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What you need to know about sexual dysfunction in women

GP Dr Mandy Fry’s questions on sildenafil for women, vaginismus and the impact of SSRIs on sexual function are answered by sexual medicine consultant Professor Alan Riley.

GP Dr Mandy Fry's questions on sildenafil for women, vaginismus and the impact of SSRIs on sexual function are answered by sexual medicine consultant Professor Alan Riley.

1 Loss of libido is often associated with depression but can also be a side-effect of treatment. Is there any way of distinguishing between these two sources of symptoms? Which SSRIs are best for women in whom this is a significant problem?

41224251It's well known that affective disorders can adversely affect sexual functioning in women and studies have shown that up to 70% of women with major depression report sexual dysfunction (SD). Reduced sex drive is the most frequent SD associated with depression.

Antidepressants can also affect sexual function, causing impaired sexual arousal, delayed or abolished orgasm, reduced genital sensation and loss of sex drive.

But some depressed women notice improved sexual functioning as their depression is alleviated with therapy.

Distinguishing between depression and its treatment as the source of sexual problems can be difficult. Considering the nature of the symptoms and when they occur can be helpful.

In my experience depression is more associated with loss of sexual drive than other forms of SD, whereas SSRIs reduce arousal and orgasm responses more frequently than sexual drive.

Obviously if the SD was present before medication was started, the drug can't be the cause.

If the SD starts within a month of taking the SSRI, and no other changes in the patient's life have occurred in that time, the chances are that there is a causal relationship.

If the onset of SD occurs after the first month of treatment, then there is unlikely to be a causal relationship.

Remember that a patient who had not previously admitted a SD may blame a pre-existing SD on the medication. It's all too easy to attribute SD to the patient's psychiatric condition or the SSRI when in fact it has another cause – such as hypothyroidism – so a thorough assessment is always required.

As for the last part of your question, I'm not convinced that SSRIs are any different from each other in their propensity to impair sexual function.

2 Loss of sex drive is relatively common in women. What are the likely causes and how is it best approached?

It is important to know what the woman means by loss of sex drive. If it is selective or situational (she has no interest in making love to her partner but continues to experience sexual fantasies and thoughts and perhaps the need to masturbate), the cause is behavioural. Relationship conflicts are a common cause, especially where either partner has been unfaithful. Other common causes are sexual boredom, not gaining satisfaction from partner-involved sex and dyspareunia.

Situational loss of sex drive benefits from early psychosexual assessment.

When the loss of sexual drive is global the chance of a psychiatric or physical cause is much increased. Depression is the most common psychiatric cause for loss of sex drive.

Physical causes include low androgen level, hypothyroidism and any chronic debilitating disease. Tiredness and significant life events – such as childbirth or bereavement – can also be triggers.

It is also a normal consequence of ageing, especially following the menopause (see question 7).

Loss of sex drive has the lowest therapeutic success rate among female sexual problems.

When the problem is global, the best approach is combined medical and psychological assessment, with treatment dictated by the results of the assessment.

Women found to have a likely physical cause often benefit from sex therapy as well as specific medical treatment for the physical disease.

3 Vaginismus is a relatively common problem and ideally we would refer these women to an experienced psychosexual counsellor. But given the relative scarcity of these – particularly on the NHS – what should we recommend to enable patients to attempt gradual desensitisation?

The effectiveness of self-treatment of vaginismus is unknown. We only see treatment failures in our clinics and many of these women have low motivation to be cured – they attempt self-treatment either to satisfy the wishes of their partner or for some other reason such as wanting to conceive.

Before advocating self-help it is important to:

• be certain that the diagnosis is vaginismus and not sexual aversion or dyspareunia

• inquire whether the patient's partner has any sexual problems

• assess the patient's reasons and motivation for treatment.

I have found the most useful make of vaginal trainer (a better term than vaginal dilators as they are not used to dilate the vagina) is Amielle Comfort, made by Owen Mumford and available from a number of online retailers.

A book by Linda Valins (see further reading) can also be recommended.

4 Dyspareunia is another frequent problem. Which factors make it more likely to be of psychological origin rather than physical origin and vice versa?

As a medical student I was told that pain is rarely entirely psychogenic. This is certainly true here – there is a two-way interaction between organic and psychogenic dyspareunia.

Many women labelled as having ‘psychogenic dyspareunia', because no physical abnormality was discovered on routine examination, are found on a more thorough assessment and examination to have an organic cause.

The reverse situation is also common – where a woman whose organic cause for dyspareunia has been treated but who continues to suffer pain because of a secondary psychological response.

Unfortunately, in my experience there are no factors in the patient's history that definitively point to an organic or psychological aetiology. Women with dyspareunia should be thoroughly assessed from both perspectives.

5 I've heard there have been trials of sildenafil to improve sexual satisfaction in women. What has been the outcome? Is there any role for phosphodiesterase type 5 (PDE5) inhibitors in women?

Studies have shown sildenafil to increase physiological sexual arousal in women during sexual stimulation with increases in vaginal and clitoral blood flow.

In many women there is poor, if any, correlation between physiological and subjective arousal, which could limit the therapeutic relevance of these findings.

But some studies and clinical observations have shown sildenafil improves arousal and sexual satisfaction in women with arousal disorder. It is being used off-licence for this purpose.

It's important to remember that most of the women who present for help with sexual difficulties don't have one single sexual symptom. They experience a combination of problems with desire, arousal and orgasm, all often associated with lack of pleasure.

So a pharmacological treatment that is effective in resolving only one of these problems may not improve the woman's sexual satisfaction.

6 Women often comment that their libido is adversely affected by contraception. Is there any evidence for this? Are there particular forms of contraception – or indeed particular versions of the Pill – that are more or less likely to have this effect?

The majority of women don't find contraception reduces their libido – in fact some say that removing the risk of pregnancy actually increases it – but a few do.

For some of these women, their libido is significantly linked to reproduction and they feel there's no point in having sex with no chance of conception.

When diaphragm use was more common, we used to see women whose libido was diminished by what one described as the ‘mechanisation' of sex. Reduced libido has been reported to occur to the same extent in women who are using oral contraception and those using IUCD.

In addition to such psychological causes for adverse effects of oral contraception on libido, hormonal factors have been implicated. Oestrogen can impair sexual functioning in women by reducing bioavailable androgen levels. I'm not convinced different COC formulations have significantly different effects from each other on libido, because psychosocial factors influencing sexual functioning probably overshadow such differences.

7 Women approaching the menopause sometimes complain of enjoying sex less. What – if any – are the treatment options for those who don't want to take HRT? For those in whom vaginal dryness is a problem, but who don't even want vaginal oestrogen, which lubricants are best?

Not all decreased enjoyment in sex that occurs at this time is hormonally induced. Psychological factors arising from the ending of the fertile phase of life, loss of femininity and reinforcement of ageing can be implicated.

Nocturnal hot sweats may cause tiredness during the day, which can adversely affect sexual enjoyment.

Encouragement of a more positive approach to life and ageing and, if the hot sweats are particularly troublesome, a non-hormonal approach to their control such as clonidine is also worth considering.

Tibolone has been shown to improve sexual functioning in postmenopausal women.

Many women are reluctant to use artificial lubricants, perhaps feeling embarrassed that they are not responding to their partner's advances.

There is a wide choice – water soluble, silicon, oily and bioadhesive – and I encourage couples to try several to discover which suits them best.

The couple should be advised to warm the product to body temperature before applying, apply to the vulva to ensure clitoral dryness is overcome and use just the amount necessary.

I believe the best approach is to apply the lubricant intravaginally before foreplay starts – her partner needn't know. This then behaves just like natural lubricant, lubricating the vulva as well as the vagina. Feminée was developed specifically for intravaginal administration and is an excellent lubricant.

8 We're all aware of the impact that diabetes and cardiovascular disease can have on men's erectile function but do they have a comparable impact on women's sexual function?

There is no doubt that diabetes and cardiovascular disease (and antihypertensive drugs) can impair women's sexual function, but the extent to which they do so has not be definitively established.

As in men, good glycaemic and blood-pressure control minimises the adverse effects of diabetes. Ensuring that women with diabetes are free from troublesome vaginal candida infection is also important.

Women with chronic diseases should always be asked about their sexual functioning at routine follow-up so that sexual difficulties can be identified and treated early and their effect on the woman's sexual relationship minimised.

9 Unfortunately I have several female patients who have been sexually abused as children. One of them is about to get married and is understandably anxious about this aspect of her forthcoming marriage – she hasn't had premarital sex. Luckily, she has a very supportive partner but do you have any suggestions of resources that might help alleviate some of her anxiety? Generally, is there a link between sexual abuse in childhood and the subsequent development of sexual disorders?

Studies have confirmed that childhood sexual abuse can have a negative impact on future sexual and, more frequently, intimate relationship functioning. But studies differ on its impact.

It would appear that sexual problems are more likely if the abuse occurred at a later age especially after age 11 if it occurred frequently and over a long time period, and if it was associated with threats and engendered strong negative emotional feelings, not just for the acts but also for the abuser.

I wonder why this couple have refrained from premarital sex. It could be on religious or moral grounds. But it does raise the possibility that she may have anxiety about sexual intercourse, which could manifest itself as vaginismus or sexual aversion, perhaps resulting from the abuse. It is important therefore to take a full history and psychosexual assessment.

I think she should be encouraged to see a sexual and relationship therapist, or a clinical psychologist with experience in managing women who have been sexually abused as children as early as possible before her wedding.

Useful self-help books are detailed in the further reading list above right.

10 Are there any sexual problems that are more common in, or restricted to, those in lesbian relationships? How might the treatment of these differ?

There is a paucity of reliable data on the prevalence of different types of sexual dysfunctions and problems in lesbians, so it is impossible to provide a meaningful answer to the first question.

Lesbians can experience reduced sexual drive, impaired arousal, inhibited orgasm and sexual pain disorder just as heterosexual women, and for all the same reasons.

The man's ‘race to intercourse and ejaculation', which is fairly common in heterosexual relationships and can result in reduced pleasure for their partners, doesn't apply in lesbian relationships, where the emphasis is often on caressing, hugging and non-penetrative pleasure giving and receiving behaviour.

But I've seen vaginismus in a few lesbian women, which caused them considerable distress in their sexual activity.

Some lesbians have confused images of their sexual orientation, which can have a negative impact on their relationships.

Sexual problems in lesbians are treated in exactly the same way as in heterosexual women.

11 Women are often very cautious about restarting sexual intercourse after childbirth, particularly if they have had an episiotomy or sustained a significant tear during the delivery. What advice would you give such women? What effect does breast-feeding have on libido and sexual satisfaction?

This concern is understandable. We know that most couples attempt sexual intercourse quite early following childbirth, some even before the perineum has completely healed. Advice on resumption of intercourse should be provided during antenatal care.

The couple should be advised to refrain from penetrative sex until the wounds are healed, the area feels comfortable and she wants to. She should not be pressured into intercourse by her partner before then.

She should use copious amounts of artificial lubricant (see question 7) and it's helpful if the couple adopt a coital position in which she is in control of penetration – female superior, for example.

If the thought of intercourse causes fear, or first attempt causes pain, the woman can be advised to use vaginal trainers (see question 3) before the next attempt. This is not to dilate her but to allow her to gain confidence that penetration is not painful. If insertion of the largest trainer is painful, the woman should seek medical advice.

Breast-feeding often has a negative effect on sexual function and satisfaction. This is the result of hormonal changes and psychological factors. Lactation is associated with hyperprolactinaemia and ovarian suppression.

Low oestrogen may cause dyspareunia, low androgen and hyperprolactinaemia causing loss of sexual drive.

Psychological factors include tiredness, feelings of guilt about erotic feelings some women experience during breast-feeding and adjusting to the role of mother while still being a wife.

Professor Alan Riley has specialised in sexual medicine for more than 40 years and was professor of sexual medicine at the University of Central Lancashire

Competing interests: Professor Riley has received fees for lectures and participation in advisory boards from Pfizer, Procter & Gamble, CST Medical and London International Group

thps What I will do now What I will do now

Dr Mandy Fry considers the responses to her questions
I found it interesting that sildenafil is being used off-licence in certain situations and it would be good to know the outcome of any studies.
I'll also endeavour to take a fuller sexual history from women describing loss of libido as I had not previously considered the very obvious distinction between selective (or situational) loss of sex drive and global causes for loss of sex drive.
I will hopefully inquire more routinely about sexual function in women with diabetes.
I found the self-help suggestions useful and will certainly find out more about them and recommend them if appropriate.
I have already identified patients for whom
to suggest the very helpful practical advice about applying lubricant pre-foreplay so as to minimise any possible embarrassment.
I found it reassuring that even the experts cannot categorically distinguish between organic and psychogenic dyspareunia, but that it is likely to be multifactorial in most cases.

Dr Mandy Fry is a GP in Cirencester, Gloucestershire, and senior primary care lecturer at Oxford Brookes University

Psychosexual counselling

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