Women’s Health

Sexual Health Concerns

Low Sex Drive

Hypoactive Sexual Desire Disorder (HSDD) is an absence of sexual fantasies and desire for sexual activity. This must cause distress or interpersonal difficulty and cannot be accounted for by another major mental disorder and is not due solely to the effects of a substance or general medical condition.

  • 33% of women are affected by low sexual desire.
  • There are many other medical conditions and medications that can contribute to low libido, decreased arousal and decreased vaginal lubrication.

Causes of low sex drive:

  • Medications
  • Menopause
  • Surgery
  • Pregnancy / lactation
  • Chronic medical problems
  • Prior history of sexual abuse or trauma

Low Desire Treatment Options:

  • Relationship issues, stress, body image issues – sometimes evaluating these issues and discussing them with your partner or a sex therapist can improve sexual desire.
  • Eliminating certain medications or treating underlying medical problems.
  • Hormone replacement therapy – sex hormones like testosterone can increase your libido and it’s not just for men anymore.
  • Addyi – new FDA approved for low libido for women.

Sexual Pain (Dyspareunia)

Dyspareunia is the medical term for pain during intercourse. This can occur in men and women but more common in women. Prior studies show that up to 45% of women have experienced painful intercourse. Pain can be associated with the vagina, clitoris and/or labia.

Causes of Dyspareunia

  • Surgery
  • Response to birth control
  • Lack of appropriate lubrication
  • Infections or dermatoses
  • Tight pelvic floor muscles
  • Infections

Treatment of Dyspareunia

  • Lubricants, vaginal moisturizers, vaginal dilators
  • Vaginal Estrogen – lack of the sex hormone, estrogen, can decrease the moisture and elasticity of the vagina.
  • Oral Medications – non hormonal.

Hormone Replacement Therapy

The tissues in the vagina are fed by the sex hormones.  You can think of your vagina like a sponge. When you are young and making hormones at the appropriate level the vagina is like a wet sponge. When the hormones are lacking then the vagina is like a sponge that has been sitting on the counter for a month without moisture.

Pelvic Floor Physical Therapy

Vaginismus or painful contraction of the vagina in response to contact or pressure, especially during intercourse.  This can happen as a natural response to try and protect your body from pain. Can be related to a traumatic experience or any painful intercourse.

Vaginal Dryness

There are any number of reasons for decreased vaginal lubrication.

Leading causes of Vaginal Dryness

  • Menopause
  • Hundreds of Medications
  • Diabetes
  • Autoimmune Disorders

Common Medications that cause Vaginal Dryness

  • Antidepressants
  • Antacid
  • Anticholinergic
  • Anticonvulsants
  • Blood pressure medication
  • Anti-inflammatories
  • Antihistamines
  • Anti-anxiety
  • Decongestants
  • Diuretics
  • Muscle Relaxants
  • Narcotic Analgesic
  • Many more. . .

Treatment of Vaginal Dryness

  • Non Hormonal Topical treatments – lubricants, moisturizers
  • Hormonal Local Topical Treatments – topical estrogen cream, compounded estrogen/testosterone creams
  • Systemic Hormone Replacement – estrogen patches or gels, testosterone creams or pellets and progesterone pills, creams or oils
  • Elimination of medications that may cause the dryness

Vaginismus

Vaginismus is an involuntary spasm of the vagina with penetration. The uncontrolled spasm can occur with intercourse or even with a tampon and is related to a tightening of the vagina and pelvic floor muscles. It is a common problem and often not discussed with medical providers. Primary vaginismus is when the painful penetration has been ongoing over the patient’s lifetime.  Secondary vaginismus is when a patient previously had pain-free penetration and is now experiencing pain with penetration and usually not associated with fear or anxiety.

Symptoms of Vaginismus

  • Difficult penetration or inability to have intercourse
  • Anxiety or fear regarding vaginal penetration
  • Inability or avoidance of gynecological exams or insertion of tampons
  • Avoidance of intercourse secondary to pain

Causes of Vaginismus

  • Gynecological Trauma
  • Childbirth or surgery
  • Strict sexual upbringing
  • Exposure to Sexually transmitted infection
  • Relationship struggles
  • Fear of sex

Vulvadynia

Vulvadynia is chronic pain associated with the external female genitalia known as the vulva.  It is typically pain that lasts more than 3 months and is not related to infection or other medical disorder. It is usually spontaneous and nonprovoked. It can be pain throughout the entire vulva or point specific pain.  The pain can be burning, stinging throbbing, irritation or even swelling.

Causes of Vulvadynia

  • Nerve damage to the vulva
  • Pelvic floor muscle dysfunction
  • Sensitivity to certain foods
  • Reaction to an infection
  • Genetic disorders

Treatment of Vulvadynia

  • Local anesthetics
  • Topical hormone creams
  • Physical therapy
  • Anti-depressants
  • Trigger point therapy
  • Cognitive Behavioral Therapy

Vestibulodynia

Vestibulodynia is chronic pain in the vestibule area of the vagina that is usually provoked either by insertion of a tampon or intercourse.  The vestibule area is where the external genitalia meets the vagina and includes the Bartholin’s glands and the urethra. The pain experienced with vestiulodynia is very individualized and can vary significantly. One person may be able to tolerate penetration for intercourse and another may not be able to even tolerate a tampon. Either way the pain is real and physical despite sometimes a normal physical exam.

Treatment of Vestibulodynia

  • Topical Anesthetics
  • Vaginal Dilators
  • Pelvic floor Physical Therapy

Orgasm

Orgasm is defined as the peak of sexual activity where the greatest pleasure and excitement is received usually through stimulation of the sexual organ and resulting in ejaculation in males and vaginal contractions in females.  The ability to orgasm and a women’s sexual satisfaction are directly correlated.

Only 30% of women can achieve orgasm through intercourse alone.  You are not alone if having an orgasm is difficult for you.  The clitoris must be properly stimulated during intercourse in order to achieve an orgasm.  Sexual position has a lot to do with proper clitoral stimulation. Therefore, if you are not having an orgasm in one position, then change it up.  Some women may experience more pleasure with stimulation of other genital areas other than the clitoris.

Every woman is different and if you are not having an orgasm every time you have sex it doesn’t mean there is anything wrong with you.  Manual stimulation can be performed by you, your partner or a device (vibrator) and before, during or after intercourse to improve your chances of orgasm. No one knows your body better than you including knowing when sex is satisfying and when it’s not.

Menopause can play a role in your ability to orgasm as well.  Hormones allow the vagina to be moist and supple and help with lubrication. Unfortunately, menopause causes a loss of hormonal supply to the vagina and thus increased difficulty achieving orgasm. Bioidentical hormone replacement can help with this.

Arousal

There is no one clear reason for decrease in sexual arousal.  It can be combined with low drive or even sexual pain.  As aging happens blood flow slows down. In men, they have difficulty achieving an erection. In women, the ability to lubricate and become wet becomes more difficult.  Therefore medications that increase blood flow like Viagra or Cialis can help women as well as men to increase their arousal.

Life can be busy and a busy schedule can absolutely play a role in decreased arousal.  Women can find it difficult to turn off their minds during intercourse so instead of focusing on arousal we end up thinking about laundry or other responsibilities that need our attention.

I have had patients tell me that they just don’t know what all the fuss is about when it comes to sex.  They get into bed with their partner and nothing seems to happen.  Overtime, this can take its toll on sexuality and possible sexual avoidance which can result in relationship problems with your partner.  Arousal can be a combination of several physiological changes in the body. These include but are not limited to: vaginal lubrication, nipple erections, vulvar swelling or a tingling sensation in the vagina.  There are treatment options for every one of these situations.

Treatment for Arousal or Difficulty Achieving Orgasm:

  • Topical treatments – warming agents, lubricants, moisturizers
  • Vibrators
  • Medications / Hormone replacement
  • Sex Therapy/ Counseling

Menopause

The change has happened.  You feel irritable and can’t seem to focus.  One minute you are freezing cold and the next you can get your clothes off fast enough you are so hot.  The night sweats soak your sheets. You can’t quite fit into your pants because your belly fat has gotten out of control and you don’t have the energy to exercise. Sound about right?

As women age, we lose our sex hormones starting in our 30’s and by 51 give or take a few years they have been depleted.  If you have had a hysterectomy and removal of ovaries you may have been depleted of your hormones earlier. Estrogen, testosterone and progesterone are all sex hormones that play a vital role in a women’s body.

Estrogen

Estrogen is likely the best known “women’s” hormone. Estrogen has many roles but is primarily responsible for the growth of the female reproductive system and sexual characteristics.  Women produce estrogen in their ovaries, adrenal glands and in fat and it is then distributed to the body via the blood stream. When we start to lose estrogen whether it is from menopause or menopause induced by a hysterectomy many changes take place and estrogen replacement also known as hormone replacement therapy (HRT) is very important.  The goal of treatment with estrogen should be the lowest dose for the shortest period of time.

Is estrogen dangerous or bad for me?

In 2002 the Women’s Health Initiative (WHI) did a study on long term estrogen and progestin.  The findings showed that the health risks of HRT outweighed the benefits and there were increased risk of breast cancer and heart disease.  This study researched oral conjugated equine estrogen (Premarin) and only medroxyprogesterone acetate (Prempro) as the hormone replacement and these medications did show an increase in breast cancer, coronary heart disease, stroke and pulmonary embolism.  This study did not take into effect the bioidentical hormones that are now available and found to be much safer than the equine estrogen that was used.

Fast forward to 2017 and the North American Menopause Society (www.menopause.org) has reviewed data put out a position statement indicating the safety of HRT.

Position Statement

The 2017 hormone therapy position state of The North American Menopause Society.

(Menopause: The Journal of The North American Menopause Society Vol. 24, No 7, pp 728-753)

Hormone Therapy (HT) remains the most effective treatment for vasomotor symptoms (VMS) and the genitourinary syndrome of menopause (FSM and has been shown to prevent bone loss and fracture.  The risks of HT differ depending on type, dose, and duration of use, route of administration, timing of initiation, and whether a progestogen is used.  Treatment should be individualized to identify the most appropriate HT type, dose, formulation, route of administration, and duration of use, using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of the benefits and risks of continuing or discontinuing HT.

For Women aged younger than 60 years or who are within 10 years of menopause onset and have no contraindications, the benefit-risk ratio is most favorable for treatment of bothersome VMS and for those at elevated risk for bone loss or fracture.  For women who initiate HT more than 10 or 20 years from menopause onset or are aged 60 years or older, the benefit-risk ratio appears less favorable because of the greater absolute risks of coronary heart disease, stroke, venous thromboembolism, and dementia. Longer durations of therapy should be for documented indications such as persistent VMS or bone loss, with shared decision making and periodic reevaluation. For bothersome GSM symptoms not relieved with over-the-counter therapies and without indications for use of systemic HT, low-dose vaginal estrogen therapy or other therapies are recommended.

Progesterone

Another sex hormone made by the body in the ovaries, adrenal glands and the placenta during pregnancy.  It is used to thicken the lining of the uterus in preparation to nourish a fertilized egg. Some of the benefits of progesterone includes: promoting bone health and avoiding osteoporosis, protects against endometrial and breast cancer and many other functions.  It is also the precursor for other hormones including estrogen and testosterone.

Testosterone

Another sex hormone made by the body in the ovaries, adrenal glands and the placenta during pregnancy.  It is used to thicken the lining of the uterus in preparation to nourish a fertilized egg. Some of the benefits of progesterone includes: promoting bone health and avoiding osteoporosis, protects against endometrial and breast cancer and many other functions.  It is also the precursor for other hormones including estrogen and testosterone.

Testosterone is not FDA approved for women in the United States.  There have been no large scale studies done for its use in women. However, there are a large number of prescriptions for testosterone written every year to treat women. Testosterone is a predominately male hormone but is also produced naturally in women. Like other sex hormones, testosterone is also produced in the ovaries and adrenal glands and is responsible for sexual desire, energy levels, mood and lean muscle mass.

The side effects of testosterone can be concerning for women however, the side effects rarely occur in women.  The most common side effect will be hair growth and the application site of the testosterone.  Other side effects, though rare, are aggressive behavior, clitoralmegally, hair loss and acne.  The side effects can easily be reversed with dose adjustment of the testosterone.
Testosterone replacement options for women can be in the form of testosterone pellets that are easily placed in the upper outer buttocks or in the form of compounded gels or creams.  

There are a number of over the counter and/or non hormonal treatment options available for patients that may be considered high risk for hormone replacement therapy. If you have a history of breast or uterine cancer, history of heart attack or stroke, have a history of blood clots or other bleeding disorders you are not a candidate for hormone replacement therapy.  Those patients that are suffering from menopausal symptoms, vaginal dryness or sexual discomfort can find other non hormonal treatment options. Make your appointment today to discuss these options.

Addyi

Addyi is the first and only FDA-approved treatment for acquired, generalized hypoactive (low) sexual desire disorder—HSDD— in women who have not gone through menopause. Symptoms of HSDD include low libido and associated distress.

Men have Viagra and Cialis and women have Addyi.  This medication is not given as needed prior to sex but is given nightly to help adjust the neurotransmitters to increase your sexual drive.  Make your appointment to see if Addyi is the right choice for you.

Frequently Asked Questions

I am a woman, why would I need testosterone?

Testosterone is a female hormone just as much as it is a male hormone.  Women produce testosterone at a smaller amount than men in the ovaries, adrenal glands and in the peripheral tissues.  Testosterone is responsible for libido (sexual desire), bone and muscle health. A lowering of testosterone is an age related issue and not specifically related to menopause.

I am not that old, why do I have no desire?

Low desire in young women can be due to a number of causes. Testosterone is a sex hormone that is responsible for sex drive. Testosterone will usually peak in a women’s 20’s- 30’s and start a slow decline from there. Testosterone will likely already be low when menopause starts and may further decline as progesterone declines during menopause. However, testosterone will continue to be produced in the adrenal glands and peripheral tissues after menopause but a smaller percentage.  

Low desire can also be attributed to a variety of other medical problems and/or medications. Oral birth control pills are one of the most common medications associated with low libido due to its role in Sex Hormone Binding Globulin.
Pregnancy and lactation and can also affect sex drive because of the drastic changes in hormone levels not mention the level of fatigue that comes with motherhood.

Can Birth Control Pills really affect me sexually?

Use of oral contraceptives made up of a synthetic ethinyl estradiol can lead to long term sexual side effects. This can include decrease in sexual interest, sexual frequency, and sexual arousal as well as a decrease in vaginal lubrication and an increase in pain with intercourse.

What are bioidentical hormones and why do I need them?

Bio-identical hormones is just a fancy term for the hormones that are naturally made in the human body. Synthetic hormones are those made by pharmaceutical companies altered from the bio-identical hormone so that a patent can be placed on the medication for profit. Bio-identical hormones are man- made but with the same chemical make- up of the human body to replace what your body has stopped making either due to menopause, surgery, medications or other life events.  There are many safe options for replacement of testosterone, estrogen and progesterone, the sex hormones needed for sexual wellness and other important purposes in the body.

I have gone through menopause. I guess sex is just over for me.

If you want to have sex and you want to enjoy it then you should be able to!!
Whatever your concern is we can help you overcome it at WISH.

You may be at risk for experiencing symptoms of sexual dysfunction if you have:

  • Heart disease
  • Use cardiovascular medications
  • Diabetes
  • HTN
  • Smoke
  • Ride bicycles for more than 3 hours/week
  • Peri or post menopausal
  • Low testosterone
  • Have or currently use oral or patch birth control
  • Take Antidepressants
  • Have anxiety
  • Have given birth
  • Had a hysterectomy