Author: Wulf Utian, MD PhD DSc

Human sexual behavior has come under the eye of medical scientists, and nowadays sex-related problems get diagnosed into specific categories. I know it sounds very sterile and clinical, but this approach does work in addressing the problem and providing therapy:

1. LOW SEX DRIVE AND LACK OF DESIRE

Desire is complicated. If desire is absent and of no concern to an individual or couple, there are lots of other ways to be intimate and enjoy life. But the woman who is bothered and concerned by her loss of desire should express that concern to her clinician.  This does not necessarily imply that there is something wrong with her body or mind. Perfect health can be associated with reduced desire. Unsatisfactory personal relationships, stress, money concerns, lack of privacy, depression, medication side effects, partner performance issues, and lack of time, are examples of impediments to desire.

Physical and hormonal changes, as previously described can also be the cause.

Clinicians should always open the door to discussing sex problems by asking a few sensitive well-directed questions. Help can come in the form of counseling, or the selective use of hormones. Hopefully a female testosterone product will come to market, as testosterone can improve desire.

2. LACK OF AROUSAL

It is possible to want sex, that is to have desire, yet fail to get aroused when the action starts. Poor arousal usually can be recognized by a failure of the vagina to lubricate during foreplay. It can be related to local vaginal atrophy or to central action of some drugs like antidepressants and antihypertensives. The former is easily cured with local estrogen or the simple use of lubricants. Some drug side effects may indicate a need for a change of medication.

3. PAINFUL SEX

Painful sex is either the result of vaginal thinning, or much less frequently a complication of surgery in the vaginal area. The best treatment for both is local application of estrogen. It is almost perfect for vaginal atrophy. For the women with a postsurgical problem not responding to estrogen, a surgical consultation with a gynecologist may be necessary.

The estrogen can be delivered as a cream, a vaginal tablet or a ring. Lubricants or moisturizers available off the shelf at drug stores work temporarily, but do not get to the root of the problem. Local estrogen is safe and I encourage its use. Keep the dose low and use intermittently.

4. DECREASED FREQUENCY OF SEXUAL ACTIVITY

The majority of factors at work with decreased frequency of sexual activity are not hormonal. Most are related to lifestyle, especially personal relationships.  Issues including fatigue, competing activities, and tensions in the relationship for a variety of reasons, are just a few examples of problems that need to be worked out. Couples need to communicate, and if sex is important, to make as much ‘bed time’ as they devote to other activities. If there is a problem in communication, the expertise of a sex counselor can be of considerable value.

5. REDUCED RESPONSIVENESS

This is part of the arousal factor. Being touched may not elicit the same pleasant sensation as it did in the past. Decreased estrogen does have an impact at the level of the brain, as well as on the skin and genital organs, and HT can prompt nerve endings to recover and grow.

6. LACK OF ORGASM

Sexual satisfaction in women can be achieved without orgasm. But lack of orgasm is a source of distress for some women. Many factors, as always, are responsible for the problem, including all the foregoing items I have listed. Interestingly, orgasms may be experienced before maximum arousal, and further orgasms may occur at the peak of arousal and during its gradual resolution. Thus for many women, orgasm and arousal are not particularly distinct entities.

Treatment for lack of orgasm really requires a frank discussion with the clinician, and if the latter is not sufficiently expert or comfortable in providing help, a skilled sexual counselor is recommended. Some evidence suggests testosterone may help, but there is no FDA-approved product.

7. THE MALE PARTNER MAY BE THE PROBLEM

Earlier research showed that older men had less interest in sex than older women. This may have been due to the fact that they were less able to gain and maintain an erection. The advent of the erectile dysfunction drugs like Viagra, Levitra, and Cialis may have changed that. Most older men are now able to use these drugs safely. Many older women in turn have been driven to seek medical help for one of the above mentioned problems, most notably vaginal dryness causing pain on penetration.