Some women have trouble with sex at some time in their lives. They often find it hard to talk about their sexual concerns—even with their partner, a trusted friend, or their doctor.

This pamphlet will explain:

The female sexual response pattern Some common sexual problems Ways to cope

For all women, talking about sexual needs and concerns is a process that should never end.

Sexuality

Sexual identity is shaped and reshaped throughout life. A number of key factors affect your sexual development. These include early role models, religious teachings, and early sexual experiences—both good and bad.

A woman's sexual response peaks in her late 30s and early 40s in most cases. A woman can have a full physical and emotional response to sex through her whole life. Many women have an active sex life that gives them pleasure well into their late years.

Most couples follow a pattern when having sex. It starts with hugging and goes to kissing to body caressing to sex. Vaginal sex is the most common sexual activity. Couples also have oral sex—the second most common activity. Many women also enjoy masturbation, fantasizing, and watching their partner undress. How often a woman has sex varies greatly.

Most women are attracted to men. Some women are attracted to other women. The term "lesbian" refers to women who are mainly emotionally and sexually attracted to other women. Some women are sexually attracted to both men and women.

Sexual Problems

A woman's progress through the sexual response cycle varies greatly from one time to another (see box). No one pattern is more "normal" than another. If any of the stages of the cycle does not occur, though, it may cause a sexual problem.

Sexual response depends on a complex interplay—physical and emotional—between two people. Because of this complex process, it's no surprise that problems with sex can happen. Sexual problems can be long-standing, or they can arise quickly. Some sexual problems are common among both women and men.

The Sexual Response Cycle A woman's body follows a regular pattern when she has sex. There are four stages: Desire—The feeling that you want to have sex. Arousal—Physical changes take place. Your vagina and vulva get moist and the muscles of the opening of the vagina relax. The clitoris swells and enlarges. The uterus lifts up, and the vagina gets deeper and wider. Orgasm—The peak of the response. The muscles of the vagina and uterus contract and create a strong feeling of pleasure. The clitoris can feel orgasm, too. Resolution—The vagina, clitoris, and uterus return to their normal state.

Sexual problems can be linked to a physical condition, such as pregnancy or an illness. They also can relate to daily stress, poor communication between partners, unrealistic ideas about sexual performance, or problems with trust and commitment. Conflicts can make it hard to have or enjoy sex. These conflicts can be within a woman herself or between her and her partner.

If problems in a relationship occur often, it's likely that they will lead to a sexual problem. Sometimes the problem is about sex only. The partner may not know what to do to please the woman or the woman does not respond. Talking between partners is the first step toward a healthy sex life.

Lack of Desire

Lack of interest in sex—or lack of desire—is the most common sexual problem in women. With a low level of sexual desire, a woman may have a hard time getting aroused.

A woman who has trouble having an orgasm may begin to think she cannot have one. This can cause her to lose interest in sex. Many women find that the stresses of daily living—such as concerns about work, family, and money—can create a lack of desire.

Women who have been abused or have had bad experiences with sex may find it hard to enjoy sex or to become aroused. Many women and men have a lack of desire at some point in their lives.

Lack of Orgasm

Most women are able to have an orgasm during sexual activity. Some may reach orgasm by masturbation or by having their partner arouse them with their hands or with oral sex.

Some women have a hard time reaching orgasm. This may result from not knowing what to do or how to tell their partners what they want. The woman and her partner may not know that orgasm can only happen with high levels of arousal. Or, the woman may have trouble talking with her partner about the best ways to touch and arouse her.

Problems with reaching orgasm can stem from negative feelings about sex learned in childhood. Women who have suffered a trauma related to sex, such as sexual abuse, may not be able to reach orgasm. Other causes may include:

• Fear of having pleasure or feeling "safe" with someone
• Anger
• Depression
• Use of medications, drugs, or alcohol

Some couples place too much importance on having an orgasm during sex. This focus on performance or technique—and not mutual pleasure—often lessens sexual excitement. The pressure to reach orgasm can create anxiety and distractions. This can cause lack of orgasm.

Most women who do have orgasms don't always do so through sex alone. They need more stimulation to be aroused than sex alone provides. The stimulation may include kissing and caressing, as well as stroking and touching sensitive areas such as the breast and clitoris.

If a woman has no orgasm during sex, it does not mean it was a failure. Sharing love, closeness, warmth, and tenderness are often enough.

Painful Sex

Dyspareunia is a term for pain during or after sex. This may include pain during entry into the vagina, pain during deep thrusting, or pain after sex. The pain can be on the surface or deep, along the middle of the pelvis, or on one or both sides.

Most sexually active women have had pain during sex at some point in their lives. The most common cause is that the vagina is not well lubricated. This can occur because of:

• Medication
• Illness
• Lack of arousal
• Infections
• Cysts or tumors
• Endometriosis

It also may occur because a woman lacks the hormone estrogen.

Vaginismus also can cause pain during sex. This is a spasm of the pubic muscles and lower vagina. It makes entering the vagina painful. In some cases, vaginismus is present the first time a woman has—or tries to have—sex. In some women the pain is related only to sex. For others, the pain is so great that they cannot even have a pelvic exam by a doctor.

Vaginismus can have many medical causes. These include:

• Painful scars in the vaginal opening from injury, childbirth, or surgery
• Irritation from douches, spermicides, or the latex in condoms
• Pelvic infections

This condition also can be caused by a response to a fear of some kind, such as fear of losing control or fear of pregnancy. It also can stem from pain or trauma, such as rape or sexual abuse. In most cases, your doctor can treat this condition with success.

Conditions That Can Affect Your Sexual Function

Some conditions can have a big impact on sexuality. They may be short-term, such as the flu or pregnancy, or may persist over time and require the couple to adjust.

Pregnancy

In most cases, sexual activity doesn't have to change during pregnancy. Sex does not harm the fetus unless certain conditions are present. Your doctor will discuss this with you. In the weeks after the baby's birth, a mixture of fatigue, changing hormone levels, and perhaps an episiotomy that is still healing may prevent couples from having sex. Couples can have sex again when the doctor says it's okay or when the woman feels ready.

Menopause

As women approach menopause, they may lose desire slowly, have a hard time getting aroused, and feel pain during sex. The lack of estrogen that occurs after menopause makes the vagina dry. Vaginal lubricants can help moisten the vagina and make sex more comfortable. Women may wish to take estrogen to help restore the vagina's flexibility and prevent other problems linked to low estrogen levels.

Cancer

Women with cancer often worry about how the disease will affect their sex life. Surgery, radiation, and chemotherapy can be painful and sap the woman's energy. She may struggle with fears of death, disfigurement, or the partner's rejection. The partner may be concerned that she may be injured during sex. Counseling before, during, and after treatment can help the couple deal with these problems.

Chronic Illness

Diseases that persist for a lifetime, such as diabetes, arthritis, or heart disease, can have a major impact on a woman's self-image and her ability to feel sexual. Some medications can affect her desire or make it hard to reach orgasm. A doctor may be able to switch medications or give advice to the woman and her partner.

Male Factor

If a male partner is having sexual problems, pleasure for both partners may be affected. Many men have trouble with impotence—not being able to achieve or keep an erection—at some time in their lives.

Impotence is usually caused by physical or medical factors. It often occurs as a side effect of some medications or alcohol and drug use. Stress, anger, or depression also can lead to impotence. In many cases, impotence comes and goes or can be reversed. Despite the cause, impotence can be a serious problem for couples and should be discussed with their doctors.

A doctor may suggest your partner take medication (for instance, sildenafil). It causes more blood flow to the penis. This allows many men to achieve and maintain an erection. Medication treats the physical problem—it does not increase desire in men. To work, the man must be sexually aroused.

If your partner is prescribed medication, you may want to use a lubricant when you have sex. This is even more true if you have not had sex for a while or are in or near menopause. Also, if your relationship has been nonsexual for a while, you and your partner may want to talk about how you feel before you have sex.

Men should not take medication for impotence if it is not prescribed to them. It is not safe to use with some conditions and medications.

If You Think You Have a Problem

Nearly every couple has a problem with sex at some time in their lives. Some problems go away on their own or can be worked out with patience and a caring and informed partner. Others may take more effort and a change of approach.

If you think you may have a health condition that is stopping you from enjoying sex, see your doctor. Any pain in the pelvic, genital, or vaginal area is a sign that there may be a problem.

If your relationship or sexual problem is new, try an open, honest talk with your partner to relieve worries and clear up conflicts. Women who learn how to better tell their partners about their sexual needs and concerns have a better chance of having a good sex life. There are also many good books with useful tips to help you discuss problems in new ways.

If you suspect a sexual problem stems from feelings you don't understand or can't cope with—like shyness, fear, conflict, or guilt—there are many people with the skills and kindness to help.

Your doctor may be able to help you. Your doctor also can refer you to other experts. Sex counseling for individuals or couples is often short term and works well. The approach used in counseling depends on the problem. You may learn exercises to do at home alone or with your partner. The counselor may teach ways to help you relax, communicate better, and find out what gives you pleasure. You also may explore feelings that affect arousal or orgasm, such as anger or fear.

Your doctor or counselor also may refer you to a support group. Such groups can be helpful because they allow women and couples to talk about their concerns with others who have the same problems. It may help to know you are not alone.

Finally...

Being able to express yourself sexually lasts a lifetime. It should be nurtured—it's a key part of feeling fulfilled. For all women, talking about sexual needs and concerns is a process that should never end. Sexual problems are common. If you are having a problem with sex, know there are many people with the skills and understanding to help.

Glossary

Endometriosis: A condition in which tissue similar to that normally lining the uterus is found outside of the uterus, usually on the ovaries, fallopian tubes, and other pelvic structures.

Episiotomy: A surgical incision made into the perineum (the region between the vagina and the anus) to widen the vaginal opening for delivery.

Estrogen: A female hormone produced in the ovaries that stimulates the growth of the lining of the uterus.

Impotence: The inability in a male to have an erection or to sustain it until ejaculation or intercourse takes place.