Women's Sexual Health:
A look at common sexual disorders and treatment options.
My name is Corey Babb, and I’m an OB/GYN with OSU Physicians, as well as the Director of the Oklahoma State University Center for Women’s Sexual Health. Last week we looked into some of the emotional, physical, and hormonal changes that occur postpartum, as well as talking about postpartum depression and mom guilt. This week, it’s a whole different ballgame; we’re talking about sex.
Before we get started, I want you to realize something. The most important thing about sexuality overall is that there is no “normal” when it comes to sex. While the national average for penetrative intercourse in married, heterosexual couples is around five to six times a month, some couples are completely fine with much less, or much more. With sex, as with many things, quality is more important than quantity. Whatever makes you happy, or where you feel comfortable can be your own normal. It should also be noted that the average length of a sexual encounter in the Unites States is seven minutes, and the average women takes approximately 10 minutes to become fully aroused, so keep that in mind when you’re examining your own sexual experiences.
Were you aware that current estimates put the prevalence of female sexual dysfunction at 40 percent? That makes sexual issues more common than high blood pressure, diabetes, or high cholesterol! Now think about the number of treatments (diets, medications, exercise regimens) you can name for high blood pressure or diabetes - most of us can at least name a few. How many treatments can you name that help improve sexual function in women? What about in men? Isn’t it ironic that there are a plethora of commercials for male erectile dysfunction remedies, but not a single one for women with low sex drive? While these facts may not surprise you, they should give you pause - if we are to call ourselves an enlightened society, how can we continue to gloss over this radical difference?
News flash: men and women view sex differently. I know, this is a crazy concept, but the importance of that statement cannot be reinforced enough. Even though humanity has known this fact to be true for millennia, the actual scientific study of female sexual health is a relative newcomer. Despite advances in women’s sexual health as early as 1908, American society has continued to repress the ideal of the sexual woman, creating the dichotomy of a saint and seductress. In other words, a woman who should be both nurturer/caretaker, AND sexual vixen, or, as the great American poet Ludacris put it, a “lady in the street but a freak in the bed.” To add insult to injury, we’ve negatively “labeled” women who lean too much towards either saint or seductress, creating even more of a fine-line for today’s woman to tow.
So now that we’ve identified part of the problem, let’s look into what we do about it. First of all, how much do you know about your body’s sexual functioning? For lots of us, sex education was something that was talked about once or twice at school, or found in a book, or that we learned in hushed tones at recess. Do you think those discussions covered everything out there? Maybe…but most likely not. In order to fully evaluate and discuss normal female sexual function, a little anatomy and physiology lesson is warranted. Now, I’m not going to get into the nitty-gritty of anatomic terms, or go through specific physiologic formulae, but I do want you to know your body, so let’s start with the basics.
The most important sexual organ is the brain. Surprised? You shouldn’t be. Think about it, your brain controls pretty much every voluntary AND involuntary function in your body. From a sexual standpoint, that means desire, arousal, and orgasm! As such, a good number of sexual dysfunctions arise from problems within the brain itself. In addition, sexuality as a whole is driven by the need to form intimate connections between individuals, so when we’re stressed, aggravated, or insecure, sexual dysfunction is one of the first symptoms many people notice.
Moving one step out in terms of importance is the endocrine system. Our endocrine glands produce the vast majority of sexual hormones, and disruption in the ability of those glands to function properly can lead to a number of sexual problems. In women, the most important endocrine organs for sexual functioning are the ovaries and adrenal glands.
Thirdly, we have the reproductive system itself. Did you know that the colloquial ‘vagina’ is actually three separate parts (vulva, vestibule, and vagina), and each plays a different role in sexual activity? For instance, with arousal, the vulva enlarges due to increased blood flow, and the clitoris becomes very sensitive to tactile and vibratory stimulation. In addition, the influx of blood to the genitalia leads to a sensation of “fullness,” and a radiation of heat due to a dilation of surface blood vessels. The vestibule begins to secrete large amounts of fluid that lubricates the entirety of the vaginal canal. The vagina elongates to accommodate penetration, and becomes highly sensitive due to an increase in blood flow and neuronal stimulation.
There are other anatomic signs of sexual excitement as well - the face and chest become flushed, the pupils dilate, lips redden, the breasts engorge, and the nipples become erect. Honestly, the list goes on, but you get the point. Our bodies are designed for reproduction, and even if we don’t “see” that response with sociosexual cues from our partner, the deep parts of our brain can readily interpret those uncontrolled, physiologic changes, and say “hey, let’s connect.”
If you put these three facets together, you have what I call the “Sexuality Triad.” Much like a tripod is dependent on each corner to stay standing, our sense of sexuality requires communication between the brain, genitalia, and endocrine system. Take one corner away, or keep it from holding its weight, and the triangle collapses. While this example is simplistic in explanation, the key fact is that we require multiple parts to function as a whole - a sexual gestalt, if you will.
OK! So now that you understand a little more about what’s actually going on with your sexual self, let’s talk about some of the issues that arise with that system goes awry. There are four main domains of sexual disorders: issues with sexual drive or libido (desire), sexual response (arousal), sexual pain (pain), and sexual climax/conclusion (orgasm). An in-depth discussion of each of these domains could be a blog in itself, so I’m just going to give you a brief overview of various causes and treatments for problems related to each area of sexual functioning. Obviously, the examples listed below are not all-encompassing, so if you have questions, please talk to your provider.
Desire disorders are the most common type of sexual dysfunction in women, representing between 25 and 50 percent of all sexual problems. They are often related to issues with either neurochemical interaction, or environmental stimuli. A woman who states “I could be fine never having sex again,” yet has adequate lubrication, and enjoys sexual activity when she does have it may have an issue with desire. Anyway, when it comes to treating issues with desire, we need to look at how a woman feels about her current sexual situation. For most women, emotional connectivity and fulfillment are necessary for spontaneous sex drive; a harried mother who feels overwhelmed with “home responsibilities” probably does not have much of a libido. That said, that same mom may have an increase in drive if her partner alleviates some of her burden, and makes her feel taken care of.
As you may expect, counseling can be very beneficial for women who have low sex drive. Couples counseling, where partners can be instructed on how their behavior affects sexual experiences within the relationship, may be a great way to help both parties have a better sex life. If counseling is not desired, or if time doesn’t allow, medications can be beneficial, especially if there is an underlying medical condition such as depression, anxiety, or fatigue, or there is a hormonal issue. As far as hormones go, both estrogens and testosterone are important for sex drive, so supplementation may be useful. Outside of that, there is currently one FDA-approved medication specifically for low sex drive, Addyi, so talk to your provider if you feel you are having problems with sexual desire.
Arousal disorders are typically due to either issues with neurovascular functioning within the pelvis, or are anxiety/fear related. A woman who has a history of sexual abuse may have difficulty with feeling aroused (decreased lubrication, absent genital ‘fullness’) by sexual experiences due to anxiety about possible pain, or perhaps reliving past experiences. Obviously, most issues with arousal are not as cut and dry as the above example, so often an evaluation of a woman’s blood flow and nerve function in her genitalia is warranted, as is a thorough history of past sexual activity. Once the source of the problem is found, medication can often be used to treat the specific cause of the problem. For example, in women with decreased blood flow to their genitalia, viagra is a wonderful treatment!
Sexual Pain Disorders:
Sexual pain disorders are anatomically dependent - the diagnosis is often dependent on the depth at which pain is provoked. Pain with superficial or initial penetration is often due to issues within the vestibule of the vagina (vestibulitis), or can be related to spasms in the muscles at the entrance of the vagina (vaginismus). Conversely, pain with deep penetration may be due to pelvic floor muscle spasms, endometriosis, or a plethora of other causes. Regardless of origin, correct treatment depends on identifying the cause of the pain - therapies that may be beneficial for vestibulitis, for example, won’t touch pain due to endometriosis. To fully diagnose causes of sexual pain (dyspareunia), a physical exam is necessary, and other studies such as laboratory tests or imaging (such as ultrasound) may be beneficial in aiding in a provider’s plan of care. As a side note, sex should not hurt. A little initial discomfort, especially if a women is not aroused enough is one thing, but if it ever hurts enough to make you stop, that deserves evaluation. The same goes for avoiding sex because you’re afraid it may hurt.
Lastly, we have orgasmic disorders. The most common type of orgasm-related problem is anorgasmia, or “absence of orgasm.” It’s estimated that approximately 10-15% of women in the USA have never had an orgasm, and that around 50% of women will have problems with orgasms at some time in their lives. The physiologic reason that we orgasm with sexual activity is to allow the egress of blood from our genitalia, preventing the persistent arousal you may have heard about on commercials (“if you have an erection lasting for more than four hours…”). That said, an orgasm is a very complicated dance between neurohormones and our autonomic nervous system, and requires sudden shifts in many uncontrollable bodily functions to happen. As you may imagine, there’s a lot that can go wrong!
To treat orgasmic disorders, we often look to those interplays, and address possible irregular or erroneous signals between the brain and body. Decreased genital sensation, medication reactions, and a heightened sense of anxiety can all lead to orgasmic issues, as can problems with blood vessels within the pelvis and surrounding structures. Once the reason for the orgasmic issue is discovered, treatment is often directed at restoring normal physiologic response, and can include hormonal therapy, counseling, or the use of prescription medical devices.
Well, that about wraps up the blog this week. Next time we’ll look at “the talk,” and how to discuss sexuality, intercourse, consent, and everything in between with your kiddos and teens. If you’re suffering from sexual issues, there are multiple resources online and in print, one of which is “Thorns & Roses: A self-help memoir for women with sexual dysfunction,” which is written by J. Cole, an Oklahoma native! I have additional resources online at my Facebook page, @DrCoreyBabb, where I do Facebook Live videos, answer questions, and post links to relevant women’s health issues. Remember you are your best advocate, so take charge of your own health!
Dr. Corey Babb is a graduate of the Oklahoma State University College of Osteopathic Medicine, and completed his postgraduate training in Obstetrics and Gynecology at the University of Oklahoma-Tulsa, as well as Oklahoma State University Medical Center. He is board-certified in Obstetrics and Gynecology, and is a fellow of the American College of Osteopathic Obstetricians and Gynecologists, the International Society for the Study of Women’s Sexual Health, and is a North American Menopause Society Certified Menopause Practitioner. His practice is devoted to the evaluation and treatment of female sexual dysfunction, and he is the only physician in the state of Oklahoma that specializes in women’s sexual health. He is currently an assistant professor of Obstetrics and Gynecology at the Oklahoma State University Center for Health Sciences, and is the director for the Oklahoma State University Center for Women’s Sexual Health.