Seth D. Cohen1 and Irwin Goldstein2
(1)
Advanced Urological Care, New York, NY, USA
(2)
San Diego Sexual Medicine, San Diego, CA, USA
Irwin Goldstein
Email: dr.irwingoldstein@comcast.net
Keywords
DiagnosisManagementFemale orgasmic disorderOrgasm
23.1 Introduction
Orgasm is a sensation of intense pleasure creating an altered consciousness state accompanied by pelvic striated circumvaginal musculature and uterine contractions that induces a state of well-being and contentment [1]. Women’s orgasms can be prompted by erotic stimulation of a variety of genital and nongenital sites. The clitoris and vagina are the most common sites, although stimulation of the periurethral tissues (G-spot), breast/nipple, mental imagery, or fantasy may also induce orgasm [2]. Female orgasms can be achieved with mechanical stimulation of the vagina alone, with direct stimulation of the external clitoris or using a combination of both maneuvers.
To date, no definitive orgasm triggers exist. Initial studies looking to define brain anatomy during orgasm used brain imaging techniques including positron emission tomography (PET) coupled with magnetic resonance imaging (MRI) [3, 4]. Increased activation at orgasm, compared to pre-orgasm arousal, has been observed in the paraventricular nucleus (PVN) of the hypothalamus, periaqueductal gray area of the midbrain, hippocampus, and cerebellum [5].
Orgasm can occur in response to imagery in the absence of physical stimulation. A study to determine whether the subjective report of imagery-induced orgasm is accompanied by physiological and perceptual events that are characteristic of genitally stimulated orgasm included women who claimed that they could experience orgasm using imagery alone [5]. Orgasm from self-induced imagery or genital self-stimulation resulted in significant increases in systolic blood pressure, heart rate, pupil diameter, pain detection threshold, and pain tolerance threshold over resting control conditions [1]. These findings provide evidence that orgasm from self-induced imagery and genital self-stimulation can result in significant sympathetic activation and increases in pain thresholds. Additional studies comparing brain regions activated by orgasm with those activated during sexual arousal without orgasm are needed to determine which brain regions are specifically responsible for triggering orgasm in women.
Some women, however, do not reach orgasm despite having different partners and using different modes of stimulation [6]. These women are the focus of this chapter.
23.2 Female Orgasmic Disorder
Several definitions of female orgasmic disorders (FOD) have been proposed. The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) defines female orgasmic disorder as a persistent or recurrent delay in, or absence of, orgasm following normal sexual excitement that causes marked distress [7]. An international classification committee sponsored by the American Urological Association defined FOD as either a lack of orgasm, markedly diminished intensity of orgasmic sensations, or marked delay of orgasm from any kind of stimulation, despite the self-report of high sexual arousal/excitement [8]. Central for all definitions of female orgasmic disorder, including the recent DSM 5, is a difficulty in achieving orgasm, substantially decreased intensity of orgasm, or both [9]. As for the diagnosis of FOD, one or both of the following should be present 75–100 % of the time: absence, infrequency, or delay of orgasm and/or reduced intensity of said orgasm.
Currently, epidemiologic data on the potential impact of orgasmic disorders on interpersonal relationships and quality of life are relatively scant. Classic descriptions of FOD have observed a prevalence of 22–24 % in the general adult female population and 26–28 % in females 20–40 years old [10]. Molina et al. [11] surveyed a sample of women from Mexico City using an online questionnaire. Women between 18 and 40 years old were selected, and the orgasm domain from the Female Sexual Function Index was used to identify FOD, with a prevalence of 18 % observed. Univariate and multivariate analyses examined the relationship between potential risk factors and sexual function. Univariate analysis identified younger age, lower degree of education, single marital status, and dissatisfaction with the thickness and/or size of partner’s penis as significant variables related to FOD [7]. Fugl-Meyer et al. compared female sexual dysfunction and personal distress, looking more specifically at associations with sociodemographics and level of sexual well-being. The subjects were a nationally representative sample of sexually active Swedish women (n = 1056) 18–65 years old who participated in a combined structured interview/questionnaire investigation. The authors concluded that three factors—sexual desire, orgasm, and genital function—were powerful classifiers of the level of sexual well-being [2].
Findings from the National Social and Health Life Survey suggest that FOD is the second most frequently reported sexual problem in women [12]. In this random sample of women, 24 % reported a lack of orgasm in the past year for at least several months. Although these data are supported by other studies, a precise estimate of the incidence of orgasmic disorder in women is difficult to determine given the lack of well-controlled studies.
23.3 Etiology
While the etiology of FOD remains uncertain, literature has identified multiple risk factors related to FOD including psychological, physiological, sociodemographic, hereditary, and comorbid medical conditions. Vascular disease, chronic diseases, diabetes, multiple sclerosis, spinal cord injury, and pelvic conditions can all exacerbate symptoms of FOD. In addition, medications such as selective serotonin reuptake inhibitors (SSRIs), antipsychotics, mood stabilizers, cardiovascular medications, chemotherapy agents, and antihypertensives can all negatively impact orgasmic potential. SSRIs, most commonly used as antidepressants, are well known to have a negative impact on orgasmic function, with approximately 31–57 % of women taking SSRIs reporting delay or inhibition of orgasm [13, 14].
Multiple psychological conditions can interfere with a woman’s ability to reach orgasm. Such conditions include, but are not limited to, anxiety, depression, attention deficit disorder, body image disorders, sexual abuse, and negative religious views on sex [15]. Because multiple factors can affect orgasmic potential, it is important to assess each patient using a biopsychosocial approach (Fig. 23.1). Lastly, there is some early evidence supporting a genetic influence on the ability to reach orgasm, with an estimated heritability variation of 34 % for difficulty reaching orgasm during sexual intercourse and 45 % for difficulty reaching orgasm with masturbation [17].
Fig. 23.1
Evaluation and treatment of female orgasmic disorder. Modified from Parish SJ. From whence comes HSDD? J Fam Pract. 2009 Jul;58(7 Suppl Hypoactive):S16–21 [16].
23.4 Assessment
An important concept in the assessment and treatment of FOD is the relatively common occurrence of other concurrent sexual dysfunctions [18]. It is estimated that among women with FOD, 31 % also reported difficulties with sexual arousal, 18 % with lubrication, 14 % with desire, 12 % with pain, and 0.9 % with vaginismus [19]. Because of this high level of comorbidity, it is often hard to determine risk factors and treatment regimens tailored specifically to FOD. It also means that most women will present with a complex combination of sexual dysfunctions, requiring a comprehensive assessment that takes into consideration other relevant biopsychosocial factors [15].
It is important to rule out insufficient and/or inadequate stimulation before assigning an FOD diagnosis. For example, case studies and quantitative empirical studies have indicated that women in relationships in which male partners have erectile dysfunction and/or premature ejaculation are likely to experience difficulties with reaching orgasm. The orgasm problem may have started as a lack of adequate stimulation, although a careful assessment is needed to identify whether other maintenance factors have developed with time [17].
Despite the fact that female urologists and urogynecologists are in a unique position to understand the anatomy and physiology of the genitalia and pelvic floor, sexual medicine issues are often highly complex and are generally secondary to interrelated psychological, physiological, and relationship issues intertwined with distinct couple dynamics. Thus, a thorough medical history is vital in the assessment of FOD. In most cases, women with sexual health concerns should consider undergoing concomitant psychological and physical therapy assessment and management by an appropriately trained specialist [20].
23.5 Psychosocial/Sexual Assessment/History
The clinician should screen all patients for obvious psychopathology that can impact the treatment algorithm for FOD (Fig. 23.1). The presence of current or previously treated psychiatric symptoms should be assessed, as these symptoms may be related to the sexual disorder. Having this information will help guide the clinician in defining goals and boundaries for the patient.
23.6 Physical Examination
The physical examination for a woman with orgasmic concerns should be tailored to the individual patient. If a woman with orgasmic problems is under the age of 50 and has sexual pain, a careful physical examination should evaluate for the presence of hormonally mediated vestibulodypnia vs. neuroproliferative vestibulodynia [21, 22]. Similar orgasmic complaints in a woman over 50 years of age should assess for the presence of vaginal atrophy with dryness, loss of rugae, mucosal thinning, pale hue, and lack of shiny vaginal secretions, all indications of a menopausal hormonal status.
Patient consent to examination is particularly important. It is vital that the patient is aware of the purpose of the exam and understands that she has the final authority to terminate the physical examination, to ask questions, to have control over who is in attendance, and to understand the extent of the assessment. Inclusion of the sexual partner, with permission of the patient, is advantageous and provides needed patient support. Allowing the patient to observe any pathology via digital photography is often therapeutic, allowing, for the first time in many cases, an illustration and connection of a detected physical abnormality with the sexual health problem. If a genital sexual pain history exists, the patient should point with her finger to the location/s of the discomfort during the physical examination.
Normal function of the pelvic floor musculature is essential in maintaining appropriate sexual function. Both “low-tone pelvic floor dysfunction” and “high-tone pelvic floor muscle dysfunction” can be closely associated with women’s sexual health concerns [23]. Hypotonus of the pelvic floor muscles, secondary to childbirth, trauma, and/or aging, is related to urinary incontinence during orgasm, vaginal laxity, and/or thrusting dyspareunia secondary to pelvic organ prolapse. Hypertonus of the pelvic floor secondary to childbirth, postural stressors, micro-trauma, infection, adhesions, and surgical trauma can contribute to symptoms of urinary retention, reduced force of stream, dysuria, urgency, penetrative dyspareunia, and/or vaginismus.
23.7 Laboratory Testing
There is no consensus on recommended routine laboratory tests for the evaluation of women with sexual orgasmic health concerns. Blood testing should be dictated by clinical suspicion, particularly based on the results of the history and physical examination. If appropriate, the clinician may assess serum hormone levels including total testosterone, free testosterone, sex hormone-binding globulin (SHBG), dihydrotestosterone (DHT), estradiol, and progesterone. Pituitary function may be measured by obtaining luteinizing hormone (LH), follicle-stimulating hormone (FSH), and prolactin levels. Thyroid stimulating hormone (TSH) should be measured to exclude subclinical thyroid disease [24, 25].
23.8 Diagnosis
The diagnosis of female orgasmic dysfunction should be based on the clinician’s judgment that the woman’s orgasmic capacity is less than would be reasonable for her age, sexual experience, and the adequacy of sexual stimulation she receives [1]. Studies of women diagnosed with FOD note a high percentage, and these women are also diagnosed with concomitant female sexual arousal disorder. Regarding women who can achieve orgasm during masturbation or during intercourse with manual stimulation but not during intercourse alone, the clinical consensus is that those women do not meet criteria for diagnosis of FOD [1].
23.9 Treatment
23.9.1 Cognitive and Behavioral Techniques
In cases where orgasm problems are acquired or manifest themselves only during partnered sex, the partner should be involved in the assessment and treatment or at least included in the communication training related to sexual problems.
The treatment of anorgasmia has been approached from many different perspectives including psychoanalytic, cognitive behavioral, and pharmacological, but substantial research is available only for cognitive behavioral therapies [26]. Cognitive behavioral therapy for anorgasmia focuses on promoting changes in attitudes and sexually relevant thoughts, decreasing anxiety, and increasing orgasmic ability and satisfaction. Behavioral exercises traditionally prescribed to induce these changes include directed masturbation (DM), sensate focus (SF), and systematic desensitization [1]. Sex education, communication skills training, and Kegel exercises are also often included in cognitive behavioral treatment programs for anorgasmia [1].
Among the different cognitive and behavioral techniques, directed masturbation (DM) training is the approach that is strongly recommended with Grade A evidentiary support by the Consensus of the International Society for Sexual Medicine [27]. DM training is a behavioral technique, consisting of 4–16 weekly therapy sessions of graded exposure to genital stimulation. This can include role-playing orgasm response, use of sexual fantasy, and/or vibrators to facilitate heightened arousal and orgasm [17]. It is highly effective based on findings in the literature; of the eight randomized controlled trials that compared DM with no treatment, only one study failed to show efficacy for the active treatment arm [28]. The success rates for DM in women with primary anorgasmia are high: 60–90 % of the women become orgasmic with masturbation and 33–85 % will become orgasmic with a partner-involved sexual activity. Some studies have shown significant results after four sessions of 30 min, while other studies demonstrated that beneficial effects extended up to 2 months after the end of therapy [29, 30].
Anxiety can cause significant disturbance that disrupts the processing of erotic pleasure by causing the woman to focus instead on lack of performance, embarrassment, and/or guilt. As originally described by Masters and Johnson, sensate focus (SF) is an anxiety-reducing technique that involves a stepwise sequence of body touching maneuvers, moving from nonsexual to increasingly sexual touching of a partner’s body [31]. Initial assessments of this approach showed promising results [29], but later studies have not demonstrated sustained, significant benefit at follow-up [30]. However, across all comparison-controlled studies, DM plus SF has proven to be more effective than DM alone [32].
23.9.2 Hormone Supplementation
Although no androgen therapies are currently approved by the Food and Drug Administration (FDA) for FOD, several are used in clinical practice. Androgens play an important role in healthy female sexual function, especially in stimulating sexual interest and in maintaining desire. Androgens are also vital for the health and maintenance of vaginal tissues including the vulva, vestibule, and vagina. A number of studies have shown that different types of androgen treatments can have beneficial effects on FOD. In one study of 300 women who received bilateral salpingo-oophorectomy and hysterectomy, a 300 mg of testosterone patch showed improvements in FOD symptoms [33]. In another study, 10 mg of testosterone gel showed similar positive effects on orgasm improvement in women [34].
23.9.3 Nonhormonal Supplementation
Currently there are no FDA-approved nonhormonal medications for treatment of FOD. However, there are medications used in an off-label fashion that have shown promising results when used in properly selected patients.
23.10 PDE-5 Inhibitors
Among the numerous strategies proposed for managing sexual dysfunction associated with SSRI treatment, phosphodiesterase type 5 inhibitors (PDE5is) have the best data to support broad-based and clinically meaningful treatment efficacy [35]. One randomized controlled study evaluated the efficacy of sildenafil for sexual dysfunction associated with selective and nonselective serotonin reuptake inhibitors in women [36]. The authors were able to show beneficial effects of PDE5is in the setting of adverse side effects of SSRI use on orgasm. Another study with no control groups observed similar positive effects of PDE5is for FOD induced by antidepressants [37]. Further research on the efficacy of PDE5is on orgasmic function is needed to better define the effects on female orgasmic improvement.
Bupropion, which is a noradrenaline and dopamine reuptake inhibitor with nicotinic antagonist properties originally marketed as an antidepressant, may have a beneficial effect on woman with FOD [38, 39]. In a placebo-controlled trial [38], the changes in sexual functioning questionnaire indicated that bupropion had significant effects on increasing measures of sexual arousal, orgasm completion, and sexual satisfaction. Traditional bupropion dosing starts at 150 mg twice a day, although low-dose bupropion at 75 mg twice a day can achieve an optimal improvement in sexual arousal potential as well.
Other dopaminergic medications used in the treatment of orgasmic dysfunction include cabergoline, administered at 0.5 mg up to three times per week, and ropinirole 0.25 mg administered daily, both of which can improve orgasmic potential [35]. Oxytocin lozenges, linked to improved arousal, desire, and orgasm, are administered at 250 IU sublingually 30 min to one hour before sexual activity. Research with oxytocin has shown marked improvement in a number of components of sexual function, including libido and orgasm [40]. Amphetamines such as dextroamphetamine and other drugs used to treat attention deficit disorder have been useful in helping women concentrate and thus improve orgasmic potential and intensity [41]. All these treatments have been trialed on small numbers of patients with no control groups, and larger, more definitive studies are needed to truly define the effects.
23.11 Conclusion
Sexual problems are widespread in society and are influenced by both health-related and psychosocial factors. The role of the latter implies that stress-inducing events, due to either individual or social sources, can affect sexual functioning in both men and women. Due to the high level of comorbidity with other sexual disorders, most women will present with a complex combination of problems, requiring a comprehensive assessment that takes into consideration the known correlates of FOD.
In the assessment and treatment of FOD, a thorough biopsychosocial history should be taken including assessing adequacy, variety, and amount of preferred sexual stimulation, specifically inquiring about known psychosocial, cognitive/affective, and relationship factors found to be related to FOD. The diagnosis of female orgasmic disorder should be based on the clinician’s judgment that the woman’s orgasmic capacity is less than would be reasonable for her age, sexual experience, and the adequacy of sexual stimulation she receives. A medical history including the use of medications known to interfere with orgasmic function is recommended.
The treatment of anorgasmia has been approached from cognitive behavioral therapy and pharmacological perspectives, but substantial empirical outcome research is available only for cognitive behavioral treatment methods. Treatment of FOD should include directed masturbation, which has shown well-established efficacy in several different treatment formats with sensate focus as a useful adjunct. A thorough understanding of the risks and benefits of hormonal and nonhormonal treatments should be discussed with the patient before initiation.
Commentary: Diagnosis and Management of Female Orgasmic Disorder
Annamaria Giraldi3
(3)
Sexological Clinic, Psychiatric Center Copenhagen, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
Progress in sexual medicine has led to an improved understanding of female orgasm, with current work being able to discern areas of the brain activated and suppressed during experience of this phenomenon. Other seminal work has defined some of the factors that facilitate orgasm, yet a complete understanding of female orgasm eludes medical science. Twenty-first century science primarily attempts to deconstruct orgasm into its individual parts and demonstrate its physiologic basis. While crucial to a thorough understanding of orgasm, such a piecemeal approach often misses the holistic perspective that needs to be considered when looking at orgasm as a whole. Similarly, the etiologies of female orgasmic disorder (FOD) are incompletely understood, leading to treatments with incomplete efficacy.
In the preceding chapter, Cohen and Goldstein provide a comprehensive overview of FOD, from epidemiology to a thorough discussion of treatment options, including cognitive behavioral approaches as well as pharmacotherapy. At the end of the chapter, the reader is left with an excellent understanding of what the current state of the art in the approach to FOD provides, which is significant. In the following commentary, a broader perspective on what orgasm is and what it means to women and their male partners is considered, uniting the approach to orgasmic disorders with a perspective on the meaning of orgasm.
The Editors
Commentary
In 1966 Masters and Johnson, in their landmark book Human Sexual Response, described the human female orgasm as a “psychophysiologic experience occurring within, and made meaningful by, a context of psychosocial influence” and as a “drive of biologic-behavioral origin deeply integrated into the condition of human existence” [1]. Orgasm has also been described as “a sensation of intense pleasure accompanied by an alteration in consciousness, contraction of the genitourinary musculature, and in some cases involuntary vocalization” [2].
Humans are one of few species (the others are chimpanzees, bonobos, and dolphins) who have heterosexual activity when the female partner is not in estrus [3], meaning that sexual activity has a recreational purpose in addition to its reproductive purpose. Sex represents an intimate bond with the partner and creates physical pleasure, which for many is an important aspect of sexual satisfaction [4].
It has been claimed that the woman’s orgasm plays a role in facilitating sperm transportation into the uterus. However, this hypothesis is not supported by the literature [5], and there is agreement that orgasm is not essential for fertility or achievement of pregnancy (for a review, see [6]). Focus has also been placed on the pleasure of orgasm, and studies have shown that prolactin and oxytocin peak during orgasm, leading to an overall sense of well-being. It has been speculated that the major effect of prolactin is sexual satiety. However, the capability of women to have multiple orgasms, despite a low postorgasmic prolactin level, contradicts this hypothesis (for a review, see [6]). The role of oxytocin has historically attracted a lot of attention. Oxytocin may be involved in the feeling of well-being, improved social intentions and trust, affiliative behavior, and fear reduction [7, 8], all effects that may facilitate bonding with the sexual partner and a desire for further sexual activity and orgasm. In a study by Behnia et al., intranasal oxytocin resulted in women feeling more relaxed and a subgroup of women expressed better ability to share sexual desire and empathize with their partners compared with the placebo group [9]. Hence, an important function of the female orgasm is related to the dynamic with the partner. In a study by Salisbury et al., men and women were interviewed about their beliefs, experiences, and concerns regarding female orgasm in heterosexual relationships. The women expressed that orgasm was a “bonus,” but for some of them, the most important component of sex was intimacy with their partners, not reaching orgasm every time. However, they also expressed that the female orgasm was important for the male partner’s ego and sense of himself as a competent lover, being “able to give her an orgasm.” Male partners expressed that he would become distressed if the female partner did not reach orgasm, given that male partners worried about their female partners’ pleasure. Furthermore, the men felt that the female partners’ orgasms were extremely sexually satisfying and important for the men’s sexual pleasure and that it was important that the female partners be communicated when they did not reach orgasm [10]. These findings emphasize the dynamic within the couple; orgasm is satisfying for the individual woman but also has a direct positive impact on the male partner’s sexuality and pleasure.
The physical and emotional well-being, as well as dyadic importance related to orgasms, explains why many women with orgasmic disorders express significant distress related to their condition. In a study by Kingsberg et al., 92 % of women with difficulties in reaching orgasm were bothered to some degree by the condition. Sixty-eight percent claimed they were very or extremely bothered, and 46 % described feeling frustrated [11], indicating that even though intimacy is important for women, lack of orgasm is a distressing condition.
The ability to reach orgasm may be influenced by many biopsychosocial factors (for a review, see [12]). Interestingly, studies have indicated that in addition to the effects of hormonal imbalances, medical conditions, and pharmacological treatments (i.e., with psychotropic medications) on women’s orgasmic function, genetic factors influence the ability of women to reach orgasm, both during intercourse and when masturbating [13, 14]. However, social factors are also important. In a large epidemiological study, Fugl-Meyer et al. observed that good orgasmic function was predicted by a relatively early age at first orgasm, a relatively greater repertoire of sexual techniques used, especially oral or manual caress by the partner, being relatively easily sexually aroused, and achievement of orgasm during vaginal intercourse [15]. Other studies have shown that relationship distress is correlated to orgasmic dysfunction, while marital satisfaction [16], happiness, and stability have been found to positively correlate with being able to reach orgasm.
Thus, the observations made 50 years ago by Masters and Johnson that the female orgasm is a “psychophysiologic experience occurring within, and made meaningful by, a context of psychosocial influence” and as a “drive of biologic-behavioral origin deeply integrated into the condition of human existence” [1] still prove to be valid. In the search for sexual health for both men and women, it is important to educate women and their partners about the female orgasm and how a woman’s orgasm is influenced by biology, her relationships, an open-minded attitude toward women’s sexuality, and the importance of sufficient stimulation as a part of pleasurable sex. Women as well as their male partners will benefit from a better understanding of the woman’s orgasm, contributing to a mutual enjoyment of a satisfying sexual life.
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