Orgasmic dysfunction is when a woman either can't reach orgasm, or has difficulty reaching orgasm when she is sexually excited.

CAUSES, INCIDENCE, AND RISK FACTORS

The condition is called primary orgasmic dysfunction when a woman has never had an orgasm. This is the case in 10 - 15% of women. It is called secondary orgasmic dysfunction when a woman has had at least one orgasm in the past, but is currently uanble to have one. Surveys suggest that 33 - 50% of women are dissatisfied with how often they reach orgasm.

Many factors can contribute to orgasmic dysfunction. They include:

• A history of sexual abuse or rape
• Boredom and monotony in sexual activity
• Certain prescription drugs, including fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft)
• Hormonal disorders and chronic illnesses that affect general health and sexual interest
• Medical conditions that affect the nerve supply to the pelvis (such as multiple sclerosis, diabetic neuropathy, and spinal cord injury)
• Negative attitudes toward sex (usually learned in childhood or adolescence)
• Shyness or embarrassment about asking for whatever type of stimulation works best
• Strife or lack of emotional closeness within the relationship

PREVENTION

A healthy attitude toward sex, and education about sexual stimulation and response will minimize problems.

Couples who clearly communicate their sexual needs and desires, verbally or nonverbally, will experience orgasmic dysfunction less frequently.

It is also important to realize that sexual response is a complex coordination of the mind and the body, and both need to be functioning well for orgasms to happen.

SYMPTOMS

The symptom of orgasmic dysfunction is being unable to reach orgasm, taking longer than you want to reach orgasm, or having only unsatisfying orgasms.

SIGNS AND TESTS

A complete medical history and physical examination needs to be done, but results are almost always normal. If the problem began after starting a medication, this should be discussed with the doctor who prescribed the drug. A qualified specialist in sex therapy may be helpful.

TREATMENT

Treatment can involve education, cognitive behavioral therapy, teaching orgasm by focusing on pleasurable stimulation, and directed masturbation.

Most women require clitoral stimulation to reach an orgasm. Incorporating this into sexual activity may be all that is necessary. If this doesn't solve the problem, then teaching the woman to masturbate may help her understand what she needs to become sexually excited.

A series of couple exercises to practice communication, more effective stimulation, and playfulness can help. If relationship difficulties play a role, treatment may include communication training and relationship enhancement work.

Medical problems, new medications, or untreated depression may need evaluation and treatment in order for orgasmic dysfunction to improve. The role of hormone supplementation in treating orgasmic dysfunction is very controversial and the long-term risks remain unclear.

If other sexual dysfunctions (such as lack of interest and pain during intercourse) are happening at the same time, these need to be addressed as part of the treatment plan.

EXPECTATIONS (PROGNOSIS)

Women tend to have better results with treatment if their orgasmic dysfunction is due to another condition. Women with orgasmic dysfunction that is not due to another condition often do better when treatment involves learning sexual techniques or a method called desensitization, which gradually stops the response that causes lack of orgasms. Desensitization is helpful for women with significant sexual anxiety.

Improved orgasmic function is usually associated with being emotionally healthy and having a loving, affectionate relationship with a partner.

COMPLICATIONS

When sex is not enjoyable, it can become a chore rather than a mutually satisfying, intimate experience. When orgasmic dysfunction continues to happen, sexual desire usually declines, and eventually sex occurs less often. This can create resentment and conflict in the relationship.

Goldwin I. Urologic Management of Women with Sexual Health Concerns. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, PA: Sauders Elsevier; 2007: chap 28.

Katz VL, Lentz GM, Lobo RA, Gershenson DM eds. Comprehensive Gynecology. 5th ed. Philadelphia, PA: Mosby Elsevier; 2007: chap 101.

Kronenberg HM, Melmed S, Polonsky KS, Larsen PR, eds. Williams Textbook of Endocrinology. 11th ed. Philadelphia, PA: Saunders Elsevier; 2008: chap 19.