Authored by Amy Rosenman, MD
Sexual complaints or problems are often difficult to bring up to your physician. These are intimate issues and we are not used to discussing them with another.
Sometimes we even have difficulty talking to our partner about these things. I try to diffuse the discomfort by asking simple questions such as:
Hopefully this opens the door to a discussion of all subjects sexual. If your physician does not specifically ask, do not hesitate to say, "I have some concerns about intercourse", or "I am concerned that I am not experiencing the same level of desire or libido as I used to experience", or "I am not able to achieve orgasm and would like to ask some questions". It is best if this can be discussed before the actual physical exam so that the doctor can address your concerns during the exam. It is not uncommon, however, that the issue is so sensitive that many patients do not open the subject until I am actually ready to leave the exam room, with my hand on the doorknob. When this happens, I understand the sensitivity of the situation and if I have the time will sit down again and continue with the visit. Sometimes this is not possible and we will schedule another visit to sit down and go over all the issues. It is not possible to cover this in just a minute or two. I will often send the patient home with written material in a folder to read over at her leisure. It is hard to absorb all the information available at one sitting. I also refer women to this website as a resource for further information.
The most vexing and frequent sexual complaint brought to my attention is reduced libido, women complaining of either less interest or even no interest at all in sex. This is sometimes a lifelong problem but often it develops as we age and our lives and bodies change. There are many possible causes. Each woman may have one of these or several causes of reduced interest in sex. This is a very disruptive problem if your partner has a different level of sexual interest because it can be a source of conflict in a marriage or relationship.
Reduced libido has a medical name: hypoactive sexual desire disorder or HSDD. There are many possible causes of this. The possibilities include: relationship problems, psychological issues, life stresses, medical problems especially painful intercourse that can occur with lower estrogen levels found in the menopause. Medications such as the SSRI antidepressants (the Prozac/ Zoloft class of drugs), sedatives and tranquilizers are known to reduce or remove libido.
We know androgens or male hormones like testosterone play a role but the actual role is unclear. The lab tests for the hormone are unreliable and there is no reliable information of what replacement levels are safe. This is why a testosterone patch, which has been under development for several years, has not been FDA approved. There is no long-term safety data for testosterone supplementation in women and giving too much of it has a deleterious effect on our cardiac lipids; it can increase our heart disease risk. Testosterone has also only been found to have any benefit if we are taking estrogen as well. In the absence of estrogen, testosterone is ineffective and some of it is actually converted to estrogen in our body.
That said there is a position statement from the North American Menopause Society (NAMS) concluding that there is evidence that adding testosterone to estrogen therapy results in positive effects on sexual function, primarily in sexual desire and further states that testosterone therapy can be considered in postmenopausal women with reduced libido associated with personal distress and no other identifiable reason for the sexual complaint. However, a task force of the Endocrine Society recommended against the widespread use of testosterone is women because of the lack of clear indications as well as concerns over long-term safety. So we can conclude that testosterone treatment is controversial. You should discuss it directly with your physician. It is my policy to discuss these facts with each individual patient and design an individual treatment plan. It is very important to closely monitor any woman on testosterone because there are serious side effects such as acne, excess hair growth, voice changes, loss of hair on the head, liver toxicity, as well as adverse effects on the cardiac lipids.
Less controversial are other approaches to reduced libido. One approach I recommend is guided imagery, thinking sexual thoughts often begets more sexual thoughts. If one thinks of our libido as a furnace we all might agree that keeping the furnace simmering makes sense. Then it is easier to turn up the heat when desirable than to start from a cold furnace. Even though our libido was on autopilot in our 20's and 30's, many women find that after 40 with family and life responsibilities, we are no longer on autopilot. Our libido benefits from some nurturing. It requires some attention. I suggest a stash of erotica that is stimulating, things you have found effective in the past, pictures, images, book passages, maybe a movie that "moved you" in the past. And refer to them regularly to "keep the furnace simmering." Developing sexual fantasies will assist with this effort. Scenarios that have worked before will often work again and may be relied upon in the future.
Another recommendation is to work with your partner to re-establish or improve intimacy. Several years ago I spent some time during my residency at UCLA in the Sexual Dysfunction Clinic. I attended patients with a co-therapist who was a psychiatrist for 4-month series of therapy sessions. In this model couples were seen by two therapists and were given assignments such as the one described above. We also assigned the couples exercises that allowed them to become more familiar with each other's physical preferences, likes and dislikes in an effort in improve communication and add to the fun of the sexual experience. This is often referred to as sensate focus exercises or sensual massage. One partner touches the other and feedback is provided. This is performed one at a time without involvement of sexual areas reducing stress, eliminating performance anxiety and allowing a couple to just relax and learn about each others preferences. After this succeeds we suggest moving on to a more sexual encounter, possibly without intercourse at first and then moving on to a full sexual encounter with intercourse. This requires some guidance, often with a therapist but parts of this can be tried at home on your own.
It is helpful to evaluate your routine. Do you need more rest? How can you minimize stress and fatigue? More exercise often reconnects our psyche and our body. Consider varying the time or the place for sexual encounters, this can increase the stimulation and improve the experience. Self-stimulation (masturbation) is another approach that keeps the furnace simmering and helps the individual maximize her familiarity with pleasurable sensations. Adding a vibrator to the mix often helps even more. I suggest a vibrator with a wave like motion rather than a buzzing like vibration. It is more physiologic and more stimulating to the female genital area.
This is often described as feeling an interest in sex but not being able to enjoy or pursue the interest successfully. It is often associated with negative past experiences that were sexual turn offs, such as sexual abuse or guilt from early adolescence. This is best handled directly in psychological counseling.
Thinning of the genital tissues after menopause is another cause. The vaginal lining becomes thin and less flexible causing pain with intercourse. This causes an aversion to sexual activity due to fear of the pain. The treatment of choice is vaginal or systemic estrogen replacement. This improves blood flow in the region, improves sexual response, and makes the entire sexual experience much more satisfying.
This is defined as a delay or absence of orgasm following sufficient stimulation. This may be life long or new onset. Causes include a fear of losing control or being vulnerable, lack of trust of others, or fear of intimacy. New onset disorders are frequently associated with medication, especially the SSRI (serotonin reuptake inhibitors), sedatives, alcohol, neurologic diseases such as Parkinsons, stroke, or multiple sclerosis, or nerve damage.
Orgasmic disorders are amenable to treatment. Usually self-stimulation is very helpful and helps the women figure out what works. Since it is imperative to reduce inhibition, it is easiest to start alone without having to worry about a partner initially. Then you can assert your preferences with your partner. Vibrators can be helpful with self-stimulation or with your partner. This disorder is also well treated by a therapist specializing in sexual problems. A multidisciplinary approach of counseling, behavioral therapy, and pelvic muscle exercises may enhance success.
Sexual Pain Disorders
Pain with intercourse (dyspareunia). The most common cause of this pain with penile penetration is estrogen deficiency leading to thinning and loss of elasticity of the vagina and vulva. There are inflammatory conditions such as vulvar vestibulitis or vulvodynia. These are conditions that merit discussion with your physician, as there are treatments available. Vaginal infection, possibly yeast or a nonspecific vaginosis can also cause pain and can be treated. Interstitial cystitis, an inflammatory painful bladder condition is treatable. Other causes include endometriosis and scarring from prior vaginal surgery, radiation, or childbirth injury. It is important to remember that these conditions have solutions. Even if they cannot be cured these conditions can be treated and your quality of life greatly improved.
Vaginal Spasm (vaginismus) is an involuntary spasm of the vaginal and pelvic floor muscles that interferes with vaginal penetration. This condition usually has a significant psychological component.
Without going into the detailed causes and treatments for all these issues, suffice it to say that treatment should be sought because there are solutions. Treating the underlying cause of the pain is imperative. The addition of vaginal estrogen and lubricants, the use of vaginal dilators or a dildo to encourage the tissues to stretch and accommodate comfortable, enjoyable intercourse, counseling, and referral to a sex therapist is helpful. If initial treatment is not successful, treatment in conjunction with a sex therapist or psychologist may lead to solutions.
Sexual problems may be multifactorial and a multidisciplinary approach is often the most affective. Do not just suffer in silence. Seek answers and solutions; they are out there.
I would like to cite as a resource for much of this information:
Singer, MD, Andrea and Smith, Judy Medical Editor; SEXUAL DYSFUNCTION A vexing problem in women's health; OBG Management supplement; September 2008.