Why no "O"?

By special request I have been asked to address orgasm dysfunction in women. Let’s begin by describing it. This definition by an International Collaborative Group gathering in 2004 to discuss orgasm defined it as this; "a variable, transient peak sensation of intense pleasure creating an altered state of consciousness, usually accompanied by involuntary, rhythmic contractions of the pelvic striated circumvaginal musculature, often with concomitant uterine and anal contractions and myotonia that resolves the sexually induced vasocongestion with an induction of well-being and contentment". Now that I have your attention, I suspect you can almost feel it based on this detailed description, eh?

 It is well known that women can be multi-orgasmic. But many are unaware that women can achieve orgasm without genital stimulation through visual or fantasy and more often by breast stimulation. One of my clinic patients could easily reach orgasm with nothing but breast stimulation. The problem was that her husband had not even gotten her pants off before getting her "off" and she would then decide she had no energy for intercourse and was not interested! Not good.

 Orgasm disorders are a close second behind arousal disorders, however hypoactive sexual desire disorder still prevails as the number one complaint. The general feeling is that PRIMARY ANORGASMIA (never had an orgasm) is more an anxiety condition and a supratentorial focus should begin. However, SECONDARY ANORGASMIA is where she has reached orgasm previously and cannot now. The etiology of this is a broad range of things.

 Keep in mind that in your initial assessment you need to address lack of adequate stimulation as this is the number one cause of secondary anorgasmia. Many women (as high as 70-90%) report an inability to reach orgasm with penetration only. Did you know that when we are developing in the womb, the embryo goes through the "indifferent stage" from 4-7 weeks gestation where the genital tubercle becomes the "phallus" in both boys and girls. Once the fetal testes secrete androgens, masculinization begins and the phallus elongates into the penis or growth ceases and it becomes the clitoris. Now why all of this science you ask?? Because it is all about the clitoris for gosh sakes! (If we are trying to keep it simple and basic)

 Ok, so we are clear that clitoral stimulation should always occur. When, you ask? My recommendation is always – FIRST! For several reasons this is beneficial. One of the most common causes of sexual pain is vaginal dryness. This can be due to inadequate arousal, among other things. Women climaxing first will engorge the vulva, lubricate the introitus, expand the vagina and make it a happy place to penetrate. Furthermore, for your male patients that are concerned about firing too soon, they have NO WORRIES, because she has already had at least one orgasm. Everyone is happy. I had this very discussion with a male clinic patient, yesterday, who came in defining himself as a premature ejaculator. He was not! He lasted 4 minutes on average – plenty of time. HOWEVER, he never (in 14 years of marriage) ever made sure his wife climaxed first. So now, when he quickly detumesces after 4 minutes, she has no time to get there. Angry woman….not good.

 Often the women are to blame, here, because when they are not interested in trying to get aroused, they simply give him a "pass" to dive in and go for it while they create the grocery list and choose new wallpaper for the bedroom in their head. By doing this, they plant a message of "sex is no fun for me" in their own brain and a vicious cycle begins. I strongly encourage women to figure out how they get to orgasm the fastest or easiest and make sure this happens nearly every time.

 I posted previously on bringing vibration into a partnered sexual encounter and this is generally a home run for all. She gets her "O", he feels that he has done his job and can enjoy penetration without guilt and she stays focused on the moment rather than the cobwebs on the ceiling. Everyone is happy.

 Chronic illness such as multiple sclerosis, chronic renal failure on dialysis, diabetes, atherosclerosis, smoking and depression are some of the most frequent conditions interfering with orgasm.

 Medications, especially antidepressants (SSRIs), and antipsychotics, are culprits; however SNRI’s may be less negative in these patients. Some are better than others.

 Estrogen deficiency and testosterone deficiency can play a role either directly due to atrophy of the tissue or indirectly due to lack of arousal and desire.

 Although the general thought is that anxiety/mood disorders, shame, guilt, poor body image, past abuse, and poor genital image are the some causes of PRIMARY anorgasmia, some recent studies suggest genetic factors. One study suggests that a single nucleotide polymorphism in glutamatergic receptor genes has been found in those with difficulty achieving orgasm.

 This discussion is too long to post here, but modify the medications as needed by adding buspirone (Buspar) or bupropion (Wellbutrin XL) or even yohimbine (Yocon). I have mentioned milnacipran (Savella) and also Fetzima as my new favorites for this if tolerated.

 Other things to be studied in the future are midodrine, oxytocin and bremelanotide.

 Without saying, behavioral or sex therapy as needed is a mainstay to the approach of this topic. Happy hunting….