Operation Big O: Understanding female orgasm disorders

You can do it too: Orgasm disorders in women can usually be overcome — with a little help

orgasm-disordersDo you remember how intimidated you once were at the prospect of learning how to drive a car for the first time? You may have been overwhelmed with initial questions like how do the gear shifts work; how much brake and gas pedal are needed for a smooth drive; and how do you interpret surrounding movement safely with rear view mirrors? Despite driving becoming second hand, we have all had the experience of getting in our car one early morning, turning the ignition, and having the car sputter and spit but not start. The same key that turns the car into active motion every other day stops short this one particular morning and despite all our grumbling and pumping of the gas pedal, the car remains cold.

Many women experience the overwhelming “how to” list of questions and the frustrating “jump-start” phenomena sexually. In fact, difficulty having an orgasm is the second most common sexual complaint worldwide. Epidemiological studies have found the estimated prevalence of orgasmic dysfunction to vary internationally from approximately 20 to 40 percent, and American studies have found that nearly a quarter of women (24%) report problems with orgasm (1,2). Medically we call difficulty with orgasm “anorgasmia” or Female Orgasm Disorder (FOD). A woman may have been orgasmic previously but then lost this ability later in life, which is referred to as acquired or secondary anorgasmia; and many women have never experienced an orgasm, which is referred to as primary anorgasmia.

Female orgasmic disorder is characterized by a persistent or recurrent delay in or absence of orgasm following sexual arousal and adequate sexual stimulation. For many women and their partners the physiology of adequate sexual response to stimulate orgasm is in fact mysterious. Yet for many men and women, acknowledging the need for more education on how to have an orgasm can feel very embarrassing and awkward. Many women expect on orgasm to occur, when in fact they are not sexually aroused. Our mind is our most powerful sexual vehicle, and sexual thoughts are necessary for most women to experience an orgasm. Furthermore, to be considered a medical diagnosis, the absence of orgasmic response must be accompanied by personal distress. Some people might calmly get out of a car that won’t start and take the bus to work. Most people though will fuss and curse and shake their fists in the air at the car that won’t start and get them to where they want to go. It is understandable that frustration and angst about impaired sexual response can cause significant conflict in a relationship.

What causes orgasm disorders?

When we study women who struggle with orgasmic function, several risk factors have been identified including lower educational attainment, a higher prevalence of mental health disorders, and more importantly a poorer health status (3). Women with depression are two- to four-times more likely than non-depressed women to report problems in reaching orgasm (3), and yet simultaneously many medications that treat mood disorders have a clear suppressive effect on orgasmic function. Population-based studies do not show a consistent link between age and problems with orgasm, however, many women will report having decreased orgasmic sensation after childbirth or after menopause.

Although FOD may manifest as a complete absence of orgasm some women report delayed orgasm, meaning they require longer or more intense stimulation to reach orgasm, or report feeling a less intense experience of orgasm despite the same level of stimulus. Women may also report a sense of impending orgasm that does not reach a peak or resolution despite continued stimulation. Many women find these changes in orgasmic sensation extremely frustrating.

What is an orgasm?

Many men and women in fact ask, what actually IS an orgasm? As simple as that may sound, and as obvious as that may be to some people, defining an orgasm from a medical standpoint can in fact prove challenging. The technical definition of an orgasm by the Kinsey Reports is “the expulsive discharge of neuromuscular tensions at the peak of sexual response.” Masters and Johnson, who were key initial contributors to the field of sex therapy, noted that an orgasm was “A brief episode of physical release from the vasocongestion and myotonic increment developed in response to sexual stimuli” (4). I always reassure women that unless they have been circumcised or otherwise anatomically impaired, they are capable of learning how to have an orgasm.

The first step in evaluating orgasm concerns in women is a candid conversation evaluating sexual experiences, beliefs around sexuality, discussing relationship status, body image, general medical health, mental health, and medications that are being taken. Discussing hormonal status, pregnancy or menopause changes, and evaluating for other endocrine factors is key. Often a woman’s concern about her ability to function sexually is paramount, but an underlying medical cause contributing to the sexual function impairment may in fact need to be addressed initially.

Many women appreciate and benefit from accurate and detailed information about anatomy and sexual function, as well as candid conversation regarding stimulus required to provoke orgasmic response. Open dialogue will at times reveal assumptions or misconceptions that may be contributing to an orgasmic problem. For example, I commonly hear women express concern that they have never experienced an orgasm during intercourse. However understanding that 95 percent of women require clitoris stimulus, which is not often experienced during intercourse, can help normalize the need for additional sexual techniques. Attainment of orgasm through vaginal intercourse may not be an achievable goal for some women, and manual and oral stimulation as normal legitimate means of attaining orgasm during partnered sexual activity is often discussed. For women who can have orgasms through self-stimulation but not during partnered sexual activity (which is called situational secondary female orgasmic disorder), education about sexual positions and activities to enhance clitoral stimulation are warranted. Treatment of the couple with cognitive-behavioral sex therapy can be helpful in cases that do not respond adequately to education alone.

Treatments for orgasm disorders

So what do we do if the car just stays cold in the driveway? Evaluating for and treating any correlated medical contributions is the first step. If there are any medications being taken that impair sexual response there are multiple strategies to add medications to an established treatment, switch to medications with lowered sexual side effects, or strategies to remove medications, which can be discussed if clinically appropriate. Hormonal changes due to menopause or endocrine disorders such as hypothyroidism can result in diminished sexual responsiveness and decreased genital sensation, and there are a multitude of treatment strategies for these conditions that can optimize sexual responsiveness. Alcohol and illicit drug use are also known to impair orgasmic function, therefore moderation of drug use is a treatment consideration in women with orgasmic complaints.

There is one FDA approved device called the ErosPump which has been shown to improve orgasmic function in some women by means of increasing circulation to the clitoral area. Testosterone therapy, vaginal DHEA, and intranasal oxytocin are off label treatments that have modest medical literature to support use in orgasmic function enhancement. There is mixed medical literature to suggest that Kegel exercises, which strengthen the pelvic floor muscles, may enhance orgasm sensation for women. Sexual complaints are generally much higher in prevalence in women who have pelvic floor dysfunction. Interstim is a sacral nerve device implanted surgically for the treatment of urinary incontinence in women, which has inadvertently been shown to improve orgasm function in some women. UroStym is a vaginal e-stim treatment for urinary incontinence, in which there has been suggested anecdotal improvement in orgasmic response.

There are no FDA approved medications for orgasmic dysfunction in women. Many women inquire as to whether erectile medications (such as Viagra) are effective for women with orgasmic concerns, and while they have been studied rather extensively in this capacity, research is mixed and overall has not found this category of medications to be useful for women. Cabergoline is a medication that reduces prolactin levels, and there have been anecdotal reports of improved orgasm function in men and women, however this has not been well studied. There are numerous over the counter as well as prescription compounded products aimed to enhance sexual response, but medical efficacy studies are small to none on these products. Zestra is a botanical formulation that has a small study showing improvement in sexual response for some women. There are many oral supplements promoted to enhance sexual function; one product called ArginMax has a small study suggesting improved sexual satisfaction for some women. Additional studies are needed to determine the efficacy and safety of botanical and off label medication use in female sexual dysfunction.

Psychosocial interventions, also referred to as “sex therapy techniques,” make up the majority of the empirical literature on treatments for female orgasmic disorder, and include strategies such as ‘directed masturbation’ and ‘sensate focus’ techniques as well as other self-awareness exercises which are commonly directed by a certified sex therapist. Medical literature has found these types of cognitive behavioral therapies to be more effective for women with primary anorgasmia over acquired or situational orgasm function impairment.

Many biological and psychosocial factors contribute to learning how to drive an orgasmic car for the first time, or how to jump start the stalled car in the driveway. Popping the hood and understanding whether or not the mechanics are working, is as equally important as learning if this particular car needs novel strategies to start the ignition. While medical literature provides numerous multidisciplinary treatment options available for women who struggle with orgasmic function, many more trials are needed to further explore botanical, medication, and pelvic floor treatment options. Fortunately current research suggests that once the individualized and diverse contributing factors are explored and understood, orgasmic disorders in women can successfully be treated.

 

  1.  Hayes RD, Bennett CM, Fairley CK, Dennerstein L. What can prevalence studies tell us about female sexual difficulty and dysfunction? J Sex Med 2006; 3:589.
  2. Waguih W MD, et al. Disorders of Orgasm in Women. J Sex Med 2010;7:3254–3268.
  3. Laumann EO, Nicolosi A, Glasser DB, et al. Sexual problems among women and men aged 40-80 y: prevalence and correlates identified in the Global Study of Sexual Attitudes and Behaviors. Int J Impot Res 2005; 17:39.
  4. Whipple, Beverly, etc al. The Orgasm Answer Guide. John Hopkins University Press. 2010.
  5. Laumann EO, Glasser DB, Neves RC, et al. A population-based survey of sexual activity, sexual problems and associated help-seeking behavior patterns in mature adults in the United States of America. Int J Impot Res 2009; 21:171.