Treating common sexual problems
| January 1, 2007
In-Depth Report
Treating common sexual problems
Unlike arthritis or high blood pressure, sexual problems aren't something most people feel comfortable discussing with friends and neighbors. Because of this tendency to suffer silently, you may be surprised by how many people contend with this issue: According to a study in the Journal of the American Medical Association, 43% of women and 31% of men under age 60 have some type of sexual dysfunction. And the numbers rise with age. The Massachusetts Male Aging Study found that by age 65, two-thirds of men have some degree of erectile dysfunction and one-sixth are completely impotent. In sharp contrast, of the adults who responded to the AARP sex survey, relatively few — just 28% of men and 10% of women — had ever sought medical advice for sexual problems.
Although many adults place a high value on a healthy sex life (see "Attitudes about sexuality and aging"), most don't know where to turn when sexual problems creep up. Some assume that the loss of sexuality is an inevitable, although regrettable, part of aging and resign themselves to a sexless existence. Others are too overcome by embarrassment to seek advice, but this may only intensify feelings of frustration, anger, and inadequacy.
The popularization of Viagra in the late 1990s went a long way toward normalizing the issue of erectile dysfunction. Countless men sought help as a result. What's less well known is that many other sexual problems can also be treated effectively in men and women, often without medication.
This section describes the major classifications of sexual problems and provides an overview of treatment options. Keep in mind that it's not unusual for a person to experience more than one kind of sexual dysfunction, and that therapies may overlap. Treatment often combines medication with sex therapy and self-help techniques.
Erectile dysfunction
There's been a revolution in the treatment of erectile dysfunction. As a result, a problem that was once spoken of only in whispers is now a topic for daytime TV. Although it still isn't easy to acknowledge intimate problems, the openness allows men with this condition to see that they are not alone.
Because many men are reluctant to acknowledge erection difficulties, it is difficult to determine just how common the problem is. However, the American Urological Association estimates that erectile dysfunction affects 25 million American men. While it can strike any man who is old enough to have an erection, erectile dysfunction becomes more common with age. One study found that approximately 40% of 40-year-old men, 50% of 50-year-old men, and 67% of 70-year-old men had some degree of erectile dysfunction.
Don't let these numbers fool you into thinking that erectile dysfunction is an inevitable part of aging. It isn't. Although age-related changes such as lower testosterone levels, decreased blood flow to the genitals, slower nerve function, less elastic erectile tissue, and increased stress all play a part, even these factors don't fully explain all the numbers. The problem often results from an illness that becomes more prevalent with age — such as cardiovascular disease or diabetes — or its treatment. Many of these conditions can be prevented with good health habits such as following a healthy diet, exercising regularly, maintaining a normal weight, and not smoking.
How an erection occurs
At its most basic level, an erection is a hydraulic event. Blood fills the penis, causing it to swell and become firm. But getting to that stage requires an extraordinary orchestration of body mechanisms. Most of the time, an erection really starts in the man's brain. A sight, smell, or touch sparks electrical signals of sexual arousal in the brain. These signals travel from the brain to an area in the lower part of the spinal cord. Nerves in this area signal nerves in the pelvis, which instruct arteries to let blood into the penis, thereby causing an erection.
Direct genital stimulation can also produce an erection, but different nerve pathways are involved. In this case, the sensation is carried by the pudendal nerve, which runs from the penis to nerves in the lower spine. Then these nerves send messages that cause the arteries in the penis to admit blood.
How is blood flow increased? Nerve cells use chemical messengers to talk to one another. These messengers boost the production of another set of chemicals, which initiates the erection by relaxing the smooth muscle cells lining the tiny arteries that lead to the corpora cavernosa, the pair of flexible cylinders that run the length of the penis (see Figure 3). As the arteries relax, thousands of tiny caverns inside these cylinders fill with blood. Blood floods the penis through two central arteries, which run through the corpora cavernosa and branch off into smaller arteries. The amount of blood in the penis increases sixfold during an erection. The blood filling the corpora cavernosa compresses the openings to the veins that normally drain blood away from the penis, temporarily closing them off. The blood is, in effect, trapped in the penis for the duration of the erection.
Obviously, an erection isn't permanent. Some signal — usually an orgasm, but possibly a distraction, interruption, or even cold temperature — brings an erection to an end. This occurs when the chemical messengers that started and maintained the erection stop being produced and other chemicals destroy the remaining messengers. Blood seeps out of the caverns of the corpora cavernosa, allowing the veins in the penis to reopen and drain blood from the penis.
Figure 3: What happens during an erection
When a man is sexually stimulated, chemical signals from the brain cause the penile arteries to widen, allowing more blood to enter the erectile bodies known as the corpora cavernosa. The tissues swell with blood, causing an erection. At the same time, blood-engorged tissues compress the veins, keeping blood in the penis and maintaining the erection. |
Causes of erectile dysfunction
In the past, most cases of erectile dysfunction were considered psychological, the result of such demons as performance anxiety or more general stress. Although these factors do cause some cases of erectile dysfunction, doctors now think that 70% of erectile dysfunction can be traced to age-related changes or a physical condition that hampers blood flow, nerve functioning, or both. Such conditions include diabetes, kidney disease, atherosclerosis, vascular disease, multiple sclerosis, and alcoholism. (See "Sexuality and health problems.") Less frequently, erectile dysfunction is an outgrowth of injury to the nerves and vessels that serve the genitals or a disease that causes scarring of penile tissue.
Unhealthy habits can also raise a man's risk of erectile dysfunction. A 2006 study in the Journal of Urology by Harvard researchers showed that smoking raises the risk of erectile dysfunction by 50%, while being obese increases risk by 90%. Men who were both overweight and sedentary were two and a half times as likely to have erectile dysfunction compared with active men of normal weight.
But thinking of erectile dysfunction as either psychological or physical can be misleading. These forces are usually intertwined. In fact, more than 80% of men with erectile dysfunction caused by an underlying physical illness develop psychological issues that further hamper erections.
Diagnosing the problem
Before going to your doctor, it's important to understand what erectile dysfunction really is. Failure to get an erection after one too many drinks or during a week of intense stress doesn't constitute erectile dysfunction. Also, normal changes in your sexual response as you age — such as having to wait a longer time after orgasm to have another erection or needing more direct stimulation — don't necessarily fall under this heading.
Erectile dysfunction is the inability to attain and maintain an erection sufficient for sexual intercourse at least 25% of the time. The penis doesn't get hard enough, or it gets hard but softens too soon. The problem generally comes on gradually. When such difficulties occur regularly and distress you or your partner, it's time to talk to your doctor.
There are many therapies — such as oral medications, injections, sex therapy, mechanical devices, and surgery. Doctors typically try to diagnose the cause of the problem before recommending a treatment. The doctor will ask about your symptoms and your health history, including any diseases and surgeries you've had and medications you're taking. The doctor will ask about feelings of depression, your stress level, and your relationship with your partner.
During a 10- to 15-minute exam, the doctor will check for conditions that can affect blood flow, such as high blood pressure or a heart murmur. He or she may test your blood to assess your risk for cardiovascular disease. The doctor will also examine your testicles, penis, and chest (small testicles and enlarged breasts are signs of low testosterone). In addition, your doctor will feel your prostate gland and test your reflexes. Now that medication can successfully treat most cases of erectile dysfunction, many once-routine diagnostic tests are rarely used. Still, if your doctor suspects that you have another condition that requires treatment, he or she may order a specialized test (see below).
Once your doctor identifies the cause of your erectile difficulty, you can begin treatment. Several options are available.
Additional tests for erectile dysfunctionAlthough the following tests are performed less frequently than they were in the past, your doctor may suggest one or more of them to assess whether you have an underlying condition that's causing erectile dysfunction. Hormone tests. If your doctor thinks you may have a testosterone deficiency, he or she will take a blood sample to measure your testosterone level. Your doctor might suggest this test if erectile dysfunction is accompanied by loss of sexual desire. Blood flow tests. A special type of imaging technique (called color duplex Doppler ultrasound) can reveal problems with blood flow through the arteries or veins of the penis. Nocturnal tumescence tests. If it's not clear whether your erectile problems stem from a psychological cause or a physical one, your doctor may suggest a test to find out whether you're having the spontaneous erections that normally occur during sleep. There are a few ways to test for nocturnal erections; for example, medical devices can be attached to your penis to monitor its rigidity or circumference throughout the night. |
Viagra, Levitra, and Cialis
When sildenafil citrate (Viagra) came onto the market in the late 1990s, it revolutionized the treatment of erectile dysfunction. The famous "little blue pill" is safe, easy to use, and effective for a broad range of causes — qualities that made it the first-line treatment for most men with erectile dysfunction. Its success spawned competitors like vardenafil (Levitra) and tadalafil (Cialis), both of which were approved by the FDA in 2003.
All three medications work in much the same way: By relaxing smooth muscle cells, the drugs widen blood vessels primarily in the penis, as well as in other parts of the body. For many men, this clears the way for an erection. These pills aren't aphrodisiacs; you've got to feel desire and be sexually stimulated in order for them to work. But if they are taken 15 minutes to an hour before intercourse, they can help you get and maintain an erection by acting on the normal physiology of the penis.
The three medications have similar success rates. In all, about 70% of men respond well to the drugs, but the rates vary according to what is responsible for the erectile dysfunction. Men with impotence of no identifiable physical cause fare best, while the drugs are less effective for men with diabetes or who have had prostate cancer surgery.
The three rivals also have similar side effects. For all, side effects are uncommon and mild when the drugs are used properly. The most common side effect is headache, which occurs in about 16% of men. Other reactions include flushing, nasal congestion, indigestion, urinary tract infections, and diarrhea. A few men who take Cialis have backaches, while a few Viagra and Levitra users have reported vision problems, typically a temporary blue tinge or haze.
There have been reports that a very small number of people using Viagra, Levitra, or Cialis have experienced vision loss. However, it's not clear that there is a cause-and-effect relationship between these medications and NAION (nonarteritic anterior ischemic optic neuropathy), a condition that can lead to blindness. While the concern isn't great enough to prevent men who need these medications from using them, it serves as a reminder to get regular eye care and remain alert for possible side effects.
While these drugs are safe for men with healthy hearts, men with cardiovascular disease should take special precautions, and some cannot use them at all. If you have had a recent stroke or heart attack, have low or high blood pressure, congestive heart failure, unstable angina, or heart arrhythmia, talk to your doctor about whether these drugs are safe for you. If you are taking medication containing nitrates (such as nitroglycerine for angina), you should avoid Viagra, Levitra, or Cialis. Mixing these medications can cause blood pressure to drop to dangerously low levels. In addition, men taking alpha blockers (medications used to treat high blood pressure and benign prostatic hyperplasia) should not take Levitra or Cialis, but they may be able to use Viagra with caution.
While Viagra, Levitra, and Cialis are quite similar, there are some differences. For example, the starting dosages are different for each. While you should take Viagra on an empty stomach, you can take Cialis or Levitra with or without food.
These medications may take effect in as little as 15–20 minutes or up to an hour. Viagra and Levitra last for about 4–5 hours, but Cialis stays active in the body far longer — for up to 36 hours. (Of course, this doesn't add up to a day-long erection. Cialis simply makes an erection possible during that period if desire and sexual arousal are present.)
Despite their impressive results, these medications have some drawbacks. Since they can take up to an hour to work, you'll need to plan accordingly. Also, they are relatively expensive, costing about $10 to $14 a pill. Some insurance plans do not cover this expense; others allow for only a few pills a month. Even if you don't think you'll use all the pills allotted to you each month, you might consider ordering them anyway so that you'll have extras on hand for vacations or special occasions.
Yohimbine: An alternative therapyThis plant-based remedy is extracted from the bark of the yohimbe tree. Studies of its effectiveness have been inconsistent, and doctors don't recommend it as a first-line therapy. However, it may be useful for men who are unable to take Viagra, Levitra, or Cialis. Side effects include insomnia, increased heart rate and blood pressure, nervousness, irritability, and dizziness. For more on yohimbine, see "Alternative therapies for sexual problems." |
Penile injections
For men who can't or don't want to use Viagra, Levitra, or Cialis, injecting medication directly into the side of the penis with a tiny needle is an effective option (see Figure 4). Injection therapy works better than erectile dysfunction pills for men whose erectile difficulties result from diabetes or prostate cancer surgery. Your doctor or nurse can demonstrate the injection technique, which most men are able to learn quickly. An erection typically occurs 5–20 minutes after an injection and lasts for 30–60 minutes. Only one drug, alprostadil (Caverject and Edex), is approved specifically to treat erectile dysfunction in this manner, although several older drugs used for other purposes are also effective. These include papaverine (Pavabid, Genabid, and others), phenoxybenzamine (Dibenzyline), and phentolamine (Regitine).
Figure 4: Injection therapy
If your erectile dysfunction is caused by diabetes or prostate surgery, you may find that injection therapy is more effective than Viagra, Cialis, or Levitra. |
The main side effects are mild to moderate pain, bruising, or scarring. Injectable drugs can cause low blood pressure, although this typically happens only if a man takes a large dose or injects himself more than once in 24 hours. Another rare complication is priapism, an erection that lasts too long. If you have an erection that lasts more than three hours after injection, you should go to the emergency room to avoid severe damage. An erection that lasts longer than six hours can cause scarring and complete loss of erectile function.
Drug pellets and MUSE
An alternative to injections is a therapy called MUSE (Medicated Urethral System for Erection). In this procedure, you use a disposable plastic applicator to insert a pellet of the drug alprostadil (the same drug that's used in injections) about an inch up the urethra. From there the drug is quickly absorbed into the erectile tissues, where it dilates the arteries. Some men find it easier to use than injections; however, clinical experience shows it's effective in only about 30% of men.
Mechanical devices
Men who can't or don't want to use medications can opt for mechanical devices that assist in producing an erection, maintaining an erection, or both.
Penile band. If you can get an erection but lose it because of leakage of blood from veins in the penis, you may find a penile band helpful. This band is fastened around the base of the penis to prevent blood from escaping. Available without a prescription under the brand names Actis and Erexel, the bands are very effective when used properly.
Vacuum erection device. This consists of an airtight plastic cylinder that's attached to a manual or battery-operated handheld pump. You insert your penis into the cylinder and pump out the air, which increases blood flow to the penis. It takes about five minutes to get an erection. At that point, you fit a rubber ring around the base of the penis to prevent the blood from draining away. The erection lasts until the ring is removed. Although vacuum pumps are about 80% effective and can be used as frequently as a man wishes, they have some drawbacks. Some men find the pump hard to use, the process may be disruptive to lovemaking, and the man's erection does not feel as natural as one produced with medication. Minor side effects such as pain, bruising, and difficulty ejaculating occur in 10% of men who use the pump.
Surgical implants
This option is reserved for cases where no other form of treatment has succeeded. Two kinds of implants are available. The first consists of two pencil-thin silicone rods implanted in the penile shaft above the urethra. The operation is done on an outpatient basis and takes about an hour. Afterward, the penis remains permanently erect, although it can be pointed down along the thigh to conceal it under clothing.
The second type of implant uses inflatable cylinders that are placed into the corpora cavernosa. When the man wants an erection, he simply squeezes a pump located in the scrotum. The pump pushes saline fluid into the cylinders from a reservoir implanted in the scrotum or abdomen. Although this device generates a more natural erection than silicone rods, it's prone to complications, such as infection or malfunction.
Treatment for specific disorders
For men whose erectile dysfunction can be traced to a specific disease, the following treatments are available.
Vascular surgery. When erectile dysfunction results from leakage of blood from certain veins during an erection or the blockage of specific blood vessels, surgery may correct the problem. To treat leakage, the surgeon ties off the leaking vessels so they retain blood. In the case of a blockage, the surgery entails bypassing the damaged vessels to allow more blood into the penis. These operations are able to restore normal erectile function less than 30% of the time.
Surgery for Peyronie's disease. In Peyronie's disease, scar tissue makes the penis bend during an erection. Surgery usually involves cutting a notch on the outside curve of the penis, then stitching the ends together. If there is too much scar tissue, the damaged portion is removed and replaced with a graft of skin tissue. However, if the underlying arteries are damaged during the surgery, the procedure could result in erectile dysfunction.
Hormone therapy. Testosterone supplements are appropriate only if you have abnormally low levels of this hormone. The supplements can help boost your libido and improve your ability to have erections. These supplements are now nearly always given in gel form, which you apply daily to your shoulders. Other forms are less convenient (doctor-administered injections) or cause skin irritation (skin patches). The exact role that low testosterone plays in erectile dysfunction remains unclear. However, at least one study suggests that using testosterone gel along with Viagra may be helpful for men with low or borderline testosterone levels who don't respond to Viagra alone.
How sex therapy can help
Sex therapy is often helpful for erectile dysfunction, even when physical factors are to blame. Sexual difficulties, no matter what the cause, can strain your relationship. Frequently a man with erectile problems experiences performance anxiety, which makes him reluctant to initiate sexual contact. His partner may perceive this as rejection, which could trigger feelings of frustration and resentment. But sex therapy can help a couple overcome these feelings and reestablish intimacy.
In addition to standard sensate focus techniques, the therapist will teach the couple techniques for overcoming worries about losing an erection during sexual activity. For example, in one case, a man and his partner would progress to the stage of stimulation where intercourse would normally begin, then purposely stop so that the penis becomes flaccid again. Then they resume stimulation until the man has an erection again. When they do this exercise repeatedly, the couple learns to relax, knowing that the man will be able to regain his erection if he loses it.
It's common for sex therapy to be used along with medications for erectile dysfunction. Doctors often prescribe drugs to help men overcome performance anxiety in the short term and recommend sex therapy to help the couple work through the emotional component of the problem. Once confidence is restored, some men are able to have erections without taking Viagra or similar medications.
Safer sex and erectile dysfunctionPassing your 50th birthday does not guarantee immunity from sexually transmitted diseases. Therefore, if you find yourself contemplating a new sexual relationship after a long stretch of monogamy or abstinence, you may be faced with taking safer sex precautions for the first time. Primary among these is the use of a latex condom during sex. Many men who have had a history of erectile difficulties balk at this suggestion for fear that a break in the action will cause them to lose their erection. Here are some tips for how you can avoid erection problems while still playing it safe: Have the condom unwrapped and within easy reach. Let your partner help you put the condom on if that person is comfortable doing so. Focus on an erotic fantasy while you put on the condom. This will keep you from worrying about your erection. Stimulate your penis as you get the condom ready and slip it on. |
Low libido
Diminished sex drive is the most common and the most elusive sexual dysfunction. According to a 1994 landmark study of sexuality in America conducted by University of Chicago researchers, 33% of women and 16% of men reported they had gone through periods of several months when they had no interest in sex. A particularly challenging aspect of the problem is that it often exists along with one or more other sexual dysfunctions. For example, a woman who experiences painful intercourse will understandably shy away from sexual activity.
What is desire?
To determine what constitutes low libido, it's important to first understand the nature of desire. Desire can be dissected into three parts: sexual drive, sexual wish, and sexual motive. Sexual drive is a hormone-dependent impulse for sexual release. It can manifest itself as a longing to reproduce or to have sex, erotic thoughts or dreams, or an urge to masturbate. Sexual wish is the willingness to have sex. Even if an individual's physiological need for sex is weak, he or she may wish to participate in the activity to feel more connected to another person, to feel more masculine or feminine, or to feel more physically energetic. Sexual motive is the combination of factors that impel a person to want sex. All three of these elements have to be taken into account when examining libido problems. Of all the forms of sexual dysfunction, low desire is the most complex and challenging to treat.
Defining low libido is quite subjective. There are no physical signs to measure, and libido varies widely from person to person, with age, sex, and personality all playing a role. Medically, low libido is defined as the absence of sexual fantasies or a lack of desire for sexual activity that causes personal distress. However, this too can be variable. Because there's a range of desire levels within "normal" libido, differing amounts of sexual interest can create tension in a relationship, even if the person with the lower libido has some sex drive.
To complicate matters, female desire has been historically misunderstood. Researchers have questioned the assumption that libido manifests itself in the same way in women as in men. They propose that while men's desire is driven by the goal of intercourse and orgasm, women's desire is mostly driven by the need for intimacy. In addition, some women may need to be physically aroused before feeling desire.
Age is also a factor, as desire tends to wane with age. It can flag in midlife for a variety of reasons — some physical, some emotional. Hallmarks of aging such as declining hormones and lifestyle and relationship transitions can all affect a person's sex drive. So too can illness and the presence of other sexual problems, such as erectile dysfunction or vaginal dryness. Of course, if a lower sex drive isn't bothersome to the people involved, then they need not take any action. If diminished sex drive is troublesome, though, treatment is available.
Diagnosing low libido
When evaluating a loss of sexual desire, your doctor will first look for physical causes. Any of a number of chronic medical conditions can impinge on desire (see "Sexuality and health problems"). So, too, can a variety of treatments and dozens of prescription medications. The emotional effects of almost any chronic disease — such as frustration, depression, anger, fear of death, and altered body image — can indirectly lead to the loss of desire. In women, low libido may stem from dyspareunia, or chronic vaginal pain.
If there are no obvious physical reasons for low libido, your doctor will explore your attitudes about sex and your partner. One important distinction to be made is whether the problem is a lifelong lack of desire, a more recent loss of interest, or a problem that occurs only with a particular partner or in a certain situation. Sometimes, a history of physical or sexual abuse can manifest as low libido (or an aversion to sex) that may not show up until after the person has married or had children.
A lifelong history of low libido is extremely challenging to treat because the problem often stems from underlying issues that are complex and deeply ingrained. Also, someone who has been interested in sex in the past has a better concept of what he or she might be missing.
If your libido has dropped, your doctor will focus on the point when the change occurred and explore potential causes. He or she will look at changes in hormone levels from menopause or aging and ask about your relationship with your partner. The doctor will also ask about your stress level, self-image, and whether depression may be a factor.
Treating the problem
If a medication is to blame, your doctor may suggest switching to a new drug or changing your dose. While hormone deficiencies are sometimes the culprit, often the problem stems from a mix of psychological and relationship issues. Or a combination of all these factors may be at work. If, after careful questioning and preliminary tests of hormone levels and blood flow, your doctor decides that the problem has psychological roots, he or she will refer you to a sex therapist or other psychological counselor.
Sex therapy. Low libido is the most common, challenging, and complex dysfunction a sex therapist encounters. An early obstacle is that individuals with low libido often aren't eager to be treated — because they don't miss sex, they don't feel hopeful about the prospect of finding a solution, or both. Most of the time they consent to therapy when they feel the problem is damaging their relationship. Therapists may address this issue in a variety of ways. Usually, the problem is recast as a couples issue; therapy isn't a means to "cure" the person with the low sex drive. Also, the therapist aims to reassure the low-desire partner that he or she won't be forced or even pressured to have sex, while suggesting that the individual may be missing out on a valuable part of life by forgoing the activity. Finally, the therapist works to dispel any pent-up resentment on the part of the higher-drive partner by reiterating that he or she is making a choice to stay committed to the relationship by engaging in the search for a joint solution. The goal of treatment is to help create an atmosphere in the relationship that is less pressured, thereby allowing the low-desire partner to become more receptive to sex.
One important step is to have the partner with the lower libido recognize and come to terms with any hidden feelings of anger, resentment, guilt, fear, or disgust that surround sex. If these feelings are present, the couple and the therapist explore the origins and effect of these emotions. The therapist will also encourage the couple to examine the dynamics of the relationship that reinforce the discrepancy in desire. For example, the bedroom may be a venue for acting out power struggles, with the person who otherwise feels ineffectual in the relationship avoiding sex as a means of control.
Once most of the emotional roadblocks have been addressed, the couple moves on to behavioral exercises designed to increase trust and sensual awareness, such as sensate focus techniques. This can help the couple begin to reestablish physical intimacy. When a person's low desire is an outgrowth of a sexual dysfunction within the relationship, treatment for low desire is usually an easier matter once the original dysfunction is resolved.
Medical treatments. Medical treatments for libido problems are often combined with sex therapy. The following options are available:
Hormone treatment for men. Although there's a clear link between testosterone production and male libido, researchers have yet to discover the exact nature of the connection. If a man's hormone level is clearly below normal, testosterone supplements can make a noticeable difference in his libido. On the other hand, supplements seem to have no effect on men whose natural testosterone is already within a normal range. The impact of testosterone supplements on men who have borderline or low-normal hormone levels is still unknown. Although desire wanes with age, this problem doesn't seem to be linked to declining testosterone.
Hormone treatment for women. Many people don't realize that women also produce testosterone naturally, and this hormone affects libido in women as it does in men. The natural decline of testosterone that accompanies aging can affect a woman's sexual responsiveness. As a result, some doctors prescribe testosterone gel in additional to estrogen and progestogen therapy (see "Testosterone for women").
Bupropion. This antidepressant seems to increase sexual desire and stimulation. In one small study published in the Journal of Sex and Marital Therapy, 60 women and men with sexual desire or arousal difficulties (but not depression) were given either bupropion or a placebo for 12 weeks. At the end of the study period, 63% of the participants taking bupropion reported improvements in their sexual functioning, compared with only 3% in the control group. People who take SSRI antidepressant medications, such as Celexa, Prozac, Paxil, and Zoloft, which may cause sexual side effects, may want to ask their clinicians about trying Wellbutrin instead.
Testosterone for womenWhen it comes to hormone therapy, estrogen gets all the attention. But testosterone is also a key player in a woman's sexual response, and testosterone replacement is currently used as a way to treat low sexual desire in postmenopausal women. Testosterone production peaks in a woman's 20s and gradually declines after that. By menopause, it registers at just about half of what it was at its peak. The hormone doesn't disappear completely, however. The ovaries manufacture it throughout life, even though they stop producing estrogen at menopause. But if a woman's ovaries are removed (which sometimes occurs in combination with a hysterectomy), her testosterone levels drop. The same decline can occur after certain forms of chemotherapy. Taking oral estrogen can also diminish a woman's testosterone levels, because her body responds to the increased amount of estrogen by boosting its production of a certain protein known as SHBG. This protein binds to testosterone, so the testosterone cannot then be used by other cells in the body. Testosterone deficiency can interfere with all phases of sexual response. Common effects include reduced libido less sensitivity in the nipples, vagina, and clitoris inability to become aroused and reach orgasm weaker, briefer, and less pleasurable orgasms loss of muscle tone and genital atrophy. Can replenishing testosterone levels reverse these effects? That's the question that researchers are still exploring. Although the medical community has long been aware of the role of so-called male hormones in women's sexuality, testosterone therapy is controversial and is only now working its way into treatment plans. One study examined the effects of a testosterone patch on 75 healthy women who reported that their sexual pleasure had declined after they'd had their ovaries removed. The women wore three different skin patches — a placebo and two different strengths of testosterone — for 12 weeks each. The study found that the women on the higher testosterone dose had sex more often and enjoyed it more. There was no significant difference between the lower-dose patch and the inactive patch. A 2005 Archives of Internal Medicine study tested three different doses of testosterone patch against a placebo. Interestingly, it found that the middle dosage modestly increased sexual desire and the frequency of satisfying sexual activity. The low-dose patch had no effect, and the high-dose patch boosted sexual desire but didn't change how often the women reported having satisfying sex. This study ran for 24 weeks and involved 447 women whose uteruses and ovaries had been removed. The patches used in these studies are not available yet for general use. However, some doctors are prescribing specially formulated testosterone lotions and gels for women. In women, side effects can include acne, liver problems, a slight drop in HDL ("good") cholesterol, as well as a deeper voice and facial and body hair. Another option is Estratest, a hormone pill that combines estrogen with methyltestosterone. This medication is commonly used for treating hot flashes and other symptoms that aren't relieved by estrogen or estrogen-progestogen combinations. Many doctors also recommend it, with some success, for desire disorders, arousal difficulties, or both. As with all medications, the benefits of the drug must be weighed against possible side effects. As with other testosterone supplements, over time side effects of Estratest can include unwanted hair growth and, rarely, deepening of the voice. Some data show that testosterone decreases the proliferation of breast cells; such proliferation is linked to breast cancer. This would seem to indicate that testosterone would not raise the risk of breast cancer, but might lower it. However, a 2006 study published in the Archives of Internal Medicine found that the risk of breast cancer was nearly 2.5 times greater in postmenopausal women who took hormone pills combining estrogen and testosterone than in those who didn't take the medications. The researchers reported that the risk of breast cancer was greater for estrogen-testosterone therapy than for estrogen alone or estrogen combined with progesterone. Clearly, more study is needed to determine how testosterone might influence the risk of breast cancer. Over-the-counter DHEA (dehydroepiandrosterone) supplements are promoted as another way to help produce testosterone in the body. There's little reliable evidence that they reduce menopausal symptoms or improve sexual function in women with normal DHEA levels. However, they may be appropriate for women with low DHEA levels. DHEA may also lower HDL cholesterol. Because the FDA doesn't regulate these supplements, the amount in each pill can vary widely (see "Alternative therapies for sexual problems"). Women who wish to take DHEA should discuss it with their doctors. It's also best to undertake testosterone therapy with guidance from a physician who is experienced in its use. |
Female sexual arousal disorder
When a woman becomes aroused through thoughts and fantasies, physical stimulation, or both, blood flows to her pelvic region, causing her genital tissues to swell and her vagina to moisten (see "The phases of sexual response"). These changes indicate her physical readiness for sexual intercourse. With female sexual arousal disorder, however, the sequence breaks down, and the woman's body doesn't produce the necessary response.
Because for years this problem was considered evidence of either a psychological issue or a hormone imbalance, treatment was either counseling or estrogen therapy. Then medical researchers examined another possibility. Since blood flow plays a crucial role in arousal, researchers speculated that blood flow problems might produce arousal disorders in women, much the same way that diminished blood flow can cause erectile dysfunction in men. The search for a female Viagra was on.
However, researchers soon learned that arousal is more complex in women than in men. Pfizer, the maker of Viagra, tested the drug in women and found that it did alter blood flow to the genitals, but it did not improve libido in most women. Still, researchers are looking at other drugs and products aimed at increasing genital blood flow in the hopes that these will be effective treatments for female arousal problems.
Making a diagnosis
Your doctor will first want to hear your account of any problems you have becoming aroused and achieving and maintaining vaginal lubrication in response to sexual excitement. To find an effective treatment, your doctor must determine the possible causes. He or she will try to identify the influencing factors by asking you detailed questions about your general physical and emotional health, the stresses in your life, your relationship with your partner, your expectations about sex based on your upbringing, the amount of foreplay and direct stimulation you receive during lovemaking, the medications you're taking, and whether you've gone through menopause. It's likely that your doctor will also perform tests to check for blood flow issues or hormone imbalances, as these are principal sources of arousal disorders.
Treating vaginal dryness
Vaginal dryness is a common cause of female sexual arousal disorder. Decreased lubrication or lack of lubrication and loss of elasticity can make intercourse uncomfortable. These changes can be approached from two directions: using lubricants to treat the symptom of dryness, or using hormones to treat the cause of the problem.
Using artificial lubrication to ease vaginal discomfort is straightforward. A certain amount of vaginal elasticity will return naturally once adequate lubrication allows a woman to engage in regular intercourse. By contrast, hormone treatments — either topical or systemic — are designed to address the problem at its source. Decreased estrogen levels diminish vaginal secretions; thus, replacing estrogen after menopause can increase lubrication. Hormone therapy for menopausal symptoms, including vaginal dryness, is available in many different combinations and preparations, such as pills, patches, and vaginal creams. Vaginal hormone treatments — in which estrogen is applied directly to vaginal tissues — are often quite effective in reversing age-related thinning and dryness.
When weighing the right approach for treating vaginal dryness, carefully consider the severity of your symptoms, your medical history and health risks, and any other menopausal symptoms you may be having. The following information may help guide your choice.
Lubricants
If vaginal dryness is your primary or only concern, a lubricating liquid or gel that temporarily alleviates vaginal discomfort may be your best solution. The following products are available over the counter.
Astroglide. This is a clear, thin, odorless liquid with a slippery feel that closely approximates natural vaginal secretions. You can apply it to the vaginal opening or to the penis before intercourse. Astroglide is nonstaining and has a neutral pH, so it won't irritate the vagina or promote vaginal infections.
K-Y Silk-E. This gel was developed by the makers of K-Y Jelly especially for vaginal lubrication. Because it was formulated to mimic a woman's natural vaginal moisture, it's a better alternative than K-Y Jelly for treating vaginal dryness.
Replens. This lotion-like vaginal moisturizer clings to the vaginal lining, simulating natural secretions. Each application lasts 48 to 72 hours. Replens is a good option if your dryness is bothersome even when you're not engaged in sexual activity. Although it may make intercourse more comfortable, Replens is not a substitute for vaginal lubricants such as Astroglide or Silk-E. This lotion does, however, have the added benefit of making your vaginal environment more acidic, which helps ward off infections. Gyne-Moistrin is a similar product.
Hormone therapy
For perimenopausal and postmenopausal women, reintroducing estrogen into the vaginal tissues can reverse vaginal dryness, thinning, shortening, and other age-related changes, as opposed to the temporary relief of dryness offered by a lubricant. Estrogen can also ease other symptoms of menopause, such as hot flashes, night sweats, palpitations, headaches, and insomnia, but it carries some risks as well. Some studies have found that women taking certain hormone products, particularly those in which estrogen is taken orally, have a higher risk of heart attack, stroke, blood clots, and breast cancer. However, these studies have their critics, who point out that since only a few specific hormone preparations have been examined, it's unclear whether other hormone products carry the same risks (see "Postmenopausal hormone therapy: Your questions answered").
Postmenopausal hormone therapy: Your questions answeredIn the wake of the Women's Health Initiative (WHI) trial, many women tossed out their hormone pills for fear that hormone therapy would raise their risk of cardiovascular problems and other ills. But some medical experts cautioned that the study had flaws. One such expert, Dr. Alan Altman, a medical editor of this report, believes that hormone therapy was painted with too broad a brush, and some data support that view. The WHI tested the hormone pills Prempro (an estrogen plus progestin pill) and Premarin (estrogen alone) for preventing heart disease, osteoporosis, and other common health problems. The trial of Prempro was stopped early, in 2002, because the women taking this medication had a higher risk of breast cancer, heart disease, stroke, and blood clots. The hormone combination showed some benefit — such as reductions in colorectal cancer and hip and spinal fractures — but this wasn't enough to outweigh the risks. The Premarin trial also ended early after researchers found that the risk of stroke increased by 40% in women using this drug. Interestingly, though, they also found that there were fewer cases of breast cancer in the women taking estrogen alone than in the women taking a placebo, and that there was a 50% reduction in heart attack risk in women who started the estrogen therapy in their 50s. Other studies on different kinds of hormonal therapy have been published and more are on the way, but many women are still struggling to make sense of the data and the diversity of opinions on hormone therapy. Here, Dr. Altman, an assistant clinical professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School, answers some questions about hormone therapy. Q. Let's start with the WHI, since it changed the public perception of hormone therapy. What did we learn from this study? A. What people were told was that the WHI showed that "hormones were bad for women." As a result of this, the FDA recommended using hormone therapy only for severe menopausal symptoms — in the lowest effective dose and for the shortest possible time. But the problem was that the WHI study wasn't about all hormones, and it wasn't about all women — it was a study of Premarin and Prempro, two hormone products that are completely different from the other 40-plus hormones available in the United States. And it's a study of women who were, on average, 12-plus years beyond their final menstrual period. Q. Why is the fact that Prempro and Premarin were used in the study important here? A. Prempro is a product that combines horse-derived estrogen and a very potent progestin, called MPA, in one pill. Many of us who specialize in postmenopausal care have been aware for years that MPA is too strong and can act to reduce the benefits that estrogens may provide. There are many other newer and safer progestins, both natural and synthetic, that are available. In fact, I don't recommend using Prempro. Both products are also oral estrogens. And there are big differences between oral and non-oral products. When estrogen is taken as a pill, it's first processed through the liver. This stimulates proteins associated with heart disease and stroke, such as C-reactive protein, activated protein C, and clotting factors. But non-oral estrogen isn't first processed by the liver and — at the same level of blood concentration — doesn't have these effects. The bottom line is that there are far better and safer combinations of hormone therapy out there, especially non-oral estrogen products like patches, gels, creams, rings, and tablets. These are all plant-based and bioidentical to the naturally occurring hormones. [Bioidentical hormones are identical in molecular structure to the hormones women make in their bodies. They're not found in this form in nature but are made, or synthesized, from a plant chemical extracted from yams and soy.] Q. Does that mean a different estrogen or combined estrogen-progestin might have fewer side effects? And a different mode of delivery, such as a transdermal (skin) patch or skin cream, might be safer? A. Exactly. Different forms of hormones are recognized differently by cells, so it makes sense that their effects might also be different. For example, one study of women taking estrogen alone found that those who took conjugated equine estrogens (Premarin) had a 78% higher risk for blood clots than users of esterified estrogen (Menest). In another study, women who took an oral estrogen increased their risk of blood clots by four times that of those who used an estrogen patch, which didn't increase the risk of blood clots at all. Also, the progestin medroxyprogesterone acetate (Provera) interferes with estrogen's good effects on cholesterol more than micronized progesterone (Prometrium) does. Q. One of your criticisms of the WHI has to do with the age of the women involved in the study. Why is age a factor? A. It's not their age per se. It's about how long after menopause the hormone therapy begins. In the WHI, only 17% of the women started the hormones within five years of their final menstrual period. Years of studies and experience in using hormones have demonstrated that estrogen is a preserver of good function. It isn't a repairer of bad function, except in the case of vaginal dryness. So if you are to get the benefits of estrogen, it is essential to start at the appropriate time. It makes sense to continue hormones following directly from the time when you had these hormones in your body, not to reintroduce them 10 years later. Most of the women in the WHI were in their 60s and 70s. Prevention needs to start earlier than that. Q. Is there evidence that women who start on hormones soon after menopause have better outcomes? A. By examining the WHI data, we found that the younger women who began taking hormones within five years of their final menstrual period cut their risk of heart disease in half. Other studies support this. In early 2006, researchers at Harvard Medical School analyzed data from the Nurses' Health Study and found that the women who started hormone therapy within about four years of menopause had a 30% lower risk of heart disease than the women who never used hormones. On the other hand, starting on hormones 10 years after menopause or after age 60 showed little if any benefit. What this shows is that the "when" part of the equation is important. The message shouldn't be "Don't take hormones." It should be "What can you take — and when." Q. These studies focus on heart health. What about breast cancer risk? Didn't the WHI demonstrate that hormones can raise the risk of breast cancer? A. WHI did find that the women taking Prempro were at higher risk for breast cancer. But in the estrogen-alone (Premarin) part of the study, the women taking estrogen had fewer cases of breast cancer (a rate of 28 per 10,000) than the women taking a placebo (34 per 10,000). The experts conducting the study reported that the difference in these rates may not be statistically significant. So there is conflicting information, and medical experts can't explain the reason for this yet. But again, different hormone products and different delivery systems have different risks and benefits. Q. Other studies are being conducted to help answer questions about hormones. In the meantime, what's your advice to women considering hormone therapy? A. Remember that each medical study that you read about is only one piece of a puzzle. Only the completed puzzle can reveal the final answer, and we don't have a completed puzzle here. So you need to carefully weigh your decision based on all the information available, not just one study. |
Estrogen comes in several forms with a range of doses and formulations. The benefits, risks, and side effects vary depending on the form of hormone replacement therapy used. Estrogen applied directly to the vaginal area (through a cream, gel, tablet, or ring) has fewer effects on the rest of the body because the hormone doesn't enter the bloodstream to the same degree as it does with pills or patches.
The following provides a brief overview of the different kinds of hormone preparations. Some doctors also prescribe Estratest, a pill that combines estrogen and testosterone, to treat menopausal symptoms and desire or arousal problems (see "Testosterone for women").
Estrogen and progestogen pills. These medications contain one or both hormones. They are quite effective in treating vaginal changes. Because these medications enter the bloodstream and have systemic effects, they also reverse bone loss and relieve hot flashes, insomnia, and other symptoms of menopause. Estrogen alone (called unopposed estrogen) is recommended only for women who have had a hysterectomy because taking the hormone by itself can raise the risk of developing uterine cancer. Adding a progestogen (a version of the hormone progesterone) to the formula protects against this risk.
Hormone patches. Applied like a Band-Aid, patches deliver a continuous dose of estrogen for up to a week. Patches are worn on the abdomen or buttocks and are replaced every three to seven days. Typically, an oral progestogen is used along with the patch, although some patches contain both estrogen and progestogen. Because this method delivers hormones systemically, it has some of the same benefits and drawbacks as hormone pills. But since the estrogen enters the bloodstream without passing through the liver, it may be a more natural way to take estrogen. It may not improve cholesterol levels to the same extent as products taken orally, but it avoids blood clotting and gallbladder problems seen with the pills. Some users report that the patch can itch or fall off.
Vaginal estrogen creams. In this therapy, a dose of cream is inserted into the vagina with an applicator two to seven days a week. Only small doses are needed to relieve vaginal dryness. Creams treat vaginal changes directly, so typically they don't address other menopausal symptoms, such as hot flashes. Initially, most of the estrogen is taken up in the vaginal tissue. However, as the vaginal lining is replenished, more of it is absorbed into the bloodstream. The use of vaginal estrogen cream has given way to more controlled delivery methods, such as an estrogen ring or patch. Estrogen cream should not be used as a lubricant before intercourse because it can be absorbed through a partner's skin.
Transdermal gels and creams. In these therapies, hormones are applied to the skin and work systemically to treat all menopausal symptoms. One product, EstroGel, comes in a clear, odorless, alcohol-based gel that's delivered from a metered-dose pump. The gel is applied once a day on one arm from the wrist to the shoulder. The gel dries completely in two to five minutes. Another product, Estrasorb, is a cream that comes in individual foil packets and is rubbed into the thighs and buttocks.
Estrogen rings. For this therapy, you insert a ring into the vagina in much the same way that you insert a diaphragm. The ring releases estrogen gradually and needs replacement about every three months. Two types of rings are currently available: one that offers local effects and one that is systemic. Estring releases a low dose of estrogen that is not absorbed into other areas of the body — which means you avoid the effects associated with hormone pills and patches, but you won't get relief from hot flashes and other menopausal symptoms. Femring contains higher doses of estrogen and offers systemic effects, so it treats hot flashes and other menopausal systems in addition to vaginal dryness. Although both rings can be removed temporarily and reinserted, neither type has to be removed before sexual intercourse.
Vaginal estrogen tablets. An estrogen tablet, sold as Vagifem, inserted into the vagina with an applicator twice a week, can relieve dryness and irritation. This form of medication treats only vaginal symptoms. Since very little estrogen is absorbed into the body, the tablet doesn't carry the risks of systemic medications and won't relieve other symptoms of menopause.
Testosterone cream. If vulvar atrophy is advanced, your genital tissue may respond to a low-dose testosterone cream. The cream is rubbed directly into the vulva three nights a week. Because the FDA has not approved testosterone creams for use in women, they are available only through compounding pharmacies, which assemble ingredients to make medications prescribed by doctors.
Increasing genital blood flow
Speculation that women's arousal difficulties may be related to insufficient blood flow opened another possible avenue of treatment for female sexual arousal disorder. But efforts to find a female Viagra haven't panned out thus far. The drug company Pfizer had long hoped to prove that Viagra improved sexual function in women. But after eight years of testing failed to yield the desired results, Pfizer announced in 2004 that it would no longer test Viagra on women. Interestingly, studies found that the drug increased genital blood flow, but for most women that didn't translate into a greater desire to have sex. Still, other researchers and companies are studying and selling products aimed at increasing genital blood flow in women. Here's a closer look at a few of them.
Topical medications. Researchers are studying several creams and gels that deliver medication to widen blood vessels. These products are rubbed into the genital tissues before intercourse to enhance arousal. One such gel, made with prostaglandin E-1, is undergoing clinical trials under the brand name Femprox. Prostaglandin E-1, a naturally occurring substance, is the active ingredient in the drug alprostadil, which is used for penile injection therapy. A small 2005 study conducted by the maker of the cream found that the cream was helpful, but more study is needed. Researchers are also investigating the effectiveness of a vaginal suppository that delivers phentolamine, another medication used in penile injection therapy. Additionally, the over-the-counter supplement Zestra claims to enhance sexual function in part by increasing genital blood flow (see "Alternative therapies for sexual problems").
Mechanical devices. A small pumplike device — consisting of a small plastic cup that fits over the clitoris and surrounding tissue — uses suction to draw blood into the clitoris, causing it to swell. This FDA-approved unit is sold by prescription to women with arousal disorders under the brand name Eros-CTD (clitoral therapy device).
Sex therapy techniques
If your doctor feels your problem has emotional roots, he or she will recommend sex therapy as the first step in treatment. The sex therapist's role is to help you identify the thoughts, feelings, and behaviors that might be interfering with your sexual enjoyment. He or she will also help you become more in touch with your erotic feelings and grow more comfortable with your sexuality. In addition to sensate focus exercises, the therapist will encourage you to try a range of techniques, such as sexual fantasy training, masturbation exercises, and the use of erotica and vibrators. Because many women find that being able to share their feelings with their partner is a prerequisite for arousal, therapy will also concentrate on improving communication and enhancing feelings of intimacy between you and your partner.
Vaginal pain (dyspareunia)
A particularly distressing sexual problem for women is chronic vaginal pain. About one in five American women may experience this problem at some point in her life. Like back pain or headache, dyspareunia is an umbrella term encompassing a variety of unpleasant sensations that have psychological or physical causes. The pain can be diffuse and intermittent, it may appear when pressure is applied to certain areas, or it may emerge only when a woman is attempting sexual intercourse. A woman who experiences painful intercourse may become reluctant or unable to have sex, which can strain an intimate relationship.
Diagnosing the problem
Obstetricians and gynecologists report that pain during intercourse is a frequent complaint. If you have this problem, your doctor will ask you about your symptoms. For example, he or she will ask you to describe the type of pain (burning, shooting, sharp, or dull) and to identify its location (deep within your vagina or around the vaginal opening). You may also be asked to point out the sensitive areas using a handheld mirror.
Next the doctor will do a complete physical exam. For women with vaginal pain, a pelvic exam can be traumatic. A good doctor will understand your fears and take extra care to perform the procedure slowly and gently.
One important element of the diagnostic workup may be the Q-tip test. Using a moistened cotton swab, your doctor will gently touch several sites on the inner labia and around the vaginal opening. You'll be asked to report the intensity of the pain on a scale of 1 to 10. Pain during the test indicates an inflammatory condition known as vulvar vestibulitis.
Your doctor will also look for signs of age-related vaginal changes that can make intercourse uncomfortable. Finally, he or she may perform laboratory tests to rule out the presence of an infection.
Types of pain
Vaginal pain is categorized based on your symptoms and what the doctor finds during your evaluation. These are some of the more common conditions.
Vaginal atrophy. Lower estrogen levels cause the vaginal lining to thin and secretions to diminish. The vagina also becomes shorter and less elastic, and the vaginal opening narrows. The result is often dryness and irritation, which can make intercourse or pelvic examinations painful or impossible. Thinning of the vaginal lining combined with changes in the pH balance can make the vagina vulnerable to infection — a condition known as atrophic vaginitis. If untreated, this problem may lead to further thinning and ulceration of the vagina.
Vulvodynia. Vulvodynia is pain with no identifiable cause that may come and go in different areas, including the clitoris, perineum, mons pubis, and inner thighs. Symptoms include burning, stinging, and irritation. The condition can make sexual intercourse uncomfortable or impossible.
Vaginismus. This condition is characterized by involuntary spasms of the muscles in the outer third of the vagina in response to any attempt at entry. It makes intercourse impossible. Vaginismus can be the result of painful intercourse, past sexual abuse, lack of sexual experience, or fear of or aversion to sexual activity.
Vulvar vestibulitis. This is a condition in which the inner labia and vaginal opening become chronically inflamed and irritated. Pressure to the area from any source such as the entry of a penis, insertion of a tampon, contact with a bicycle seat, or even wearing tight pants can cause extreme tenderness. The exact cause of vulvar vestibulitis is unknown.
Adhesions (internal scar tissue). Adhesions are bands of tissue that form in response to injury or infection inside the body. Abdominal surgery (including C-sections and hysterectomies) can create adhesions, which can bind internal organs together or to the pelvic wall. Scars from an episiotomy, an incision in the perineum to enlarge the vagina during childbirth, can also create adhesions. Adhesions can lead to painful sex and decrease a woman's ability to have an orgasm.
Tips for making sex more comfortableIf you suffer from vulvar pain, here are some things you can do to reduce your discomfort and enhance your enjoyment during sex. Use plenty of lubricant. Use a topical anesthetic gel with a 5% concentration of the local anesthetic lidocaine to ease burning during intercourse. You can get this with a prescription from your doctor. Apply a frozen gel-pack wrapped in a towel to your vulva to ease irritation after manual sexual stimulation or intercourse. After intercourse, urinate (to avoid an infection) and rinse your vulva in cool water. Adapted from "Self-Help Tips for Vulvar Skin Care," with permission from the National Vulvodynia Association ( |
Treating vaginal pain
Treatment for vaginal pain depends on the root of the problem. Vaginal atrophy can be treated with lubricants that allow a return to sexual activity or hormone treatments that can reverse the atrophy. If vaginismus is a reaction to pain, sex therapy can alleviate the problem once the pain has been treated. Since vulvodynia and vulvar vestibulitis have no known cause or cure, treatment usually centers around pain-management techniques. Sex therapy can also help a woman deal with the effect of the pain on her sexuality and rebuild a pleasurable sex life.
Medication. An assortment of medications are used for vaginal pain, with varying degrees of success. Steroid creams are effective in treating vaginal atrophy. If the primary cause of the pain is vaginal thinning and dryness, estrogen — in the form of a ring, tablet, cream, patch, or oral medication — can help restore natural lubrication (see "Hormone therapy"). If the pain stems from an infection, your doctor may prescribe antibiotic creams or pills. While anesthetic ointments are sometimes used, these preparations can cause allergic reactions in some women. In the case of vulvar vestibulitis, interferon injections have been successful in controlling the inflammation. Other medications such as tricyclic antidepressants and certain anticonvulsant drugs work in some cases.
Surgery. If you have vulvar vestibulitis and medications have failed, laser or traditional surgery to remove the affected tissue may help. Approximately 60% of women who have this procedure report that intercourse is no longer painful.
Pelvic floor physical therapy. This technique shows great promise in treating unremitting vaginal or pelvic pain. It uses hands-on physical therapy to relax muscles in the lower pelvis. The physical therapist uses a massage-like technique, known as myofascial release, to help stretch and release the fascia (connective tissue between the skin and underlying muscle and bones). Pelvic floor physical therapy is also used to treat other causes of dyspareunia, such as vulvodynia and vulvar vestibulitis, as well as urinary incontinence.
Behavior management. Biofeedback has been used successfully to control vulvar pain. You begin by inserting special sensors into the vagina or rectum to help identify overly tense pelvic floor muscles, which can be a cause of vulvar pain. Then, you perform targeted exercises to relax these muscles. Acupuncture or the use of cold packs may also be helpful. In the case of vaginismus, you might try using a series of successively larger penis-shaped plastic dilators to learn how to relax vaginal muscles.
Sex therapy. Painful intercourse often causes people to feel anxious about sexual activity and to avoid it completely. Eventually this fear and withdrawal become as formidable as the pain itself. The fear of pain can also contribute to performance anxiety, creating a vicious cycle. By working with a sex therapist, you and your partner can learn to focus on sexual and sensual activities that are pleasurable. The therapist will use structured activities such as sensate focus techniques to direct your attention to activities and parts of the body that don't provoke anxiety or cause pain.
Coping with a history of sexual abuseIt's not surprising that people with a history of sexual abuse or rape are likely to develop sexual difficulties. While sexual abuse is more common in women, it also affects men. Experts define childhood sexual abuse as occurring when a child engages in sexual activity for which she or he did not give consent, is unprepared for developmentally, or can't understand. It includes fondling and all forms of sexual contact with the child, even if the child is clothed. Abuse that doesn't involve touching, such as exhibitionism, voyeurism, or involving the child in pornography, is also included. Experts have stated that about 20% of girls and 9% of boys are involved in inappropriate sexual activities, but these figures are probably an underestimate because children often keep sexual abuse a secret. Sexual assault or rape (any sexual act performed by one person on another without consent) is even more common: 1 in 6 women and 1 in 33 men report having experienced an attempted or completed rape at some time in their lives. But in both sexes, reported rapes are probably only a fraction of those actually committed. As you might expect, these experiences often affect a person's attitudes and feelings about sex. For instance, a history of chronic pelvic pain — an obvious barrier to satisfying sex — has been linked to a history of sexual abuse in women. What may be surprising, but not uncommon, however, is when a person suddenly develops sexual difficulties after previously appearing to enjoy a good sexual relationship with his or her partner. In some cases, problems crop up after the relationship undergoes a major change. After a couple makes a formal commitment to each other, for example, a woman with a history of sexual abuse may now feel that she is part of a family, with its concomitant obligations and expectations. If a family member abused her, she may now recall those experiences and be reluctant to have sex. Likewise, the birth of a child may trigger memories of childhood abuse. Or the memory may reappear when the child reaches the age the person was when the abuse occurred. For couples facing such problems, a treatment plan might include: individual therapy for the survivor of abuse simultaneous individual or group therapy for the partner couples or sex therapy to help the couple find ways to stay close and connected couples or sex therapy to address any sexual or complicated relationship issues once the survivor of abuse feels ready to do so. |
Orgasm difficulties
Few aspects of human sexuality have incurred the intense debate that has surrounded orgasm. As scientists struggle to quantify this holy grail of sexual experience, certain questions come up repeatedly: Are orgasms the same for women and men? Is an orgasm primarily a psychological or physiological experience? Do women have more than one kind of orgasm, and which type is better? The frenzy of speculation on these points will no doubt continue, but the highly individual and subjective nature of orgasms forces another important question: When does an orgasm difficulty become a dysfunction? As with other sexual problems, an orgasm that is premature, delayed, or absent warrants special attention only when it causes you or your partner distress.
Problems in men
The amount of penile and other stimulation a man needs before ejaculating varies greatly. A young man who is highly aroused may feel the urge to ejaculate very quickly after entering his partner. With experience, most men learn to anticipate the moment of ejaculation and employ techniques to slow their orgasm.
As a man ages, several changes take place. An older man ejaculates less semen, so the fluid may release less forcefully. Having less ejaculate translates into less intense pressure for release. This allows a mature man to enjoy a longer period of stimulation before feeling an overwhelming urge to ejaculate.
Often, men can adjust lovemaking routines to accommodate natural age-related occurrences. However, some of the following conditions can disrupt a man's sexual pleasure and that of his partner.
Premature ejaculation. Premature ejaculation is a common problem in which a man ejaculates as soon as intercourse starts or even before he enters his partner. It often leads to anxiety that the problem will occur again. The woman may become frustrated as she finds her sexual arousal continually thwarted, and she may lose interest in sex as a result.
Rarely, early ejaculation can be traced to a medical problem. Your doctor will want to rule out urologic conditions, diseases, or an injury to the nervous system.
If an underlying physical problem isn't to blame, treatment usually involves medication, sex therapy, or both. Ironically, an adverse side effect of certain antidepressants can be put to positive use in treating premature ejaculation. In several studies of paroxetine (Paxil), sertraline (Zoloft), and clomipramine (Anafranil), men reported having more time before ejaculation and greater sexual satisfaction for themselves and their partners.
In sex therapy, the therapist will help you and your partner explore and address the issues that may be contributing to the dysfunction. In addition, you'll learn behavioral exercises such as sensate focus and a start-stop technique that is often very helpful. You'll also be encouraged to adapt your foreplay and lovemaking style to increase your sexual enjoyment.
Delayed ejaculation or orgasm. Delayed ejaculation occurs when a man is able to have an erection but isn't able to ejaculate. There's no "right" amount of time for a man to take to reach orgasm. An older man will generally need more prolonged stimulation for arousal and orgasm. Also, some men reach orgasm much more easily through manual and oral stimulation. Because the urge to ejaculate lessens with age, an older man may be able to enjoy intercourse without needing to ejaculate every time. However, if the urge is present but orgasm fails to occur after a lengthy period of intercourse, he may give up trying. Alternately, the man's partner may need to halt lovemaking because of vaginal discomfort. Delayed ejaculation is a relatively rare problem, affecting only 3%–8% of men.
When assessing the problem, one of the first things your doctor will do is ask you which medications you take. Many antidepressants, blood pressure medications, and medications for obsessive-compulsive disorder can produce orgasm difficulties. To correct the problem, your doctor may recommend reducing the dosage of the drug, changing the frequency at which you take it, or switching to a different drug altogether. Don't stop taking a medication or alter your dose without speaking to your doctor first, though. Another possibility is to take bupropion or the herb yohimbine; both may counteract the sexual side effects of other medications.
Much more rarely, the inability of a man to come to orgasm has a psychological origin. This may be the case if the problem has persisted throughout life. A sex therapist can explore the emotional issues at the core of your inability to have an orgasm. He or she can also help you relax and focus on letting go so you can fully experience pleasure during sex.
Problems in women
A common complaint from women is a complete lack of orgasms or an inability to have an orgasm with a partner. In a 2004 survey of 862 sexually active older women, about 13% of the women reported that they had never or had rarely experienced orgasms during the past six months. As with other sexual dysfunctions, female orgasm difficulties can stem from physical and emotional causes, as well as issues involving the couple's relationship or sexual practices. Often, it's the result of a combination of factors.
If you've been able to have orgasms with your partner in the past, your doctor will investigate possible physical causes. These might include insufficient hormone levels, nerve damage from pelvic surgery (such as a hysterectomy) or even long-distance bicycle riding, vaginal pain, depression, or side effects of medications such as antidepressants.
If no physical problems are uncovered, the next step is sex therapy. The therapist will first ask whether you've ever been able to have an orgasm — either through masturbation or with a partner.
If you've never had an orgasm, the therapist will explore issues in your past such as sexual abuse or negative messages about sex or masturbation. The therapist will also encourage you to become more familiar with your body and what pleases you sexually. Books and videos are often helpful; the therapist may suggest that you buy a vibrator and experiment with using it to stimulate yourself, eventually in front of your partner if you're comfortable doing so. This technique is often successful in helping a woman learn to have orgasms. The orgasm rate is somewhat lower when these women have sex with their partners, but most report that after therapy, they enjoy sex more and have a more relaxed attitude about it.
In some cases, women enter sex therapy being able to have orgasms through masturbation, but not with a partner. The therapist will approach this situation by exploring how the couple stimulate each other. He or she will also delve into emotional issues that may be getting in the way, such as how you and your partner relate to each other and what your orgasms mean to both of you. Another important element of treatment is sensate focus exercises. If difficulty communicating your sexual needs is at the root of the problem, these exercises can help the two of you develop these skills. By placing the emphasis on enjoyment rather than reaching orgasm, a woman can relax and focus on her own pleasure.
Sex therapy underscores that orgasmic responses vary. At one extreme are the rare reports of women having orgasms from fantasy alone or just from having their breasts caressed. Somewhere in the middle are women who can, in one position or another, reach orgasm during intercourse. However, still more women find they need direct clitoral stimulation. A good therapist will reassure couples that there is no one right way to experience sexual pleasure and encourage them to adapt their lovemaking style to best suit their needs.
Alternative therapies for sexual problemsCan an herb or supplement improve your sex life? The market is flooded with herbal products whose manufacturers claim they can, but consumers should treat these claims with skepticism. Most of the creams and herbal supplements available over the counter and sold on the Internet have not been studied rigorously. Since the FDA doesn't regulate the use and dosage of herbal products, their safety and effectiveness are unknown. Dosages can vary widely from product to product and even pill to pill. Keep in mind, too, that "natural" doesn't mean harmless. Herbal products can cause side effects and interact with other medications. Also, what's listed on the label is not necessarily what's inside the bottle. This is illustrated by a 2006 FDA warning that urged consumers to avoid the following dietary supplements that claim to treat erectile dysfunction and improve sexual performance: Zimaxx, Libidus, Neophase, Nasutra, Vigor-25, Actra-Rx, and 4EVERON. The FDA found that these products contained sildenafil, vardenafil, or substances that are nearly identical to these medications. But none of these chemicals were listed on the products' labels. In fact, the packaging was misleading. According to the FDA, the packaging claimed that the products were "all natural" and did not contain the active ingredients used in FDA-approved erectile dysfunction drugs. This poses a serious health risk to consumers who might take such a product unaware that it could interact with other medications. Like sildenafil or vardenafil, the chemicals in these supplements can interact with nitrates (which are commonly used to treat angina and congestive heart failure) and cause blood pressure to drop to dangerously low levels. There is a dizzying array of other products marketed for improving sexual function. The chart below examines a handful of commonly known alternative therapies. But medical experts agree that it's best to opt for well-tested, FDA-approved medications. If you do decide to use an alternative therapy, tell your doctor about it so he or she can watch for possible side effects and drug interactions. |
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Common alternative therapies |
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Name |
What is it? |
How does it work? |
Is it safe? |
Yohimbine |
Oral treatment for erectile dysfunction. Derived from the bark of a West African evergreen. |
Opens blood vessels in the skin and mucous membranes. May be helpful for men who can't take Viagra, Cialis, or Levitra, although its effectiveness has not been clearly established. |
Side effects include anxiety, insomnia, increased heart rate and blood pressure, tremors, nervousness, irritability, and dizziness. |
Ginkgo biloba |
Chinese herb said to improve libido and erectile function. Available in pill form. |
Opens blood vessels and increases blood flow. May be helpful if your erectile problems are the result of inadequate blood flow. |
Can cause headache, stomach upset, dizziness, diarrhea, and skin reaction. Has a blood-thinning effect, so should not be used with anticoagulant medications or before surgery. |
DHEA |
A dietary supplement that is converted into testosterone and estrogen in the body. Said to improve libido, female arousal and orgasm, and erectile dysfunction. |
Increases body's testosterone and estrogen levels. May improve libido and erectile function in isolated cases, but little reliable evidence on its effectiveness exists. More information is also needed on long-term effects. |
May cause growth of facial hair and acne in women. High doses could cause depression, jaundice, and an increased risk for liver cancer. |
Zestra |
A plant-based arousal oil for women made from a blend of borage seed oil, evening primrose oil, vitamin E, and other herbs. This topical treatment is applied to the clitoris and labia during foreplay. Shown in a small clinical study to help enhance sexual function in women with sexual arousal disorder. |
The makers of the oil claim that it increases genital blood flow and improves the workings of the genital sensory nerves. Contains large amounts of a fatty acid that the body converts to prostaglandin, which helps increase blood flow and nerve conduction. |
When used as directed, few side effects have been reported thus far. Some women who had yeast infections at the time of usage developed mild skin irritation. |
Review Date: 2007-01-01
Harvard Medical School does not endorse products or services.
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