Many of you have reached out over the past several months to tell me that you are struggling with sex. A few months ago in our Hot Flash reader survey, one overwhelming sentiment was that you don’t just want to have sex more, you want to want to have sex more. A few of you have noted that your lack of interest in sex is causing problems in your relationship with your partner.
Sexual dysfunction can take many forms, from lack of desire to difficulty becoming aroused to problems achieving orgasm. In all its presentations, it can be frustrating. Sex is supposed to be an enjoyable way to connect with our partner, not a source of stress. And yet for many women, it is stressful.
What do we know about sexual dysfunction, and what can you do if you are having symptoms?
How common is sexual dysfunction in women?
Sexual dysfunction is defined as any problems someone is experiencing related to sex that interfere with personal or interpersonal stress. More simply, it is any issue you might experience that bothers you or is causing stress between you and your partner.
If you are experiencing sexual dysfunction, you are not alone. It is quite common. The studies we have regarding the prevalence of female sexual dysfunction are old; it is generally accepted that about 40% of women complain about sexual problems. About 12% of women say those problems cause them stress or are a source of stress in their relationships.
Sexual dysfunction typically falls into four categories, related to the four stages of the female sexual response cycle: decreased sexual desire, decreased physical excitement, difficulty with orgasm, and problems with resolution. The first three problems are much more common than problems with resolution. Pain during sex can affect any or all of these stages.
What causes sexual dysfunction in women?
There are many factors that can impact sexual function. Hormones are definitely involved. Low estrogen, whether it is caused by perimenopause, breastfeeding, or something else, can lead to decreased desire and decreased arousal. Decreased arousal can manifest as a decrease in vaginal lubrication, which can in turn make sex painful. In a longitudinal study of more than 400 women, low estrogen levels were associated with participants reporting vaginal dryness, decreased arousal, and more painful sex.
Women have a number of male hormones, or androgens, circulating in their blood. These include testosterone, DHEA sulfate, DHEA, and androstenedione. Androgens appear to have a part in female sexual function, but this is poorly understood. However, we do know that some women experience a significant drop in androgens during perimenopause that may contribute to decreased sexual desire.
Thyroid hormone has also been shown to affect sexual function in women. Having either too much or too little thyroid hormone can affect all four areas of female sexual response. Thyroid hormone imbalances can also cause vaginal dryness, leading to painful sex.
Changes in thyroid function are common during big shifts in other hormone levels, such as pregnancy, the postpartum period, and perimenopause. These are times when sexual dysfunction is common, and it is often worth checking thyroid hormone levels to determine if they are playing a role.
What are the treatment options for female sexual dysfunction?
Given that there are so many factors that can impact sexual dysfunction, there are also many possible treatment modalities. Here are four treatment possibilities.
1. Estrogen
If there is an underlying cause, such as an underactive thyroid, treating it can be all that is needed. Treating vaginal dryness and atrophy with topical or systemic estrogen may improve sexual function in perimenopause, although systemic estrogen has not been shown to improve sexual function.
2. Testosterone supplementation
Testosterone supplementation can also be helpful for some women. A randomized controlled trial of 261 women ages 35 to 46 looked at whether a testosterone spray applied to the abdomen increased the number of satisfactory sexual events the women experienced in a month. The researchers tested three different doses of testosterone. They also measured the women’s testosterone levels in their blood before and after the testosterone, or a placebo was given. All groups, including the placebo group, saw improvement in sexual desire, but the difference between the placebo and testosterone groups was not statistically significant.
3. Erectile dysfunction medications
Medications used to treat erectile dysfunction in men, such as sildenafil (Viagra), have been studied as treatment options for sexual dysfunction in women. The best-quality data regarding sildenafil comes from a randomized controlled trial sponsored by Pfizer, the original patent-holder on sildenafil. More than 700 women, both pre- and postmenopausal, were enrolled and randomized to take sildenafil or a placebo. Participants were given several validated questionnaires, including a sexual function questionnaire, before and after taking the medication or placebo. The investigators did not find a significant difference between the sildenafil group and placebo group. This suggests that sildenafil is not an effective treatment.
4. Addyi
Flibanserin (Addyi) is the only drug FDA-approved for the treatment of female sexual dysfunction in premenopausal women. The medication works by temporarily decreasing serotonin levels and increasing dopamine levels in the brain. In clinical trials, women who took flibanserin daily had a statistically significant increase in satisfactory sexual encounters compared with those who received a placebo. However, in real terms, the treatment group reported an increase of only half a satisfactory sexual encounter per month.
To add to that, flibanserin must be taken daily to be effective. Common side effects include dizziness, somnolence, nausea, and fatigue. And patients taking it cannot drink any alcohol or take certain medications. As a result, its adoption by doctors and patients has been limited.
Several other medications, including bupropion (Wellbutrin) and buspirone, have been studied for the treatment of female sexual function, with minimal benefit.
Given the lack of success across all four of these treatment possibilities, this is clearly a subject that is sorely in need of more attention and research.
The bottom line
- Female sexual dysfunction is quite common and can affect one or several aspects of the female arousal cycle.
- Treating underlying causes, such as vaginal atrophy, can improve sexual function.
- Several treatments have been explored for the treatment of female sexual dysfunction, including testosterone, sildenafil, and flibanserin, but treatments have been at best minimally effective.
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Dr Emily Nagoski explores decrease in sexual desire a lot in her books “Come as you are” and “Come Together”. So often it is a response to burn out, or a misunderstanding of how to “turn on” sexual desire.
For people with a high sex drive it can be turned on very quickly, but a lot of people need several triggers and the right environment to turn it on. Any change in the environment can turn off sexual desire so quickly (the fear of kids walking in, lights on, the laundry needing to be done).
I know it’s an internal medicine doctor who wrote this post, but I think it’s concerning that the socio aspects of sexual desire are completely absent from a post about how to improve sexual desire.
I’d love a collab with Dr Nagoski because I think her work is incredibly relevant to parents.
I really enjoy reading your articles – you talk about things that affect women that a lot of other people aren’t talking about. However, I feel like today’s article about sexual disfunction in women really missed the mark.
Throughout the whole article, you explained how the hormonal changes that women experience that lead to decrease desire for and enjoyment in sex are completely normal. If these changes are completely normal, then why is the resulting decrease in sexual desire or enjoyment considered “disfunction”? Why is just not considered a difference in how men and women feel about sex? Why should women feel the need to take hormones or other “fix” this situation? It is infuriating that our cultural prioritizes sex, and specifically the male drive for sex, over pretty much everything else, and that a completely normal decline in the desire for sex is causing us to ignore what our bodies are telling us?
I understand lots of women said in the survey they wanted to want more sex, but is that because they actually wanted more sex, or because they were feeling pressure to want more sex because their partner does? Your articles usually advocate for women to do what is best for their bodies and mental health, but today it seems like you just gave into the cultural narrative that we should all be wanting as much sex as the men in our lives want, even when our bodies are telling us something different.
I think your thoughts here are important. My thought when reading this was how it does not go into the social aspects of sexual relationships. This article focuses solely on biological functions, whereas sexual relationships are deeply social, cultural, and even political. I don’t know if this is a forum that has the space to tackle such a complex issue but a nod in that direction would have been nice.
I agree this isn’t the place to dive into all the complexities of sexual relationships. That said, by approaching women’s completely normal biological functions around sex as “dysfunctions”, like this article does, takes a pretty strong stance on what is “right” in sexual relationships. What if the whole tone of the article was “this is what your body is doing, it’s totally normal and not ‘dysfunctional’, but if you want to change it anyways here are some things you could do.”
The author didn’t define any decrease in desire as a dysfunction, only if “ [it] bothers you or is causing stress between you and your partner.”
My take on this definition is that if you aren’t concerned, and it’s not causing stress in your relationship, it’s not a dysfunction.
My concern is that the post only addressed biological solutions. If the woman isn’t concerned but her partner is, then perhaps it’s a social/psychological intervention that’s needed rather than an internal medicine intervention.