FEMALE

ORGASMIC
DISORDERS

WHAT IS IT?
Female orgasmic disorder (FOD) involves difficulty in

achieving orgasm, substantially decreased intensity of

orgasm, or both.

Female orgasm is defined as 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 wellbeing and contentment.

Particular attention should be paid to the terms variable,

usually, often, sometimes, and partially in this definition.

The use of such terms in a statement presumably meant to
be precise and specific may indicate that the subject being
defined is in fact highly variable, that there is little agreement
on its objective characteristics, or both.

INTERNATIONAL STATISTICS
The Global Study of Sexual Attitudes and Behaviors (GSSAB) found that for women

aged 40-80 years, decreased libido and inability to achieve orgasm were the most
common types of sexual dysfunction across world regions, with reported frequencies
of 26-43% and 18-41%, respectively.[16]

SIGNS AND SYMTHOMS

The medical history should address the following
Chronic and acute medical conditions, including psychiatric conditions
Current and, when relevant, past medications, over-the-counter drugs, and

supplements

Any patterns of substance abuse

Sexual complaints

EXAMINATIONS
General examination
Cardiac, pelvic, and neurologic examinations to eliminate any coexisting medical

conditions that might be contributing to the orgasmic dysfunction

Mental status examination (usually normal in primary FOD; mild, anxious, or

depressed mood or affect should be investigated)

DOCTOR- PATIENT
CONSULTATION

PATHOPHYSIOLOGY
The female sexual response is mediated primarily via spinal cord reflexes under the tonic descending inhibitory control of the brainstem. Afferent signals from clitoral

stimulation are transmitted via the pudendal nerve. Signals from vaginal stimulation are transmitted via the pelvic nerve alongside the pudendal and hypogastric nerves.

The nucleus paragigantocellaris in the ventral medulla, which has direct projections to the pelvic efferent neurons and interneurons in the lumbosacral spinal cord,

appears to be an important regulatory site mediating orgasm. Sympathetic nervous system (SNS) activation facilitates the female sexual response.

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.

Estrogens and androgens have been implicated in the regulation of libido and sexual responsiveness. The role of testosterone in sexual dysfunction in women is not well

established; decreased estradiol levels have been associated with decreased sexual interest and arousal.

It is noteworthy that consciousness seems not to be an absolute requirement for orgasms to occur; orgasms in mature women have been reported to occur during

sleep.therefore t spontaneous orgasm for which no obvious sexual stimulus could be ascertained.

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.

PET and fMRI studies show that CSS activates the region of the medulla oblongata to which the vagus nerves project (ie, the nucleus of the solitary tract)

Brain regions activated during orgasm include the following:

1. Hypothalamus
2. Parts of the limbic system (medial amygdala, hippocampus, cingulate cortex, insular cortex, nucleus accumbensbed nucleus of the stria terminalispreoptic area)
3. Neocortex (including the parietal and frontal cortices)
4. Basal ganglia (especially the putamen)
5. Cerebellum
6. Lower brainstem (central gray matter, mesencephalic reticular formation, and the nucleus of the solitary tract)

PATHOPHYSIOLOGY
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, the nucleus accumbens, the paraventricular nucleus of the hypothalamus, and the
hippocampus are also activated.

Some have suggested that the differences in the timing of regional activation (during as opposed to before

or after orgasm) may reflect a relatively direct relation between some regions (eg, paraventricular area of the
hypothalamus, medial amygdala, anterior cingulate region of the limbic cortex, and nucleus accumbens) and
orgasm.

Although the fMRI findings are interesting, they do not help in differentiating between activation that may

occur uniquely at orgasm and gradually increasing activity that exceeds an arbitrary detection threshold at
orgasm.

In general, neuroimaging studies of female orgasm are limited by the small samples and the lack of control

groups. Additional research is necessary to confirm the purported anatomic-physiologic substrate of female
orgasm in heterogeneous populations and to facilitate additional state or group comparisons between brain
activation during orgasm and sexual arousal without orgasm, as well as to assess orgasm associated with
different eliciting mechanisms (eg, clitoral/vaginal stimulation vs imagery-based elicitation)

TYPE OF ORGASMIC
DYSFUNCTION
There are four types:
1.

Primary anorgasmia is a condition in which youve never had an orgasm.

2.

Secondary anorgasmia is a condition in which you have difficulty

reaching orgasm, even though youve had one before.

3.

Situational anorgasmia is the most common type of orgasmic

dysfunction. It occurs when you can only orgasm during specific
situations, such as during oral sex or masturbation.

4.

General anorgasmia is a condition in which you cant achieve orgasm

under any circumstances, even when youre highly aroused and sexual
stimulation is sufficient.

DIAGNOSING FOD
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), classifies FOD as belonging to a group of sexual

dysfunction disorders that are typically characterized by a clinically significant inability to respond sexually or to experience sexual pleasure. [1]

Sexual functioning involves a complex interaction among biologic, sociocultural, and psychological factors, and the complexity of this

interaction makes it difficult to ascertain the clinical etiology of sexual dysfunction. Before any diagnosis of sexual dysfunction is made,
problems that are explained by a nonsexual mental disorder or other stressors must first be addressed. Thus, in addition to the criteria for
FOD, the following must be considered:

Partner factors (eg, partner sexual problems or health issues)

Relationship factors (eg, communication problems, differing levels of desire for sexual activity, or partner violence)
Individual vulnerability factors (eg, history of sexual or emotional abuse, existing psychiatric conditions such as depression, or stressors such

as job loss)

Cultural or religious factors (eg, inhibitions or conflicted attitudes regarding sexuality)

Medical factors (eg, an existing medical condition or the effects of drugs or medications)

The specific DSM-5 criteria for FOD are as follows[1] :

In almost all or all (75-100%) sexual activity, the experience of either (a) markedly delayed, markedly infrequent, or absent orgasms or (b)

markedly less intense orgasms

The symptoms above have persisted for approximately 6 months

The symptoms above cause significant distress to the individual
The dysfunction cannot be better explained by nonsexual mental disorder, a medical condition, the effects of a drug or medication, or severe

relationship distress or other significant stressors

DIAGNOSIS
Diagnosis
By definition, the diagnosis of FOD requires that the following criteria be met:
Another disorder does not account for the orgasmic dysfunction better than FOD does
The dysfunction is not exclusively due to a direct physiologic effect of a substance (eg, a drug of abuse or medication) or a general medical

condition

Lab Work up:

Complete blood count (CBC)
Chemistry panel
Hormone panel
Vitamin B-12 and folate levels
An informative hormone panel should include the following:
Thyroid test (thyroid-stimulating hormone [TSH] and free T4)
Estradiol
Follicle-stimulating hormone (FSH) and luteinizing hormone (LH
Prolactin
Testosterone (total and free) only in monitoring testosterone therapy

DIAGNOSING FOD
The severity of female orgasmic disorder is specified as mild, moderate, or severe on

the basis of the level of distress the patient exhibits over the symptoms. The duration
of the dysfunction is specified as follows:

Lifelong (present since first sexual experience)

Acquired (developing after a period of relative normal sexual functioning)
In addition, the context in which the dysfunction occurs is specified as follows:
Generalized (not limited to certain types of stimulation, situations, or partners)
Situational (limited to specific types of stimulation, situations, or partners)

FACTORS CONTRIBUTING TO
FOD
A history of sexual abuse or rape
Boredom in sexual activity
Certain prescription drugs, including common drugs used to treat depression, such as fluoxetine

(Prozac), paroxetine (Paxil), and sertraline (Zoloft)

Hormonal disorders, hormone changes due to menopause, and chronic illnesses that affect health and

sexual interest
Fatigue and stress
Negative attitudes toward sex (often learned in childhood or adolescence)
Shyness or embarrassment about asking for the type of stimulation that works best
Medical conditions that cause chronic pelvic pain, such as endometriosis
Medical conditions that affect the nerve supply to the pelvis, such as multiple sclerosis, diabetic

neuropathy, and spinal cord injury

PROGNOSIS OF FOD
Little is known about the natural course of FOD or about the prognosis for women with

untreated FOD. Some cases of the acquired and situational types seem likely to
resolve spontaneously. Patients with lifelong and generalized types of FOD appear to
have a good prognosis with treatment but an uncertain prognosis without treatment.

MANAGEMENT
In general, the initial goal of therapy for FOD is to enable the patient to reach orgasm as desired

under any circumstance.

Psychotherapeutic interventions include the following:

1.

Cognitive-behavioral therapy

2.

Sensate focus therapy

3.

Adjunctive approaches (eg, sex education, training in communication skills, and Kegel
exercises)

4.

Directed masturbation

5.

Eros Clitoral Therapy Device

6.

Couples or family therapy

7.

Individual or couples sex therapy

PHARMACEUTICAL
INTERVENTIONS FOR
SECONDARY ANORGASMIA
As a rule, pharmacologic interventions for secondary anorgasmia should consider the

underlying medical etiology, as follows:

1.

Antidepressant-induced anorgasmia Reduce the antidepressant dose, or switch

to a different medication; alternatively, give bupropion

2.

Anorgasmia related to substance abuse Identify and treat the underlying abuse

3.

Anorgasmia in postmenopausal women with decreased sexual desire Consider

testosterone plus estrogen or tibolone

4At present, no medication has been specifically approved by the FDA. Agents that
have been used, with mixed results, include the following:
5. Bupropion
6.Phosphodiesterase type 5 inhibitors (eg, sildenafil, tadalafil, and vardenafil)
7. Apomorphine

REFERENCES
1.

http://emedicine.medscape.com/article/2185837-overview