Sexual Health Q&A: Excerpt from session "Everything you always wanted to know about female sexuality, but were afraid to ask" Rachel Pauls, MD, FACOG Division of Urogynecology and Reconstructive Pelvic Surgery Co-Director, Women’s Center for Specialized Care  Good Samaritan Hospital - Cincinnati, Ohio

1. Although I desire intimacy, I feel that sometimes my vagina is very dry… what options exist for me?

Vaginal dryness also known as vaginal atrophy, is extremely common, affecting 50% or more of women at different times in their life. The most likely cause is changes in the amount of estrogen produced by the body, either due to menopause, breastfeeding or medications. The thinning of the vaginal lining may lead to irritation, dryness, burning or painful intercourse.

Several options exist for this problem. In mild cases, use of a lubricant may help with dryness associated with sexual activity. Vaginal moisturizers, used on a regular basis, may also improve the symptoms associated with atrophy. Frequent sexual activity may increase blood flow and lessen symptoms of dryness.

For more severe cases, use of local estrogen may be suggested by your physician. Estrogen creams, tablets or rings target the vaginal tissues with much lower absorption rates than estrogen taken orally. This local treatment can vastly improve symptoms without many of the side effects associated with hormone replacement therapy.

2. I just don’t feel interested in sex the way I once was. I worry that my partner is getting frustrated with me. Is there anything I can do?

Sexual dysfunction impacts between 40 and 50% of women, and loss of desire is the most common disorder. For many women, this can lead to feelings of guilt and result in relationship strain.

For starters, ensuring adequate physical and emotional health is important. Stress reduction, proper sleep, physical fitness and good body image help improve libido. Communication problems or tension in a relationship would need to be treated as well.

Physiologic changes may lead to low desire. This may be associated with such events such as pregnancy, use of oral contraceptives, menopause, removal of one or both ovaries surgically, or due to medication side effects. In some situations, hormone replacement therapy may be suggested by your physician.

Finally, although some research studies suggest improved libido with use of testosterone, to date there is no FDA-approved testosterone therapy for women and long-term safety is not known. Hopefully in the upcoming years new medications will be available to target this common problem.

3. Although I enjoy being sexual with my partner I have pain with penetration…what could be causing this?

Painful intercourse is the second most common sexual problem for women. This pain can be located at the outside parts of the vagina (the vulva), which might be noticed early in penetration, or further in the vagina, which might only be noticed with deeper activity.

Some causes associated with vulvar pain include loss of estrogen or vaginal atrophy, certain infections such as yeast or herpes, and inflammation of the glands at the opening- a condition commonly known as vulvar vestibilitis. Causes of deeper pain include endometriosis, pelvic infections, ovarian cysts, uterine fibroids or pelvic muscle spasm.

Because of the many possible conditions associated with pain, a thorough discussion and physical exam by your physician is essential to help discover the cause. A treatment plan would follow based on the underlying problem.

Painful intercourse is not normal, and if untreated, can worsen or lead to other associated relationship and sexual problems. It is important to let your physician know if you are experiencing such symptoms.

4. My doctor recommends a hysterectomy for my heavy periods. Can this affect sexual function?

Hysterectomy is defined as the surgical removal of the uterus, also known as the womb. Removal of the ovaries may be done at the same time, depending on your age and medical history.

Hysterectomy continues to be ranked as one of the most common surgical procedures among women. There are numerous indications for performing a hysterectomy and in most cases a hysterectomy means improvement in quality of life for affected women. Although most studies have suggested that hysterectomy improves sexual function, there may be some situations in which there is a negative impact. Discussing your sexual function with your doctor prior to any hysterectomy is suggested to help get a clear picture of this. Additionally, if removal of the ovaries is undertaken before natural menopause it could lead to symptoms of hormone deficiency which may require treatment.

5. I am getting near menopause and am worried that my sex life will change…will it, and how can I prevent it from changing?

For many couples, menopause may result in sexual freedom. Often this is a time in couples’ lives when their personal schedules are more flexible, either due to retirement, or empty-nesting; the lack of need for contraception may improve spontaneity. However, in other cases the hormonal changes associated with menopause may result in vaginal dryness, diminished desire and change in ability to achieve orgasm. Additionally, male sexual dysfunction is more common, and may lead to problems with intimacy.

Communicate any changes to your partner and your physician. Keep an open mind about sexual activity. For women, increased stimulation may be required due to reduced sensation of the vulva and vagina; occasionally the use of bedroom toys or lubricants may be suggested to help with this. In other cases, hormones either vaginally, or via a patch/pill/topical cream or gel may be prescribed to reduce the negative impact of menopause.

Having a healthy sexual life at any age requires commitment, communication and creativity. With appropriate attention, sexuality can continue to be satisfying throughout the course of your life.