Heather Sutton Walsh, MD, PhD
Experts and popular culture all agree: better sex and better intimacy lead to overall well being. However, many women do not have a fully satisfying sexual life, and a majority of them do not seek help from their doctors. Many factors contribute to our silence related to sexual health, but chief among these is the idea that we are the only one with our particular problem.
Many factors affect female sensuality. Masters and Johnson created a model of normal sexual function that described a progression from excitement, to plateau, to orgasm, and then resolution. Today, the sexual model proposed by Rosemary Basson is considered more representative of female sexuality. Basson described women’s desire as a response to intimacy and sexual stimulation. Some women do not necessarily have a strong desire to have sex, but once they are stimulated by a loving partner, desire develops.
Medical barriers to sexual well-being most often develop from chronic disease, especially coronary heart disease, diabetes, depression, and cancer, or hormonal issues that may or may not be related to increasing age, and side effects of medications. These conditions can interfere with all aspects of sexual functioning.
Female sexual dysfunction is related to the same risk factors as coronary vascular disease: smoking, high blood pressure, and high cholesterol. Women with hypertension may have decreased vaginal lubrication, decreased orgasm, and increased pain. Some antihypertensive medications can induce sexual dysfunction in otherwise normally functioning patients. Experts theorize that women with diabetes may experience decreased sexual function due to neuropathy, hormone changes, and vascular disease.
Women with diabetes may also have decreased vaginal lubrication, decreased orgasm, and increased pain with intercourse. Sexual problems related to cancer can develop after surgery, chemotherapy, radiation, hormonal manipulation, and medications.
Married women are at higher risk for depression than non-married women. Depressed women are at risk for sexual disorders. Another mental health issue that affects sexual function is chronic and acute stress.
Relationship variables, attitudes towards sex and aging, and cultural background have a greater impact on sexual function than hormones and aging. Indeed, it has been shown that a good relationship protects against sexual decline in menopause. While hormones (estrogen and testosterone) are important in maintaining normal sexual function in women, the extent is still unclear. Aging will naturally lead to a decline in sexual activity, and a decline in hormone levels can lead to a decline in desire, vaginal atrophy, and/or delayed orgasm.
There is controversy regarding the sexual effects of hormonal contraception. Some research reports an increase in desire with oral contraceptive use, while others show little to no change, and still others show decreased desire. Some prescription medications improve sexual function, while others impair it. Common medications that may impair sexual function include antidepressants, antihistamines, antihypertensives, antipsychotics, anti-anxiety meds, cardiovascular agents, and chemotherapy.
Relationship and communication barriers are also frequent sources of female sexual problems. The ability of partners to have conversations about intimate issues such as lubrication, sexual self image, body image, and clitoral stimulation is the foundation of sexual health in committed relationships. Couples need to understand that long-term sexual relationships are complicated and change over time. As individuals change, the couple’s relationship changes, and there may be gender differences in feelings and thoughts about sexuality. To be successful in long term relationships, it is critical for couples to have interactive skills to build sexual communication and sexual technique compatibility, and to learn how to successfully manage health, psychological, and life stage issues.
Female sexuality experts agree there should be a focus on the more positive aspects of sexuality for women. Your doctor should be willing to have open, frank discussions about any sexual concerns you may have. He or she can offer help for sexual problems and also assist those without sexual problems who simply wish to enhance their sexual lives. Since sexual problems usually involve both medical and psychological issues, these problems need careful assessment. Treatment for any underlying disorders is important, as is consideration for referral to a sex therapist. Lubricants can be recommended to reduce sexual discomfort and potentially enhance feelings of sensuality and intimacy. These products may help women overcome medical and psychological barriers to sexual well-being.