In short
Women’s sexual problems come in four kinds, and they get lumped together far too often. Each has different causes and different treatments.
| Low desire | 39 per cent report it, distressing in 10 to 14 per cent |
| Low arousal | 26 per cent, distressing in 5 per cent |
| Difficulty with orgasm | 21 per cent, distressing in 5 per cent |
| Pain with sex | 14 to 16 per cent, and around 40 per cent of postmenopausal women with vaginal dryness |
Pain is the one most often treated as a desire problem, and it has its own specific and effective treatment.
Condition Overview
Why does separating them matter?
Because the treatments are entirely different, and because the most treatable of the four, pain, is the one most often relabelled as low desire.
Around 40 per cent of women report a sexual concern worldwide. About 12 per cent, one in eight, have a problem associated with personal distress, which is what defines a sexual dysfunction.
Pain with sex, and why it gets missed
Genitourinary syndrome of menopause is the usual cause after menopause. Falling oestrogen thins the vulval and vaginal tissue, causing dryness, discomfort and fragility, sometimes with small tears and bleeding after sex.
- In one survey of menopausal women, 48 per cent reported vaginal discomfort, most often dryness at 85 per cent and painful sex at 52 per cent
- Bothersome vaginal dryness makes sex uncomfortable in roughly 40 per cent of postmenopausal women
- Women with vaginal discomfort reported loss of libido and avoidance of intimacy, which their male partners confirmed
Other causes of pain are quite different: pelvic floor hypertonus, endometriosis where deep pain is a cardinal symptom, and fibroids.
It also affects women who are low in oestrogen for other reasons, including hypothalamic amenorrhoea and the postpartum period.
What about after childbirth?
Common and usually temporary, but the numbers are higher than most people expect. In a study of over 400 first time mothers, 83 per cent reported sexual problems at three months and 64 per cent at six months.
Mode of birth does not appear to change sexual function. Greater number of children was not associated with more low desire or lower satisfaction.
The conditions that get overlooked entirely
- Urinary incontinence. Sexual dysfunction is reported by 26 to 47 per cent of women with it, and 11 to 45 per cent experience leakage during sex
- Prolapse, which combined with incontinence carries a higher rate than either alone
- Endometriosis and fibroids, both causing deep pain
- Overactive thyroid, which roughly doubled the risk of sexual dysfunction in one meta analysis
- Raised prolactin, associated with lower desire, arousal, lubrication, orgasm and satisfaction
- Cancer treatment, particularly aromatase inhibitors, which cause profound oestrogen deficiency and a high rate of sexual problems
Does anyone ask about this?
Mostly not. Sexual problems in women remain largely unrecognised and untreated, often because clinicians feel they lack the time or knowledge.
Women are usually glad to be asked. It should form part of any comprehensive health visit, in the same way as asking about contraception.
When to See a Doctor
- Sex has become painful, dry or uncomfortable
- Arousal or orgasm has changed, which is a different problem from desire
- You leak urine during sex, or have prolapse symptoms
- Deep pain during sex, which can indicate endometriosis or fibroids
- Sexual problems started after childbirth and have not settled after six months
- Bleeding after sex, or any bleeding after the menopause, which needs assessment
- A new lump, ulcer or skin change on the vulva
- Severe or worsening pelvic pain, which needs investigating on its own terms
How Dr. Felix Assesses This
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1
Which of the four it is
Desire, arousal, orgasm or pain. Many women have more than one, but establishing which came first usually identifies the driver. Pain very often causes the loss of desire rather than following it.
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2
Onset and context
Whether it has been present since sexual activity began or was acquired later, and what else changed at the same time: a birth, a medication, the menopause, a diagnosis, or a change in the relationship.
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3
Examination where pain is involved
Pain is a tissue problem until proven otherwise. Examination identifies vulvovaginal atrophy, pelvic floor hypertonus and other causes that will not respond to anything aimed at desire.
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4
The medical and medication picture
Thyroid and prolactin where indicated, incontinence and prolapse, endometriosis and fibroids, and medication including SSRIs, antipsychotics and benzodiazepines.
Treatment Options
Women’s Sexual Health Consultation
Why is order the main principle? Because improving one problem frequently improves another. Successfully treating sexual pain often improves interest,…
View Treatment
Libido Optimization Program
Why is this page sceptical? Because the market sells hormones for a problem that is usually not hormonal, and because…
View Treatment
Sexual Wellness Program
Who is this for? People with problems affecting more than one aspect of sexual function, couples where both have a…
View Treatment
Why Early Treatment Can Matter
Why is pain the priority?
Because it is the most treatable and because it drags the rest down with it. Untreated, it produces avoidance, and avoidance produces loss of desire that then gets treated as a separate problem.
Where the symptoms are genital only, low dose vaginal oestrogen is used rather than systemic hormone therapy. It works locally and can be continued indefinitely, including after systemic hormone therapy has stopped.
Where systemic hormones are involved
The route matters. Oral oestrogen raises sex hormone binding globulin and lowers free testosterone. Transdermal at normal doses does not.
In recently menopausal women, transdermal oestradiol improved the overall sexual function score against placebo, while oral did not. So transdermal is preferred where sexual concerns are part of the reason for treating.
What about arousal and orgasm?
These are their own diagnoses with their own treatments, and they are frequently medication related. Where problems with arousal or orgasm began after starting an SSRI or after the onset of depression, treating the mood disorder or changing the drug usually improves them.
What about the relationship?
It is the principal determinant of sexual satisfaction, more than hormones in midlife. A partner’s sexual problems, most commonly erectile dysfunction, also affect a woman’s sexual experience directly.
Sexual activity and satisfaction also decline as relationship duration increases, which is a normal pattern rather than a fault.
What is not offered
- Compounded hormone mixtures and saliva hormone testing
- Systemic DHEA, which does not improve sexual function in women without adrenal insufficiency
- Routine testosterone, for the reasons set out on the low libido page
Why Early Treatment Can Matter
Why is pain the priority?
Because it is the most treatable and because it drags the rest down with it. Untreated, it produces avoidance, and avoidance produces loss of desire that then gets treated as a separate problem.
Where the symptoms are genital only, low dose vaginal oestrogen is used rather than systemic hormone therapy. It works locally and can be continued indefinitely, including after systemic hormone therapy has stopped.
Where systemic hormones are involved
The route matters. Oral oestrogen raises sex hormone binding globulin and lowers free testosterone. Transdermal at normal doses does not.
In recently menopausal women, transdermal oestradiol improved the overall sexual function score against placebo, while oral did not. So transdermal is preferred where sexual concerns are part of the reason for treating.
What about arousal and orgasm?
These are their own diagnoses with their own treatments, and they are frequently medication related. Where problems with arousal or orgasm began after starting an SSRI or after the onset of depression, treating the mood disorder or changing the drug usually improves them.
What about the relationship?
It is the principal determinant of sexual satisfaction, more than hormones in midlife. A partner’s sexual problems, most commonly erectile dysfunction, also affect a woman’s sexual experience directly.
Sexual activity and satisfaction also decline as relationship duration increases, which is a normal pattern rather than a fault.
What is not offered
- Compounded hormone mixtures and saliva hormone testing
- Systemic DHEA, which does not improve sexual function in women without adrenal insufficiency
- Routine testosterone, for the reasons set out on the low libido page
Pain treats well
Low dose vaginal oestrogen treats genitourinary syndrome of menopause locally, can be continued indefinitely, and usually restores the desire that the pain removed.
What gets overlooked
Urinary incontinence, prolapse, endometriosis, fibroids, thyroid disease and raised prolactin, all of which affect sexual function and all of which are treatable.
Four problems, not one
Desire, arousal, orgasm and pain have different causes and different treatments. Separating them is what makes the rest work.
Cost & Consultation Investment
The consultation is quoted individually, and any tests are quoted before they are ordered. Examination is part of the appointment where pain is involved, because pain is a tissue problem until proven otherwise. Vaginal oestrogen and other treatments are ordinary prescriptions bought at pharmacy prices. Where onward referral to a gynaecologist, a pelvic floor physiotherapist or a psychosexual therapist is right, that is said plainly.
Frequently Asked Questions
Almost certainly not. Pain is a tissue problem until proven otherwise, and it commonly causes the loss of desire rather than resulting from it. Treating the pain usually restores the desire.
The changes to the vulva, vagina, urethra and bladder caused by low oestrogen after menopause. It causes dryness, burning, irritation, reduced lubrication and pain, plus urinary urgency and recurrent infections.
No, if the symptoms are genital only. Low dose vaginal oestrogen treats it locally and can be continued indefinitely, including after systemic hormone therapy has stopped.
Common, certainly. In one study of over 400 first time mothers, 83 per cent reported sexual problems at three months and 64 per cent at six months. Beyond six months it is worth assessing rather than waiting.
The evidence says mode of birth does not appear to change sexual function, and having more children was not associated with lower desire or satisfaction.
It is connected. Sexual dysfunction is reported by 26 to 47 per cent of women with urinary incontinence, and 11 to 45 per cent leak during sex. Both are treatable and both should be raised.
Directly, yes. A partner's sexual problems influence your own sexual experience, and this has been shown in studies rather than just assumed. It is worth addressing together.
Evidence
Where this information comes from
Every figure on this page is taken from the sources below. All of them are free to read, so you can check them yourself.
This page is general medical information and does not replace a personal consultation. Trial results are averages across large groups, not a prediction for any one person.