eMedicine Specialties > Psychiatry > Adult

Anorgasmia, Female

Author: Adrian Preda, MD, Associate Professor of Psychiatry and Human Behavior, University of California Irvine School of Medicine
Contributor Information and Disclosures

Updated: Jan 5, 2009

Definitions and Diagnosis of Anorgasmia

A comprehensive definition of female orgasm, as Meston et al proposed, is as follows:¹

"[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 (sometimes only partially), usually with an induction of well-being and contentment."

Note the terms variable, usually, often, sometimes, and partially in the stated definition. The use of such terms in a statement meant to be precise and specific may indicate that the subject being defined is highly variable and/or that its objective characteristics are poorly agreed upon.

The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) defines female orgasmic disorder (FOD, formerly inhibited female orgasm) as a persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase.²

The type or intensity of stimulation that triggers female orgasm varies widely among women. Therefore, the diagnosis of female orgasmic disorder, according to the DSM-IV-TR, is based on these 3 criteria:

• Criterion A: A clinician must judge that a woman's orgasmic capacity is less than what is reasonable for her age, sexual experience, and the adequacy of sexual stimulation she receives.
• Criterion B: The disturbance must cause marked distress or interpersonal difficulty.
• Criterion C: Another axis I disorder (except another sexual dysfunction) does not account for the orgasmic dysfunction better than female orgasmic disorder does, and the orgasmic dysfunction is not exclusively due to the direct physiologic effects of a substance (eg, drug of abuse, medication) or a general medical condition.

In the DSM-IV-TR, female orgasmic disorder specifiers include the following:

• Lifelong or acquired
• Generalized or situational
• Due to psychological or combined factors

The presence of a normal sexual excitement phase is a prerequisite for female orgasmic disorder. In other words, if the absence of orgasm follows a time of decreased desire for sexual activity, an aversion to genital sexual contact, or a decreased lubrication-swelling response, diagnoses such as hypoactive sexual desire disorder, sexual aversion disorder, or female sexual arousal disorder, respectively, might be more appropriate, even if anorgasmia is the common final outcome.

For related information, see eMedicine's article Anorgasmia, Male.

Anatomic and Physiologic Considerations

Erotic stimulation resulting in female orgasm can originate from a variety of genital and nongenital sites. Although the clitoris and vagina are the most common sites of stimulation that result in an orgasm, stimulation of other body sites (eg, periurethral glans, breast, nipple, or mons) can trigger an orgasm, as can mental imagery, fantasy, or hypnosis.³

Of interest, consciousness does not seem to be an absolute requirement for orgasms to occur, as orgasms in mature women have been reported to occur during sleep.⁴ Polatin and Douglas also described the phenomenon of spontaneous orgasm for which no obvious sexual stimulus could be ascertained.⁵

The question of the underlying neurocircuitry of the orgasmic response has been addressed in animal studies and, most recently, in functional neuroimaging studies including positron emission tomography (PET) and functional MRI (fMRI). Such studies are performed in an attempt to clarify the peripheral/afferent circuitry and the central/brain circuitry of the orgasmic response.

Clinical studies have been conducted to study orgasmic responses in women with complete spinal cord injury at the level of T10 or higher. Such women were able to experience orgasms by means of vaginal-cervical mechanical self-stimulation (CSS). This finding suggests that the vagus nerve, bypassing the spinal cord, might provide the afferent pathway for orgasmic perception.

Additional evidence for this hypothesis comes from PET and fMRI studies, which shows that CSS activates the region of the medulla oblongata to which the vagus nerves project (ie, the nucleus of the solitary tract).^6,7 Brain regions activated during orgasm include the hypothalamus, parts of the limbic system (ie, medial amygdala, hippocampus, cingulate cortex, insular cortex, region of the accumbens-bed nucleus of the stria terminalis-preoptic area), the neocortex (including the parietal and frontal cortices), the basal ganglia (especially the putamen), and the cerebellum, in addition to lower brainstem (central gray matter, mesencephalic reticular formation, and nucleus of the solitary tract).

The fMRI data suggest that different brain regions are activated in sequence. The earliest activation in response to CSS occurs in the medial amygdala, the insula, the basal ganglia, and the cingulate cortex. At the time of orgasm, additionally activated areas are the nucleus accumbens, the paraventricular nucleus of the hypothalamus, and the hippocampus.

Some have suggested that the differences in regional activation during versus before or after orgasm may reflect a relatively direct relationship of some regions (eg, paraventricular area of the hypothalamus, medial amygdala, anterior cingulate region of the limbic cortex, nucleus accumbens) to orgasm.

Although the fMRI findings are interesting, they do not help in differentiating between activation that may occur uniquely at orgasm versus gradually increasing activity that exceeds an arbitrary detection threshold at orgasm.

General limitations of the neuroimaging studies of female orgasm are the small samples and lack of control groups. Future research is necessary to confirm the purported anatomic-physiologic substrate of female orgasm in heterogeneous populations and to facilitate additional state or group comparisons of brain activation during orgasm versus sexual arousal without orgasm or of orgasm associated with different eliciting mechanisms (eg, clitoral/vaginal stimulation vs imagery-based elicitation). To the author's knowledge, no researchers have performed neuroimaging studies of female orgasmic disorder.

History of Anorgasmia

The traditional view that Masters and Johnson promoted is that the male and female sexual response is characterized by a gradual, sequential progression of events starting with sexual interest and culminating with orgasm.^8,9 However, this linear model has proven to be only marginally useful for assessing and treating women’s sexual difficulties. Therefore, more recent theorists accept that female sexual responses of the mind and body may follow more than 1 set pattern.

In terms of sexual motivation, most authorities agree that awareness of sexual desire at the outset of a wanted sexual experience is not required for orgasm to occur, particularly in women. Either sexual or nonsexual erotic stimulation may result in orgasms. Furthermore, despite sexual satisfaction, orgasms may occur in multiples or not at all.

Authors increasingly accept that the traditional view of a simple, gradual progression through the stages of desire, excitement, orgasm, and resolution (as still presented in the DSM-IV-TR) likely oversimplifies and possibly mystifies evaluation of the sexual response. Instead, recent advances suggest that adequate evaluation of the sexual response must account for many variables and possible outcomes, especially in women.¹⁰

Psychosocial Factors

Age, education, social class, religion, personality, and relationship issues have been studied in relationship to female orgasm. To date, no consistent, empirical findings substantiate the hypothesis that psychosocial factors alone can lead to female orgasmic disorder.¹ The DSM-IV-TR reports that no association has been found between specific patterns of personality traits or psychopathology and female orgasmic disorder. Of note, this report should not be interpreted as a lack of effect of psychosocial factors alone.

In light of the DSM-IV-TR diagnostic criteria (see Definitions and Diagnosis), studies of psychosocial contributors to female orgasmic disorder are clearly subject to the inherent difficulty of first defining normal. According to the DSM-IV-TR, a diagnosis of female orgasmic disorder requires that the experience of orgasm must be less than what is reasonably expected given the patient's psychosocial-demographic characteristics (ie, age, sexual experience, and adequacy of the sexual stimulation she receives). In other words, for any discussion of psychosocial contributors to be meaningful, one must first establish the patient's normal range of expectation in the context of her specific psychosocial demographic details.

No substantial evidence links childhood sexual abuse to female orgasmic disorder.

Epidemiology

Investigators from the National Social and Health Life Survey noted that problems related to orgasm are the second most frequently reported sexual problems in women. In this study, 24% of a random sample of 1749 women from the United States, reported having no orgasms for at least several months in the previous year.¹¹ Pooled data suggest a community prevalence of 7–10% for female orgasmic disorder.¹²

Of note, studies of women with female orgasmic disorder tend to reveal that female sexual arousal disorder is also diagnosed in a high percentage. This observation suggests that clinicians often ignore the DSM-IV-TR criterion of an absence of orgasms after a normal sexual excitement phase or that the difference between the diagnoses is only illusory, as they may in fact reflect a common underlying pathophysiologic pathway.

Furthermore, epidemiologic researchers in the field of orgasmic disorders among women must contend with the challenge of investigating outcomes based on subjective patient reports with poor collateral confirmatory evidence. This situation is opposite to that encountered in men, in whom equivalent pathology can easily be objectively quantified and verified by co-informers.

In conclusion, due to the lack of well-controlled studies, the wide variability, and the lack of objective diagnostic markers for female orgasmic disorder, the available epidemiologic evidence is informative at best. Further epidemiologic research is needed to accurately estimate the de facto incidence of orgasmic disorders among women across age groups, races, cultures, relationship status, and countries, among other psychosociodemographic variables.

Anorgasmia Differential Diagnosis

By definition, the diagnosis of female orgasmic disorder requires that another axis I disorder does not account for the orgasmic dysfunction better than female orgasmic disorder and that the dysfunction is not exclusively due to a direct physiologic effect of a substance (eg, drug of abuse, medication) or a general medical condition (DSM-IV-TR criterion C, see Definitions and Diagnosis).

If the aforementioned criterion is not met, female orgasmic disorder is ruled out, and a secondary orgasmic disorder is diagnosed instead. Therefore, the first steps in clarifying the diagnosis and establishing a treatment plan are good medical history taking, comprehensive examination (including neurologic examination), and laboratory testing (including evaluations of testosterone levels and thyroid function).

Both depression and anxiety disorders can result in sexual dysfunction in general and anorgasmia in particular. If these axis I disorders are diagnosed, they should be treated before anorgasmia is diagnosed and targeted for specific treatment.

A number of illicit drugs or prescribed medications may affect sexual functioning indirectly by causing sedation or directly by impairing orgasmic responsiveness. Depending on the dose, alcohol can affect the orgasmic response both directly and indirectly (see Alcohol and Substance Abuse Evaluation.) Antidepressants of the selective serotonin reuptake inhibitor (SSRI) class (including fluoxetine [Prozac], paroxetine [Paxil], and sertraline [Zoloft]) and antihypertensive agents (especially angiotensin-converting enzyme [ACE] inhibitors), among others, are common causes of delayed orgasm, unsatisfying orgasm, or lack of orgasm in both women and men.

Medical conditions that affect the nerve supply to the pelvis, such as multiple sclerosis and diabetic neuropathy, can sometimes result in anorgasmia. The evidence about anorgasmia secondary to spinal cord injury is mixed (see Anatomic and Physiologic Considerations).

Other possible contributors include hormonal disorders (notably hypothyroidism and decreased androgen levels) as well as chronic illnesses that affect general sexual interest and health.

Lifelong or generalized type specifiers should prompt an inquiry about negative attitudes toward sex that might be the result of childhood sexual experiences or unresolved feelings associated with early experiences of sexual abuse or rape.

Acquired or situational type specifiers are appropriate if a woman previously achieved orgasm on a regular basis but is not doing so at present or if the problem is limited to a specific relationship. A lack of emotional closeness may lower sexual desire; if this is the case, couples or family therapy is recommended. In addition, boredom or monotony in sexual activity may contribute to secondary orgasmic dysfunction. Women are frequently embarrassed to share with their partner intimate details or sexual techniques that they require for satisfaction. If this is the issue, individual or couples sex therapy is indicated.

Anorgasmia Psychotherapy

In general, the initial goal of therapy of anorgasmia is for the patient to reach orgasm as desired under any circumstance. Evidence about the effectiveness of psychoanalytically or psychodynamically oriented therapies is inconclusive.

Cognitive-behavioral therapy (CBT) for anorgasmia focuses on promoting changes in attitudes and sexually relevant thoughts. The underlying assumption of CBT-based interventions is that orgasmic ability and satisfaction can be increased by reducing sex-associated anxiety and cognitive distortions. This strategy follows the common belief that (performance) anxiety interferes with sexual functioning and orgasm by misdirecting the subject's focus from the processing of erotic input to performance-related concerns, embarrassment, and/or guilt.

Following this hypothesis, Masters and Johnson's sensate focus therapy is essentially an anxiety-reduction technique.⁸ This treatment is a sequential approach of gradually increased (and focused) body-touching exercises, moving from nonsexual to increasing sexual touching of the patient's and partner's bodies.

Systematic desensitization studies in women have shown decreases in sexual anxiety and occasional increases in the frequency of sexual intercourse and sexual satisfaction. However, they have not demonstrated consistent and substantial improvements in orgasmic ability.

Likewise, Meston et al wrote, "of the few controlled studies that have included sensate focus as a treatment component, none have reported notable increases in orgasmic ability."¹ Based on such findings and contrary to popular belief, these authors suggested that, in most cases, "anxiety does not appear to play a causal role in anorgasmia and anxiety reduction techniques are best suited for anorgasmic women only when sexual anxiety is coexistent."

A review of studies suggested that sex education, training in communication skills, or Kegel exercises may be beneficial adjuncts to therapy. Still, no direct empirical evidence indicates that any of these interventions alone is an effective treatment for primary or secondary anorgasmia.¹

Behavioral exercises involving directed masturbation has been effective for treating anorgasmia in a variety of modalities including bibliotherapy as well as group, individual, or couples therapy. Meston et al reported that masturbation was an empirically valid and effective treatment for women with lifelong, generalized anorgasmia.¹ Directed masturbation may be beneficial for women with acquired anorgasmia who are averse to touching their genitalia.

Anorgasmia Pharmacotherapy

To date, only 2 drugs have been systematically studied for the treatment for female sexual dysfunction: bupropion and sildenafil citrate. Neither has a US Food and Drug Administration (FDA)–approved indication for the treatment of female orgasmic disorder.

Bupropion

Bupropion has emerged as an alternative treatment for female orgasmic disorder, mostly because case reports and case series described antidepressant-induced sexual dysfunction when bupropion was added as adjunctive therapy.

To the author's knowledge, only 1 double-blind, multiple-site, escalating-dose, randomized placebo-controlled trial of bupropion sustained release has been conducted in the setting of idiopathic, acquired, and global hypoactive sexual desire disorder.¹³ After the 4-month trial, investigators observed superior effects with bupropion compared with placebo. Further research with double-blind, randomized, placebo-controlled study designs is indicated to study the direct effectiveness of bupropion in managing female orgasmic disorder.

Sildenafil citrate

Sildenafil citrate is an orally active, potent, and selective inhibitor of cyclic guanosine monophosphate (cGMP) specific phosphodiesterase type 5 (PDE5). This drug is FDA approved for the treatment of male erectile dysfunction.¹⁴ As Claret et al discussed, experimental evidence suggests that the nitric oxide–cGMP pathway may be important in producing clitoral engorgement, pelvic vasocongestion, and vaginal lubrication (to enhance the female sexual arousal response).¹⁵ In pilot studies, sildenafil citrate effectively enhanced genital blood flow, as well as vaginal and clitoral engorgement, in a few female subpopulations.

Caruso et al reported an improvement in sexual performance (subjective arousal and orgasm) after a 4-week double-blind, crossover study of sildenafil citrate 25 and 50 mg versus placebo in 53 premenopausal patients with female sexual arousal disorder.¹⁶ However, 2 parallel-group, 12-week, double-blind, randomized studies in which patients received sildenafil 10–100 mg or placebo showed no benefit of the drug over placebo.¹⁷

The published pharmacologic studies of female orgasmic disorder had a few important limitations that future investigators must carefully consider. Drawbacks have included small samples, lack of placebo control, strong placebo effects over time, differences in designs or durations, mix of patient subpopulations, variations in data-collection instruments, and dissimilarities in clinical endpoints.

In their 2004 review, Meston et al concluded that no pharmacologic agents have been proven to demonstrate long-term benefits on orgasmic function in women with female orgasmic disorder beyond a placebo effect.¹ Because of the limitations stated above, their 3-year-old conclusion still stands.

Course and Prognosis of Anorgasmia

Little is known about the natural course and prognosis of women with untreated female orgasmic disorder. Some cases of the acquired and situational types seem likely to remit spontaneously. Patients with lifelong and generalized types of female orgasmic disorder appear to have a good prognosis with treatment but an uncertain prognosis without treatment.

Patient Education Resources

For excellent patient education resources, visit eMedicine's patient education article Female Sexual Problems.

The following Web sites are also useful:

• Anorgasmia at http://www.mayoclinic.com/health/anorgasmia/DS01051
• Orgasmic Disorders at http://sexuality.about.com/od/orgasms/a/orgasmic_disord.htm

Physical Examination

A general physical examination is always necessary. Careful cardiac, pelvic, and neurologic examinations are recommended to eliminate any contributing medical pathology.¹⁸

Laboratory work up should include blood glucose levels, a chemistry panel (including calcium levels) to rule out any electrolyte abnormalities and a hormonal panel including androgen, estrogen, testosterone, prolactin and thyroid hormones levels. A full blood count and B12 and folate levels need to be checked to rule out a peripheral neuropathy.¹⁸ Most of these tests can be performed in a primary care office. More specialized assessments, which require referral to a specialist, include vaginal PH and local vascular function assessment using photoplesmography and vagina thermal clearance.¹⁹

For primary female orgasmic disorder the mental status examination is most times within normal limits. Mild, anxious, or depressed mood and/or affect are at times seen in patients with female orgasmic disorder. If that is the case the temporal relationship between the mood changes and the sexual problems needs to be clarified as sexual problems can be both a cause or a manifestation of depression and anxiety.

Keywords

orgasm disorder, female orgasm disorder, FOD, female orgasmic disorder, anorgasmia, frigidity, inhibited sexual excitement, inhibited female orgasm, women's sexual problems, female sexual dysfunction, female sexual problems, female sexuality, sexuality, sexual desire, sexual activity, sexual arousal, male anorgasmia, hypoactive sexual desire disorder, sexual aversion disorder, female sexual arousal disorder, vaginal-cervical mechanical self-stimulation, CSS, delayed orgasm, unsatisfying orgasm, lack of orgasm, sexual interest, sexual health, primary anorgasmia, secondary anorgasmia, sexual motivation

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