery. Better control of diabetes, thyroid conditions, kidney disorders, and high blood pressure may alleviate problems with sexual functioning. Low sex drive after menopause may be treated with combinations of oral estrogen and testosterone.

Postmenopausal estrogen therapy may be tried first. Vaginal estrogen in topical or pill form can reestablish and restore the ability to have an orgasm. If improvement does not occur within three to six months, testosterone may be added. Research has not established a relationship between a specific level of testosterone and diminished sexual symptoms. Androgen replacement may be considered if you’ve entered menopause before age 40.

Arousal problems may be difficult to resolve if you’ve never experienced sexual satisfaction. Therapies are designed to help the patient relax, become aware of feelings about sex, and eliminate guilt and fear of rejection.

Inadequate lubrication in a healthy, premenopausal woman may reflect either a muted sexual response or inadequate arousal by the partner. Explore feelings about sex and seek to eliminate guilt and fear of rejection. Extended foreplay, masturbation, and relaxation techniques may help. Artificial lubricants are available over the counter at any pharmacy.

For an inability to achieve orgasm, communicating with your partner about your desires for sexual foreplay and intercourse is an essential first step toward satisfaction. Psychotherapy may help improve communication skills and help resolve underlying conflicts about sexuality. With therapy and a supportive partner, the improvement rate is good.

For pain during intercourse, first make sure there is adequate stimulation and lubrication. A physical exam may reveal a need for medication to treat infection. Or it may be necessary to remove scars around the hymen or gently stretch painful scars at the vaginal opening. Laparoscopic surgery to relieve “deep pain” can often treat endometriosis and pelvic adhesions. Problems related to menopausal change may be relieved with postmenopausal hormone therapy. If pain persists, psychotherapy may help uncover hidden fears about intercourse. Certain exercises — called sensate focus exercises — can teach appropriate foreplay and de-emphasize intercourse until both partners are ready. Education can reduce fears of pregnancy or of harm to the fetus.

Vaginismus is difficult to reverse without professional help. If you have a partner, seek therapy together in a safe and supportive environment. To accustom your body to the feeling of penetration, a therapist may recommend inserting a series of vaginal dilators, each slightly larger than the last. You advance at your own pace until you are comfortable inserting a dilator the size of your partner’s erection. Contraction and relaxation exercises can teach control of the vaginal muscles and increase sexual responsiveness.

Kegel exercises to improve vaginal muscle tone can help improve sexual responsiveness and enjoyment. These exercises involve clenching those muscles involved in stopping the flow of urine, holding for about five to 10 seconds, and then relaxing. You’re usually asked to do three sets of 10 to 15 contractions daily. Frequently, consultation with a physical therapist skilled in treating pelvic muscle problems can improve the success when treating problems arising from the muscles around the vagina.

Sex therapy treatment may include exercises that ask you to participate in sexually stimulating behaviors, initially avoiding genital contact. You are asked to concentrate on the pleasurable sensations, simultaneously attempting to relax and ward off negative feelings, such as anxiety, fear, or guilt. When you can do this, you are then given instructions on how to masturbate.

The goal is to learn how to derive pleasure from self-stimulation without allowing negative feelings to interfere. When you are comfortable with these acts and can participate in them without negative feelings or pain, you’ll be asked to begin to include your partner. Slowly, gradually, and progressively, you and your partner move towards increasing sexual intimacy, perhaps ultimately including vaginal penetration.


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