“Approximately 43% of American women report experiencing sexual problems, with 12% considering this problem to be so bothersome that it leads to personal distress.[1]” My hope is that providing some basic information here will encourage women to speak to their physicians if they are having this experience.
Doctors use the term female sexual dysfunction to refer to a group of problems including lack of interest in sex, pain with sex, and lack of satisfying sexual experience. A woman’s sexual response depends on many physical and psychological factors, so it is often difficult to identify and treat a single cause. Estrogen plays an important role in a woman’s sexual response. Estrogen levels decrease as a woman approaches menopause. Estrogen has a role in maintaining the sensitivity, muscle tone, moisture, and other conditions of healthy genital tissues.
A woman’s body also produces testosterone, although at lower levels than in men. The role of testosterone in women’s sexual desire is not well understood. Testosterone levels also decrease as a woman ages.
Nonetheless, the causes of women’s sexual dysfunction are more complex than just growing older. If my patient shares this concern during an office visit, we will plan an evaluation of her problem. I rely on her description of changes in her sexual function and any emotional or psychological contributing factors. The gynecologic examination may identify possible physical causes. A thorough evaluation may require a follow-up visit.
Causes of female sexual dysfunction include pregnancy-related problems, menopausal issues, medications, emotional or psychological factors, and others; and causes sometimes overlap.
Pregnancy-related Sexual Dysfunction
Discomfort caused by tearing of tissue around the vagina, a cesarean incision, or the anxiety of expecting sex to be uncomfortable can be a real concern for a woman after childbirth. Breastfeeding can also cause some vaginal dryness. Fatigue caused by frequent infant feeding and the physical and emotional adjustment to a mother’s new role sometimes interfere with sexual desire. We may discuss whether she is experiencing post-partum depression. I also try to offer common-sense advice about when she can resume vaginal intercourse, use of lubricants, and reassurance that her concerns are normal.
Menopausal Sexual Dysfunction
As a woman’s hormone levels decrease, the tissues in and around the vagina thin and moisture decreases. As a result, many women experience uncomfortable dryness, irritation, burning or pain with intercourse, urinary tract infections, and other urinary symptoms. Doctors refer to this situation as genitourinary syndrome of menopause. If over-the-counter lubricants are not helpful enough, we can prescribe estrogen-containing medications. Vaginal gels, creams, etc. containing estrogen can often resolve painful intercourse caused by dryness. Women who are also experiencing hot flashes or other uncomfortable symptoms of menopause may prefer hormone replacement therapy (oral medication, patch, gel, etc.). Ospemifene, an oral medication known as a SERM (selective estrogen-receptor modulator), offers a non-estrogen alternative that may improve genitourinary syndrome of menopause.
We want to caution our patients about procedures marketed for so-called vaginal rejuvenation or vaginal resurfacing. Brand names include ThermiVa, Mona Lisa Touch, FemTouch, and others. In July 2018, the FDA issued a strong warning…
To alert patients and health care providers that the use of energy-based devices to perform vaginal “rejuvenation,” cosmetic vaginal procedures, or non-surgical vaginal procedures to treat symptoms related to menopause, urinary incontinence, or sexual function may be associated with serious adverse events. The safety and effectiveness of energy-based devices for treatment of these conditions has not been established.
FDA Commissioner Scott Gottlieb added: “The deceptive marketing of unproven treatments may not only cause injuries but also keep some patients from accessing appropriate, recognized therapies to treat severe medical conditions.”
Problems of Decreased Interest in or Response to Sex
Women can experience periods of low sexual desire at any stage of life. Changes in stress levels, sleep patterns, relationships, lifestyle and substance use, weight or body image, and overall health can contribute. Some women describe that their only sexual thoughts are about how to avoid it. Some of these factors will come and go in any life. When a woman describes this problem, we try to identify factors that can be improved or controlled. Changes in sexual desire or response may be related to a medical condition or new medication. Some medications, for example, SSRIs (selective serotonin-uptake inhibitors) used to treat depression, may interfere with desire. If you keep us informed of your medications us, we may be able to offer alternatives.
We want to refer you to the most skilled provider to address significant changes in your physical or emotional health. Research has shown that cognitive-behavioral therapy can offer improvement for several types of sexual dysfunction.
Researchers and pharmaceutical companies have directed much effort to develop a medication that will improve sexual dysfunction for women. One much-discussed option is testosterone (applied to the skin). Women’s health experts have differing opinions about its effectiveness. The American College of Obstetricians and Gynecologists (ACOG) advises that testosterone may be offered as an option for post-menopausal women who understand its risks. Based on the lack of adequate research, ACOG does not recommend for or against testosterone therapy for younger women. Possible risks of testosterone therapy include increase in body hair, acne, deepening voice, and clitoral enlargement. These may be irreversible.
FDA Approves Two New Medications
Flibanserin (Addyi) was approved in 2015 for pre-menopausal women without depression. We are not enthusiastic about this option. Its effectiveness is limited. Women who used the medication during research studies experienced less than one additional satisfying sexual encounter per month, compared with those who took a placebo (sugar pill). Side effects include nausea, dizziness, and drowsiness. Alcohol must be avoided during treatment due to the risk of dangerously low blood pressure.
This past June, the FDA approved bremelanotide (Vyleesi) to treat low desire in pre-menopausal women. The medication is taken by injection under the skin shortly before beginning sexual activity. Its effectiveness was modest in clinical trials. About 25% of research patients rated their sexual desire as improved, compared with 17% of those taking the placebo. Its side effects may include, increased blood pressure, nausea, vomiting, and headache. About 40% of women experienced nausea at first use. Vyleesi may also cause darkening of skin on the face, gums, or breasts (hyperpigmentation). The risk of pigmentation changes was greater for women taking more than 8 does per month, but some of the darkening may be permanent. We don’t anticipate Vyleesi gaining wide popularity among women.
We urge our patients to be cautious when seeking alternative treatments.
Sildenafil (Viagra) is not used outside of research for women’s sexual dysfunction problems.
The O-shot is an injection of the patient’s own plasma (the liquid part of the blood) into sensitive genital tissues. Physicians who offer the procedure claim that it increases sexual response/satisfaction. We know of no evidence, appearing in a peer-reviewed medical publication, that supports these claims. Dr. Jen Gunter, a board-certified ObGyn physician and New York Times women’s health contributor, provides a well-written criticism of the procedure for lay people. Read more.
The take-away: I encourage women to have a discussion with their doctor. Sexual function is an important part of women’s health care, and we are confident of our ability to put you at ease during our discussion. We are also confident of our ability to offer you helpful options and steer you away from ineffective or potentially harmful treatments. Women’s physicians hope that research will increase our understanding of the mechanisms of women’s sexual function, and lead to the development of safe, effective pharmaceutical treatment in the future.
[1] From the American College of Obstetricians and Gynecologists, based on published research.