Female Orgasmic Disorder

Female orgasmic disorder is marked delay, infrequency or absence of orgasm, or markedly reduced intensity of orgasmic sensation, on all or almost all (75 to 100 percent) occasions of sexual activity for at least 6 months, causing significant distress, and not better explained by a non-sexual mental disorder, relationship distress, substance or medical condition.

About 10 percent of women have never experienced orgasm, and 20 to 30 percent report orgasm difficulty with partnered sex, but only a part experience distress. It may be lifelong or acquired, generalised or situational (for example orgasm by masturbation but not with a partner). About 30 to 50 percent of women do not reach orgasm through intercourse alone and need clitoral stimulation, which is a normal variant.

Contributing factors:

• lack of knowledge of own anatomy or insufficient stimulation
• performance anxiety and spectatoring
• negative beliefs about sex
• cultural or religious restraint
• history of abuse
• relationship problems
• depression and anxiety
• antidepressants (selective serotonin reuptake inhibitors in 30 to 50 percent of users, serotonin noradrenaline reuptake inhibitors, tricyclics)
• antipsychotics
• opioids
• benzodiazepines
• antihypertensives
• hormonal changes (menopause, oestrogen and androgen deficiency, hyperprolactinaemia, thyroid disease)
• neurological conditions (multiple sclerosis, spinal cord injury, diabetic neuropathy, pudendal nerve injury)
• pelvic surgery or radiotherapy
• genital cutting
• pelvic floor weakness or hypertonicity
• alcohol or substance misuse

• Persistently delayed or absent orgasm despite adequate arousal and stimulation; or markedly diminished intensity; some women have normal arousal and desire.
• Frustration, distress, avoidance of sex, sexual dissatisfaction, strain on the relationship, and secondary low desire.
• Associated features depend on cause: vaginal dryness and hot flushes (menopause), mood and sleep problems, medication use, altered genital sensation, urinary incontinence or pelvic organ prolapse.
• Examination is usually normal; assess genital sensation, clitoral hood adhesions or phimosis, vulvar dermatoses, atrophy, pelvic floor tone and strength, and neurological signs (sacral reflexes).

• A sexual history is the basis of diagnosis: primary or secondary, situational or generalised, masturbation orgasm capability, stimulation type and duration, desire and arousal, pain, medications, comorbid illness, past trauma, mood, and relationship issues; assess the partner's sexual function.
• Validated tools: Female Sexual Function Index (orgasm domain), Female Sexual Distress Scale.
• Pelvic examination, genital sensation, and neurological assessment where indicated.
• Laboratory tests if clinically indicated: TSH, prolactin, glucose or HbA1c, oestradiol and FSH, testosterone (with limited interpretive value), and screening for depression and anxiety.
• Medication review is a key step, as drug induced anorgasmia is common.

• Education and normalisation: anatomy of the clitoris and its role in orgasm (most women need direct clitoral stimulation), the variation in orgasmic response, and encouragement of exploration; time and adequate stimulation, and removing performance pressure.
• Directed masturbation programme for lifelong anorgasmia (the first line behavioural treatment, with success rates of 80 to 95 percent for orgasm by self-stimulation): stepwise self-exploration with genital anatomy mapping, tactile exploration, use of a vibrator, erotic material and fantasy, pelvic floor engagement, then transfer to partnered activity (partner guided stimulation, sensate focus, use of a vibrator or other sexual aids during intercourse, positions that permit clitoral contact such as female superior, and the coital alignment technique).
• Cognitive behavioural and sex therapy: treat anxiety, spectatoring, negative beliefs and trauma; mindfulness based therapy improves orgasm; couple therapy for relationship problems; trauma focused therapy when there is a history of abuse.
• Medication adjustment: for antidepressant induced anorgasmia, reduce the dose if feasible, wait 4 to 6 weeks for tolerance, add bupropion 150 mg daily (up to 300 mg), buspirone 15 to 60 mg daily, or sildenafil 50 to 100 mg an hour before intercourse (best evidence in selective serotonin reuptake inhibitor induced dysfunction), or switch to bupropion, mirtazapine, or vortioxetine; time sexual activity before the daily dose; consider a drug holiday for 2 to 3 days at the weekend for short half life drugs.
• Hormonal therapy: vaginal oestrogen (estradiol 10 microgram tablet daily for 2 weeks then twice weekly) for atrophy; testosterone for postmenopausal women with associated low desire (transdermal about 300 micrograms/day with monitoring); treat hyperprolactinaemia (cabergoline 0.25 to 0.5 mg weekly) and hypothyroidism.
• Pelvic floor physiotherapy: strengthening (Kegel exercises, 10 contractions of 10 seconds three times daily) for hypotonia and relaxation techniques for hypertonia; biofeedback.
• Clitoral stimulation devices: vibrators, and the clitoral vacuum device.
• Treat comorbid conditions (diabetes, vascular disease, depression), manage alcohol use, and encourage exercise.
• Prognosis is good for lifelong anorgasmia with directed masturbation, and for acquired disorder when the cause is found; there are no approved drugs specifically for orgasmic disorder.