If a woman has been orgasmic in the past, but complains about anorgasmia, inquire about changes in medications or over-the-counter (OTC) or herbal remedies.
Further, when a patient reports that sex no longer feels like it used to, she should be carefully assessed for depression. There are several brief questionnaires, e.g., the Beck inventory, that can easily be incorporated into a gynecologist’s office routine to screen for depression.
Relational issues can negatively affect orgasmic function as well. Some women may continue to permit sexual activity even when they feel angry, used, or abused by their partner. Sexual activity may even be forced upon them. Similarly, the social situation can interfere with a woman’s ability to achieve orgasm. Women with small children frequently split their attention between the sexual activity and surveillance of the household for crying babies. This inattention to physical sensations can preclude satisfactory arousal and orgasm.
Finally, some women complain about difficulties achieving orgasm during penile-vaginal intercourse. This situation requires some education of both the patient and her partner. While approximately 25% to 30% of women may at times achieve orgasm with intercourse alone, the vast majority require clitoral stimulation. At times, with sufficient mental and physical stimulation, a woman may experience orgasm without direct stimulation, but that is the exception, not the rule. Women anxious about needing clitoral stimulation in order to climax should be reassured that they are sexually normal and functional.
Pain disorders. Pain disorders include dyspareunia, vaginismus, and a new category called “noncoital sexual pain disorders.”10 Dyspareunia may be secondary to medical conditions such as vestibulitis, vaginal atrophy, or infection, or it may be psychologic in origin. It may even contain both physiologic and psychologic elements. In contrast, vaginismus is a conditioned response to fear or pain. It is a reflex contraction of the levator ani muscles in response to attempted penetration and, except in extremely rare cases, is involuntary and out of the patient’s control. It is a learned response to painful attempts at penetration.
In general, pain disorders are easier to evaluate than disorders of libido and arousal. After all, our training emphasizes careful pelvic examination to isolate areas of concern. Unfortunately, if a physician does not understand normal female sexual responses, he or she may mistake an arousal disorder for “bump dyspareunia”—a sensation deep in the pelvis as though something is being hit.
In women, arousal elongates the vagina by approximately 30% and tents the uterus up and out of the cul-de-sac as the tissues engorge, unless the structures are tethered by adhesions and pelvic pathology. Penetration and deep thrusting before a woman is adequately aroused will commonly cause bump dyspareunia. Even in women with significant adhesions or endometriosis, attention to foreplay to assure arousal prior to intercourse often can alleviate discomfort.
I begin my assessment by asking the patient whether the pain occurs with every sexual encounter or is positional or related to the menstrual cycle. Does the pain occur at initial penetration or is it experienced deep in the pelvis? Pain around the time of menses would lead me to suspect endometriosis or adenomyosis as an etiology, whereas pain with penetration is more likely related to vaginismus or vulvovaginal disorders.
An abdominal exam can help identify tense muscles, a clue to a possible history of abuse. I then direct my attention to the vulva, looking for areas of tenderness at the introitus that suggest vulvar vestibulitis. I also look for atrophic changes or signs of chemical irritation. Many women consider their genitalia “dirty” and scrub the vulva with antibacterial soap several times a day. Pain with penetration can be dramatically reduced by paying attention to perineal hygiene and avoiding irritating chemicals, soaps, and commercial products sold to keep women “fresh.”
I examine the vagina initially without a speculum, paying careful attention to the muscle tone of the levators. Women who have a pelvic floor like a rock, i.e., you find yourself fighting the muscles throughout the exam, have been sexually abused until proven otherwise. Involuntary levator contraction can be a withdrawal response precipitated by early painful penetration attempts. (Physical therapy with biofeedback using external sensors along the pelvic floor is highly successful in creating conscious awareness of the muscle tension and in treating vaginismus.)
As the bimanual examination is completed, I look for fixation of the internal genitalia or tender nodules suspicious for endometriosis.
In evaluating the relational component of pain, I ask about any difficulties, particularly discrepancies in expectations between women and their partners, as these can result in complaints of pain.