Female Anorgasmia

Introduction

Female or Assigned Female at Birth (AFAB) Anorgasmia is a clinical presentation that is most often referred to as “Female Orgasmic Disorder (FOD)”. This condition presents as inability to achieve orgasm or significant sexual pleasure despite significant stimulation and arousal. Formal diagnostic criteria includes inability to achieve orgasm in almost all (75-100%) of sexual encounters, persisting for at least 6 months, which causes significant distress to the patient. This presentation can be described as a primary condition if the patient has experienced the symptoms lifelong or a secondary condition if the symptoms are acquired after a period of relatively normal sexual function. [1]

Definitions

DSM-5 [2]: Female Orgasmic Disorder (FOD)

A) Presence of either of the following symptoms and experienced on almost all or all (approximately 75-100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts):

1. Marked delay in, marked infrequency, or absence of orgasm 2. Markedly reduced intensity of orgasmic sensations B) The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months C) The symptoms in Criterion A cause clinically significant distress in the individual D) The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress (e.g. partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition. - Lifelong or acquired (the disturbance began after a period of relatively normal sexual function) - Generalized or situational (only occurs with certain types of stimulation, situations or partners) - Severity 1) Mild: evidence of mild distress over the symptoms in Criterion A 2) Moderate: evidence of moderate distress over symptoms in Criterion A 3) Severe: evidence of severe or extreme distress over the symptoms in Criterion A

Note: “Many women require clitoral stimulation to reach orgasm, and a relatively small proportion of women report that they always experience orgasm during penile-vagial intercourse. Thus, a woman’s experiencing orgasm through clitoral stimulation but not during intercourse does not meet criteria for a clinical diagnosis of female orgasmic disorder.” ● The most recent version (2022, Version 11) of the International Classification of Diseases and Related Health Problems (ICD), no longer uses “FOD”, instead classifying the condition as Anorgasmia (including psychogenic anorgasmy). [3] - “Anorgasmia is characterized by the absence or marked infrequency of the orgasm experience or markedly diminished intensity of orgasmic sensations. In women, this includes a marked delay in orgasm, which in men would be diagnosed as Male Delayed Ejaculation. The pattern of absence, delay, or diminished frequency or intensity of orgasm occurs despite adequate sexual stimulation, including the desire for sexual activity and orgasm, has occurred episodically or persistently over a period at least several months, and is associated with clinically significant distress.” - The ICD also distinguishes cases of anorgasmia which are lifelong vs. acquired, and generalized vs. situational. - Other research will refer to lifelong as “primary” and acquired as “secondary” [1] - ICD 11 [3]: Female Pelvic Floor Dysfunction “Any condition affecting females, caused by an altered or lack of function of the female pelvic floor. These conditions are characterized by weakened or tightened pelvic floor muscles, or an impairment of the sacroiliac joint, lower back, coccyx, or hip joint.”

● Orgasm [4]: “a variable, transient peak sensation of intense pleasure creating an altered state of consciousness usually with an initiation 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 (sometimes only partially) and myotonia usually with an induction of well-being and contentment.”

Diagnostic Procedures

● Physiological changes that occur during female orgasm include hormonal changes, pelvic floor musculature activity and and changes in brain activations. Although these changes are measurable, they vary widely between individual patients. ● Clinically, the diagnosis of FOD or anorgasmia is based on the patient’s self-report. [2]

Clinically Relevant Anatomy: Pelvic Floor

● A full overview of the pelvic floor musculature (PFM) anatomy can be found here Pelvic Floor Anatomy - Physiopedia ● A frequently referenced study by Graber & Kline-Graber [5] quantified the relationship between the function and strength of pelvic floor musculature (PFM) and ability to orgasm in 1979. - They demonstrated a significant decrease in strength of the pubococcygeus muscle contractions in anorgasmic women, compared with women capable of orgasm. They suggested that the pubococcygeus muscle plays an important part in the pathophysiology of female orgasm.

- Further, they demonstrated a distinction in PFM strength between women able to orgasm through clitoral stimulation but not with sexual intercourse, who had weaker PFM, and the women who were able to orgasm in both scenarios who had the strongest PFM.

● We now know that the pubococcygeus and iliococcygeus muscles of the pelvic floor are responsible for the involuntary rhythmic contractions during female or AFAB orgasm. ● A more recent (2010) study by Lowenstein et al. [6] looked at the strength and duration of these muscle contractions correlated with the orgasm and arousal domains of the Female Sexual Functioning Index in a population of 176 women, 40% of whom were experiencing anorgasmia. - Women with stronger PFM contractions scored significantly higher on both the orgasm and arousal domains compared to the women with weak PFM contractions. There was also a moderate correlation between the duration of the contractions with the orgasmic and arousal domains. ● Better sexual functioning, including orgasm, was again found to be correlated with stronger PFM by Martinez et al. in 2014. [7]

Epidemiology

● Anorgasmia is under-reported as discussions of sexual functioning are often not routinely initiated by health care providers. Only 14-17% of women report that their doctor had brought up the topic of sexual function, and most women report never having spoken to a doctor about sex in their lifetime. [8] [9] ● 11-41% of women world-wide experience orgasmic dysfunction, this number would be much larger if we considered the number of women who are unable to achieve orgasm but do not report being “distressed” about the condition. ● This is the second most common sexual problem in women, following low sexual desire. [4]

Etiology

● The inability to achieve orgasm can be due to one, or multiple of the following: - Pelvic Floor Dysfunction [10] - Genetics - Medical conditions (neurologic disorders, endocrine dysfunction, cardiovascular disease (diminished blood flow), pelvic conditions) [8], Diabetes (neuropathy, vascular insufficiency), multiple sclerosis, fibromyalgia) [4] - Medications - Alcohol and drug use - Other sexual dysfunctions - Mental illness - Life stressors - Communication deficits - Relationship issues

● Orgasmic capacity often varies, with an individual being able to achieve multiple orgasms in one situation, but being unable to orgasm at all in a different situation (partners, alone, positions, environments, mood, etc.) [4]

Risk Factors

● Genetics [8] - Variable clitoral structures - 5-HT2A receptor polymorphisms which can cause women to be more susceptible to SSRI-associated sexual dysfunction - Dopamine (D4) receptor polymorphisms which impacts all phases of the sexual response cycle (desire, excitement, plateau, orgasm, resolution) [10]

● Vulvovaginal atrophy [2] [1] ● Menopause

- highest rates of sexual dysfunction are in the 45-64 year age group - Vaginal atrophy and dyspareunia can occur due to decreased estrogen, which are linked to difficulty with orgasm and often worse after surgical menopause than natural ● Past sexual trauma ● Lack of emotional well-being ● Dissatisfaction with a partner or relationship distress ● Radical Hysterectomy - potential for nerve damage leading to inability to orgasm ● Use of illicit drugs, alcohol, chronic opioid use, or withdrawal from any of these substances

Differential Diagnosis

● Nonsexual Mental Disorders (major depression, anxiety, etc.) ● Substance/Medication-Induced Sexual Dysfunction ● Interpersonal Factors (severe relationship distress, intimate partner violence, etc.) ● Multiple Sclerosis or Spinal Cord Injury (pudendal nerve dysfunction) ● Diabetes ● Hypertension [4] [2]

Physiotherapy Management

● Orgasmic dysfunction is frequently associated with poor pelvic floor positioning, tone and strength. [11] ● Anorgasmia can be the result of either overactive or underactive PFM or restriction in the noncontractile connective tissues. Hypertonic or hypotonic muscles should be digitally evaluated through volitional contraction, relaxation and elongation as these muscles participate in vasocongestion leading to orgasm and the rhythmic contractions of orgasm. [10] - External examination and functional testing for the pelvic girdle and lumbopelvic movements should also be conducted. - In some cases, a full-body scan of musculoskeletal impairment may be necessary as physical patterns occur throughout the entire body during orgasm and any impairment could potentially inhibit or alter orgasm experience.

● Pelvic Health Physiotherapists, taking a holistic whole-body approach, are well-equipped to assess and treat sexual dysfunction. These approaches can include: [12] - Myofascial release in relevant musculature (pelvic, core, back, hips, legs) - Stretching techniques - Breathing and relaxation techniques - Pelvic floor musculature training - Manual therapy modalities - Pelvic and core mobilization and stabilization - Prescription of vaginal dilator exercises or tissue release[10] ● In the case of overactive PFM identified via internal exam, additional holistic treatment approaches can be indicated: [13] - Postural correction - Joint mobilization (hip, spinal, particularly coccygeus and sacral) - Gait modification - Deep friction techniques - Home program of PFM awareness and active relaxation ● Wurn et al. [14] found that site-specific manual soft tissue release was effective for treatment of patients experiencing painful intercourse and/or difficulty or inability to orgasm secondary to symptoms suggestive of abdominopelvic adhesions (fibrous tissue formed in response to tissue injury in the abdominopelvic region due to infection, inflammation, surgery or trauma). - Patients who were experiencing difficulty or inability to orgasm, who had received the recommended 20 hours of cumulative treatment reported significant improvement in all 6 domains of the FSFI (desire, arousal, lubrication, orgasm, satisfaction and pain) with patient-reported orgasms increased 56%. ● A study by Beji et al. [15], although primarily focused on using PFM training to improve symptoms of urinary incontinence, found that the same PFM training was also useful for some of the participants experiencing difficulty or inability to reach orgasm. The treatment program used involved kegel exercises performed with biofeedback as well as kegel exercises done in combination with FES.

● The same improvement in sexual functioning, including ability to orgasm, through PFM training was found by Zahariou et al. in 2008. [16] ● Brækken et al. (2015) [17] conducted a similar study focusing on women with pelvic organ prolapse. The PFM training group participated in daily near maximal PFM contractions for 3 sets, 8-12 repetitions after very thorough instruction and with frequent PT check-ins over the 6 month study duration. - Improvement in sexual function, including orgasm frequency, intensity and ability to achieve orgasm, was reported by 39% of the training group and 5% of the control group. - The participants who reported improvement in sexual functioning were the participants who demonstrated the greatest increase in PFM strength and contraction endurance over the 6 month period.

● A 2021 study by Sartori et al. produced data that supported the theory of “use it or lose it” for PFM in sexual functioning. They found that although the frequency of sexual intercourse and orgasm tended to decrease with age for women, functioning of PFM needed to achieve orgasm was consistently greater in women participating in sexual activity compared with non-sexually active women.[18] Patient Education [1]: - Anatomy and physiology - Variations in sexual response - Forms of stimulation used to reach orgasm - Lubricants - Expectations [8] PLISSIT MODEL: a model of assessment and treatment. [19] - Permission, Limited Information, Specific Suggestions, Intensive Therapy - Permission: includes conversation with the patient regarding normalization of sexual behaviours, (some patients will benefit from “permission” from a professional authority to masturbate or touch themselves during sexual activity, to reduce the distress they feel about doing so [4]) - Limited Information: providing information regarding behaviors that could improve sexual arousal (anatomical and physiological information to restore the patient’s sexual functioning including erogenous zones and the role of the clitoris in orgasm[4]) - Specific Suggestions: can include lubricants, specific positions, and modifications to sexual encounters that may assist in ability to achieve orgasm. (this step may often be better left to specialized therapists[4]) - Intensive Therapy: includes referral to a sex therapist to further evaluate and treat possible sources of the dysfunction, including tools to decrease anxiety

around sex and the use of sensate focus exercises, depending on the needs of the couple.

Pelvic Floor Muscle Function and Strength

● Multiple studies including Volloyhaug et al. (2016) have found strong correlation of measurement of PFM function/strength between digital palpation and methods such as ultrasound measurements or perineometry. [20] ● Modified Oxford Grading System [20] [21] 0: no contraction 1: minor muscle “flicker” 2: weak muscle contraction 3: moderate muscle contraction 4: good muscle contraction 5: strong muscle contraction

Jo Laycock (2001) proposed the use of “The PERFECT Scheme” for pelvic floor muscle assessment [23]

- The PERFECT scheme is meant to inform patient-specific exercise program planning, highlighting areas for improvement or progressive overload with strength, endurance, repetitions and speed. [24] - Reduced endurance of the pelvic floor contraction is mainly a slow-twitch fiber disorder and requires endurance training by increasing the length of contractions and the number of repetitions - Reduced pelvic floor strength is predominantly a fast-twitch fiber disorder and requires strength training with maximum voluntary contractions until the muscle fatigues - The PFM work synergistically with the deep abdominal muscles, deep lumbar musculature, and the diaphragm. Contraction of transverse abdominis co activates the PFM, a pattern which can be utilized for pelvic floor re-education.

Outcome Measures

● The Standardization Committee organized by the International Society for Sexual Medicine recommended the Female Sexual Functioning Index (FSFI) as the best to use, out of the 27 most commonly used questionnaires and screeners for the assessment of female sexual dysfunctions. [4] - Test-retest reliabilities for all six domains (desire, subjective arousal, lubrication, orgasm, satisfaction, and pain) are high (r = 0.79 to 0.86 for individual domains, 0.88 overall, 0.80 for orgasm domain) and have a high degree of internal consistency (all domains > 0.82). [25] - Wolpe et al. (2017) evaluated the gold standard questionnaire when used in visual analogue scale (VAS) and found that the FSFI-VAS also had high test- retest reliability (reproducibility = 0.94), good internal consistency (0.66-0.88) and construct validity (0.73). [26]

Mixed Treatment Approach

● Although there is a variety of evidence for a relationship between a strong pelvic floor and the improved quality and intensity of orgasm, there is little evidence to suggest that anorgasmia will consistently be resolved by increasing PFM strength alone. [10] ● Due to the variety of possible contributing factors causing female or AFAB anorgasmia, it can often require a mix of approaches to remedy the issue. A pelvic health physiotherapist may often want to refer out for psychotherapy, sexual therapy, or to a general practitioner for pharmacologic intervention.

Psychological Treatment Approaches [1] [27]

● Cognitive Behavioural Therapy - to identify and modify factors that contribute to or exacerbate sexual dysfunction - addressing maladaptive thoughts, unreasonable expectations, behaviours that reduce interest or trust in the relationship ● Sex Therapy - Sensate focus techniques - Directed masturbation (exercises focused on self-awareness, exploration and improving comfort with erotic areas of the body) - Use of vibrators in conjunction with cognitive therapeutic support ● Psychotherapy - When the disorder is driven by deeply rooted conflicts with self-image or sexual trauma ● Couples Therapy ● Systematic Desensitization [8]

● McCabe (2001) [28] found that the use of Cognitive Behavioural Therapy in conjunction with sensate focus, systematic desensitization, and directed masturbation reduced anorgasmia in a sample of “sexually dysfunctional women” from 66% to 11%.

Pharmacologic Therapies and Interactions [1] [27]

● At present, there are no medications for specific treatment of anorgasmia,rather medications may be used to treat the root cause of the anorgasmia if it is due to a hormonal deficiency or an underlying health condition. If these causes are suspected, a patient should be referred to their primary health provider for screening. ● There are many approved and off-label pharmaceuticals for treatment of other aspects of sexual dysfunction which often act as comorbidities (sexual interest and arousal disorders) to increase ability for mental and physiological arousal. ● Particularly, sildenafil has shown some promise in improving ability to reach orgasm when it is used to treat comorbid sexual arousal disorders, but these findings have not been replicated for exclusive treatment of anorgasmia. [4] ● Pharmacotherapies used to treat psychological conditions which can contribute to the inability to orgasm, such as benzodiazepines, selective serotonin reuptake inhibitors (SSRIs), and mood stabilizers often contribute further to the physiological inability to achieve orgasm. [1] ● Medications like SSRIs, which allow for increased free serotonin, can interfere with both arousal and orgasm. Serotonin mediates uterine contractions during orgasm, and can inhibit orgasm by stimulating 5-HT2 receptors in women using SSRIs. The excess serotonin can also interfere with arousal by negatively impacting sensation and inhibiting synthesis of nitric oxide, a neurotransmitter that contributes to vasocongestion of clitoral tissue during arousal.[8] ● Patients who are taking SSRIs and experiencing inability to orgasm as a result can speak with their doctor about adding medications such as bupropion or sildenafil to combat the side effects. [19]

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