Women Without Orgasm: Now or Not Ever

There are two parts to this information session lecture, one from Dr. Stanley Ducharme, a sex therapist, and one from Dr. Irwin Goldstein, a sexual medicine physician.

Stanley Ducharme, Ph.D.

Female orgasmic dysfunction is defined as a persistent or recurring difficulty, delay or inability to attain orgasm following sufficient stimulation and arousal. Orgasmic dysfunctions typically cause personal distress. There are no defined requirements on what defines an orgasm and these tend to vary from woman to woman. In addition, women exhibit a wide variability in the type or intensity of stimulation that triggers orgasm. The disorder is present when there is distress and the woman’s orgasmic capacity is less than reasonable for her age, sexual experience and the adequacy of sexual stimulation that she receives. Psychologists believe that there is a subjective experience that accompanies an orgasm based on factors such as feelings toward the partner, level of comfort, feelings of trust, ect.

A woman’s ability to achieve an orgasm is based on both her physiology as well as her emotional well-being. The psychological issues that affect the ability of a woman to achieve orgasm include emotional, physical or sexual abuse, early psychological trauma, a history of poor relationships, substance abuse, depression, anxiety or psychiatric disorders. The woman’s emotional response to her sexual dysfunction often intensify and contribute to the orgasmic difficulties. These emotional reactions include inadequacy, sadness, feelings of loss, frustration, anger and a sense of failure. Various psychotropic medications may also inhibit the woman’s ability to have an orgasm.

Dr. David Barlow, a psychologist at Boston University, has done extensive research on the relationship of anxiety to sexual functioning. His work has demonstrated that anxiety associated with past negative sexual experiences may interfere with relaxation, prevent arousal and inhibit orgasmic responses. It is not uncommon for sexual activity to serve as a trigger for emotionally painful experiences in a woman’s past.

The partner’s sexual functioning is another factor affecting the woman’s ability to have an orgasm. For heterosexual women, these may include a man sexual performance including early ejaculation, erectile dysfunction, low libido of partner and pressure on the woman to be orgasmic. Men often blame themselves for a woman’s sexual difficulties and question their own attractiveness and desirability. Ultimately, this only adds to the pressure being experienced by the woman.

Treatment for woman’s orgasmic difficulties often involves a combined medical and psychological approach. In addition to androgen therapy that may be prescribed by the urologist, the sex therapist may utilize a cognitive behavioral approach. The goals of cognitive behavioral sex therapy are to promote an attitude shift, encourage relaxation and reduce anxiety.

Current behavioral approaches are relaxation training done at home on a daily basis and directed masturbation. The procedure includes a period of education and information followed by visual and kinesthetic self-exploration of the woman’s body. Often, a vibrator is used in self-exploration. The psychologist or sex therapist should provide emotional support to the woman, provide education and information, and promote relaxation and exercises designed for self-exploration and increased comfort with one’s body. The therapist should also address relationship issues.

Women Without Orgasm: Now or Not Ever

Irwin Goldstein, M.D.

Biology is the foundation for good health and intact biologic processes such as appropriate nerves, blood supply and hormones, are important for sexual functioning.

One third of women age18-49 years have sexual problems. In the past, these sexual problems have largely been considered to be exclusively psychologic. We are now identifying several biologic concerns in pre-menopausal women. Using a combined biologic and psychologic approach to management of women with sexual health concerns, the repeat sexual distress scale completed after 1 year of treatment shows that 70% of women have decreased sexual distress. Sexual dysfunctions occur in desire, arousal, orgasm and pain. Far more women than men have trouble achieving orgasm. This is the second biggest complaint of women appearing at the Center for Sexual Medicine.

During orgasm, several physiological changes are noted including: a) increases in heart rate, blood pressure, breathing rate, vaginal and clitoral blood flow, b) rhythmic muscular contractions in the vagina, uterus, anal sphincter and c) increases in the circulating levels of hormones such as prolactin (maintained x 60 min), vasopressin, oxytocin, adrenaline and vasoactive intestinal polypeptide. Orgasm is a reflex action, therefore intact sensory nerves are needed in the labia, clitoris and genital area. Researchers are showing that the nerves involved in transmitting sensory information to the spinal cord (sacral roots S 2, 3, and 4 – the pudendal nerve) are sensitive to the level of sex steroids in your body. To help diagnose patients with orgasmic disorders, patients should undergo “quantitative sensory testing”. Quantitative sensory testing is based on administration of quantified stimuli, usually of vibration or temperature, in a controlled way tot he genital area. Quantitative sensory testing is repeatable and, therefore, a valid descriptor of the sensory state. The subject defines the sensory threshold by indicating the onset of perceived sensation. Age-corrected normograms for thresholds of vibratory and thermal sensations for the clitoris and vagina are published. Many women wioth orgasm problems have abnormal quantitiative sensory testing of the labia and clitoris.

Sex steroid hormones are critical for sexual function and help make the genital sensory nerves sensitive. Androgens are as natural to women as estrogens. Without sex hormones your body is like it was before puberty. Sex steroids act on many parts of the body: heart, blood vessels, skin, hair, bones and brain. In the laboratory animal model studies, the vagina of the rat shrivels when you take away sex steroids, the walls of the vagina become paper thin and lubrication decreases and becomes more watery.

There are several reasons for women who come to our clinic with the complaint of lack of orgasm:
1) Hysterectomy: nerves to the deep inside portion of the vagina may be damaged if the cervix is removed, and the ability to achieve an internal orgasm may be lost
2) Childbirth: after 6 months 15% have persistent orgasm problems
3) Antidepressant medication such as SSRI’s
4) Birth control pills: 70 million women worldwide take the oral contraceptive pill (OCP). The OCP stops ovarian testosterone synthesis and increases the level of sex steroid binding globulin which binds to testosterone rendering much of the circulating testosterone inactive. Low bioavailable or free testosterone values may be a cause of diminished sensation in the genitals leading to difficulty with orgasm and a loss of sexual interest. It is curious that sexual side effects of the oral contraceptive pill are not listed in the PDR (Physician’s Desk Reference). Women on the OCP may also have pain because the vestibular glands near the hymen require testosterone to remain healthy.

An evaluation for lack of orgasm includes a psychological evaluation, sexual and medical history, physical exam, quantitative sensory testing, and blood tests in which as many of the 10 steroids as possible are measured. An individual plan for each patient is developed. DHEA and testosterone may be prescribed as double blind placebo-controlled tests for safety and efficacy have been published for both. The major side effect of androgen therapy is hair growth – including moustache, chin, abdomen and thighs. EROS therapy (a device applying vacuum intermittently to the clitoris) helps makes the sensory nerves to the clitoris more sensitive. For pain, physical therapy to learn relaxation and contraction has been found to be helpful. You CAN do something about your sexual problem.

Primary teaching affiliate
of BU School of Medicine