Exams and Tests

Women often begin the process of diagnosing a sexual problem by noticing an absence of sexual desire or satisfaction.

Your doctor will work with you to identify your symptoms and the history of those symptoms by:

• Asking questions about your complete medical history, including a complete sexual history. This will include questions about any medicines you are taking.
• Having you fill out questionnaires. These are special questions that can help your doctor find the cause of a sexual problem.
• Doing a physical exam, in some cases. For a sexual pain problem, this may include a pelvic exam.
• Ordering laboratory tests, if they are needed. This includes blood tests to check hormone levels and thyroid function.

Your doctor will use the information from the history and exams to determine the cause of your sexual concerns.

Throughout the appointment and future treatment of a sexual problem, your doctor should establish an encouraging atmosphere for you to discuss your concerns. All of your communications about your sexual concerns should be maintained in a professional, confidential, and nonjudgmental manner. See a list of questions you might be asked by your doctor.

What to Think About

By definition, a sexual problem is a sex-related stressor for you and/or your relationship with a partner. If you have a symptom that you are not troubled by and that isn't causing a relationship problem, then it is not considered to be a problem.

Treatment Overview

Many sexual problems can be managed when you understand what is causing them. Effective management requires a high level of comfort between you and your doctor, possibly along with your partner.

Because a sexual problem often has multiple causes, treatments cannot be universally applied—what works for one woman may not work for another. An effective plan will address and manage the cause. And if you have a partner, your plan will also include ways to build and strengthen intimate communication between you and your partner. The best results will help you find methods of having a satisfying sexual life.

Treatment may include:

• Medical treatment for any cause.
• Education about your body, your sexual signals and receptors, and changes in sexuality as you get older.
• Communication counseling for you and your partner.
• Psychological therapy. Therapy for sexual problems often involves cognitive-behavioral therapy.
• Sex therapy.

Treatment for decrease of sexual desire

A decrease in your level of desire might be expressed by fewer sexual thoughts and/or a reluctance to engage in sexual activity. Treatment for physical causes can include:

• Changing from a medicine that has been curbing your interest in sex.
• Relieving pain, illness, or sleep problems that are curbing your interest in sex.
• Hormone therapy with estrogen. After menopause, low levels of estrogen in the body cause vaginal dryness. This can be painful during sex. Estrogen reverses this.
• Testosterone. Normally, a woman's testosterone slowly declines with age. It drops suddenly when a woman has surgery to remove the ovaries (oophorectomy, causing surgical menopause). Testosterone is sometimes used after natural or surgical menopause to improve sex drive. When taken in too high a dose, testosterone causes male-type side effects, such as a deepening voice, thinning scalp hair, and growth of facial and body hair. Testosterone risks are not fully researched.
• Exercise, to improve your mood and increase natural testosterone levels.

Your doctor can treat physical or hormonal causes, and you can work on other facets of sexual desire. For example:

• Changing your setting and routine can improve your time together. Do you have enough privacy and time? Are you interested in trying something new?
• Having a partner you feel comfortable and nonstressed with plays a big part in your desire level.
• Getting counseling as a couple can help strengthen your emotional connection with your partner. Improving a stressed relationship is likely to improve your sexual relationship.

It is normal to lack desire for a partner who forces sex or is verbally abusive or physically violent. For more information, see the topic Domestic Violence.

Treatment for decrease of sexual arousal

A decrease in the level of arousal might be noticed as an inability to feel or maintain sexual excitement. A woman's sexual arousal often is enhanced by, and is sometimes dependent on, stimulation in areas other than the genital area, especially the breasts. Treatment for a decrease in your sexual arousal may include:

• Increasing the level of intimacy and sexual arousal with your partner before penetration.
• Liberal use of vaginal lubricants.
• Masturbation, possibly with the aid of a vibrator and/or with your partner.
• Education about the role that emotions play in sexual arousal.
• Counseling, to help adjust expectations of sexual activity. If too much pressure is put on partners to perform, arousal may be reduced.
• Treatment changes for other conditions, if needed to eliminate side effects that decrease arousal.

Treatment for an inability to reach orgasm

A woman may seek treatment because she has never experienced an orgasm, is experiencing long delays in reaching orgasm, or has become unable to reach orgasm. Treatment usually begins with changing any medicine that is known to affect orgasm. (Talk to your doctor before you stop any medicine you are taking.)

It is also important to understand what a normal sexual stimulation phase would be for that woman. If a woman is experiencing a delay or absence of orgasm after adequate sexual stimulation, treatment may include:

• Self-stimulation, along with erotic fantasy. If a woman is able to become highly aroused but is unable to have an orgasmic release, the use of a vibrator may help.
• Talking and listening to each other more. This includes talking openly about sex, what each of you needs, and what you want to do differently together.
• Learning more about sexual response. For example, it may help to learn that most women find it easier to have an orgasm from direct clitoral stimulation and that most couples do not have orgasms at the same time.
• Decreasing inhibition with fantasizing, distractions, and/or listening to music.

Treatment for pain during intercourse

Pain during intercourse often is caused by a physical reason, such as vaginal dryness or infection. This is why treatment must start with finding out the cause of a sexual problem. If a physical condition is the cause, treatment of that condition may eliminate the pain. But pain during intercourse may have more than one cause, including psychological causes such as anxiety or the memory of sexual assault.¹

• Pain that occurs during initial penetration by the penis may be caused by involuntary contractions of the vagina (vaginismus). Vaginismus is more common in young, inexperienced women and is sometimes related to a lack of education or preparedness for sexual intercourse.³ Treatment may include a program of progressive muscle relaxation and gradual vaginal dilation, possibly including psychotherapy. But pain during initial penetration also may be caused by vaginal irritation or an anatomical condition. If so, getting rid of the pain will require treating the physical reason.
• Pain that comes from the vestibule, which is the area around the opening of the vagina, may be from localized vulvodynia.
• After menopause, it is common to have vaginal dryness. This can cause pain during initial penetration or after intercourse has begun and the penis is in the vagina. Try using liberal amounts of vaginal lubricant. If this does not work as well as you need it to, talk to your doctor about vaginal estrogen, which can reverse vaginal dryness and sensitivity.
• If the pain is caused by the deep thrusting of the penis, the cause may be a pelvic disease. But it may also be caused by an inability to relax. An open and trusting relationship with your doctor will enable you to explore the cause of the pain and decide on a course of treatment.

Treatment for aging and menopause-related sexual problems

It is common for a woman's sexual desire to decrease gradually as she ages. In some cases this decrease is caused by the lack of a partner. But women continue to be sexually interested and to have the capability for sexual pleasure throughout their lives.¹ Hormonal changes may be a cause of decreased sexual function in older women. During and after menopause, levels of the hormones estrogen, progesterone, and testosterone in a woman's body decline.

• Nonprescription water-based products that provide vaginal lubrication are available. You can typically find these products, such as Astroglide and K-Y Jelly, at pharmacies, usually near the condoms. Vaginal moisturizers, such as Replens, are not for use right before sexual intercourse. But when used regularly, they can help with vaginal dryness and with keeping your vaginal pH normal.
• Vaginal estrogen therapy can reduce vaginal dryness and irritation and increase the blood flow in the vagina. If you have only vaginal symptoms (and not hot flashes, for example), you can use a low-dose estrogen cream, ring, or tablet in your vagina. Many women find that using cream or a tablet twice a week is often enough.
• Systemic estrogen therapy is a high enough dose that it affects your whole body and can help with several menopausal symptoms. If you have symptoms that affect your physical and mental well-being, talk to your doctor about the risks and benefits of taking daily estrogen. Estrogen therapy can be oral (pills), vaginal, or transdermal (with a patch). Estrogen therapy may affect sexual desire, arousal, and enjoyment, as well as the capability to reach an orgasm. But taking daily estrogen without progestin can cause cancer of the lining of the uterus (endometrial cancer). So a woman who has a uterus and wishes to take systemic hormones usually takes estrogen in combination with progestin to protect her uterus. This is called estrogen-progestin therapy, also known as hormone replacement therapy.

Testosterone therapy helps some postmenopausal women who have a low sex drive, especially those who have had their ovaries removed. Surgery to remove the ovaries (oophorectomy) causes sudden menopause—testosterone and estrogen, and sometimes sex drive, suddenly drop. (Normally, testosterone slowly declines with age.) Some postmenopausal women take testosterone to improve sexual desire and responsiveness and to increase the frequency of sexual fantasies and interest.

If you are considering taking testosterone supplements, talk to your doctor about the potential side effects. Make sure you are taking the lowest possible dose and are carefully monitored for side effects while taking testosterone.

What To Think About

Over time, an untreated sexual problem can increase its impact on your quality of life. As the cause of a sexual problem creates discomfort and dissatisfaction, sexual activity may become a tense and unwelcome experience.