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Seeking Medical Assistance
drOnly 20% of women with sexual dysfunction actually seek medical advice for a cure. Help is available and you should not be embarrassed to ask for assistance. If you are not comfortable discussing your sexual issues with your local family doctor, consult a physician skilled in the area of sexual health. Skilled health professionals in this area include women’s health specialists, medical obstetricians and gynecologists, sex therapists, reproductive endocrinologists and specialist nurse practitioners. Often, allied health professionals such as relationship counselors, physiotherapists, massage therapists and pharmacists can be part of a sexual health team.

It is very important for your doctor to be skilled in discussing, understanding and managing problems associated with sexual matters. In terms of obtaining your sexual history, it is vital the practitioner knows his or her limits. If the doctor has little or no training in sexual counseling, a referral to a trained sex counselor or sexual health doctor is recommended.

A doctor should:
1: not be judgmental due to his or her own sexual prejudices or hang-ups
2: ensure the patient understands the issue of doctor-patient confidentiality
3: be sensitive and optimistic when dealing with relationship is- sues
4: encourage consultation with partner present
5: allow extended time for consultations
6: understand problems may not be revealed without specific inquiry
7: understand sensitive and embarrassing issues may not be readily volunteered
The following is an overview of what will most likely happen if you approach a skilled doctor for assistance with your low libido.


Sexual History

Secondly, your health professional will question you about your current state of health, workplace hazards, living conditions, past surgeries and illnesses, and hereditary diseases in your family. You may be asked if you had a high libido with a different partner.


Be prepared to answer these standard questions:

How old were you at the time of your first kiss and your first intercourse?
When did you first notice your lack of libido?
Have you ever had a sexually transmitted infection (STI)?
Do you have any vaginal or nipple discharge, and if so, what color and consistency?
Have you gained or lost any hair on your chest, underarms or face?
Do you also have enlarged breasts?
Does your breast size vary or remain the same?
Is there tenderness or pain in your groin, breasts or pelvis?
Have you ever had your nipples or genitals pierced, and if so, were there complications?
Do you regularly use prescription or street drugs?
Do you regularly drink alcohol?
Do you use herbs or body-building preparations?
Are you ever able to achieve vaginal lubrication and an orgasm?
Have you noticed any purple stretch marks on your skin, or facial swelling?
Have you ever had abnormal vaginal bleeding?
Have you ever had a urinary tract infection?
Have you ever had yellow jaundice or hepatitis?
Have you been fasting or unable to take regular nourishment until recently?
If you have bronze skin, it may flag your doctor to ask in-depth questions about your liver and kidney function. Dialysis and liver patients often have low libido. Tell your doctor if you are using a self-tanner or tanning bed.

Your doctor may inquire about the detergent and fabric softener you use, and the clothing you wear. If your lack of libido is due to a burning and stinging vulva (vulvodynia), then your condition may be aggravated by bleach, perfumes and dyes. You may be advised to change to a less toxic laundry routine. You may need to air dry your underwear. Vulvodynia is triggered by tightly fitting clothing, bike riding, tampons, yeast infections, medical examinations, and sexual intercourse. However, none of these are the specific cause. Regular use of medicated creams to relieve itching may worsen vulvodynia. Vulvodynia not only prevents intercourse or lessens its pleasure, but it also makes it difficult to drive long distances, perform desk work while seated, exercise or socialize.

Your doctor needs to know if you have had pelvic surgery or genital piercings of any kind. These could have compromised the bloodflow and nerve supply to your reproductive organs, caused a deep-seated infection, or pelvic inflammatory disease (PID).

Your doctor may ask if you book an adequate time and place for sexual intercourse. People who prefer to be spontaneous about sex may seldom have it on a regular basis. Your doctor will ask you questions about your sexual response cycle and if you experience pain during all sexual activity, just with penetration or only during a particular position. They will also ask if you have no or limited sensation.


Physical Examination

Thirdly, your doctor must perform a physical examination, including an internal exam. Depending on the findings of the physical exam, your
doctor may order medical imaging and laboratory tests to rule out diseases that cause low libido.

Starting with your head and working downwards, the doctor looks for clues that could indicate an underlying illness responsible for your low libido. The doctor will check your:
Eyes for droopy or pale lids, abnormal movements, dryness, and visual loss or disturbance
Nailbeds for pallor, indicating anemia
Ears for hearing loss and unusual ear placement
Reflexes and abnormal movements (synkinesia)
Hair in your underarms (axilla) and on your genitalia, scored according to Tanner criteria
Your doctor will also perform a pelvic exam to check for cancer, benign tumors, lesions, discharge, and sexually transmitted infections. Your doctor will feel your breasts in a circular motion and look for color changes, nipple discharge and asymmetry. Your doctor will feel (palpate) for a mass in your pelvis to rule out fibroid and cancerous tumors. Your doctor must look at your groin for ambiguous genitals (pseudohermaphroditism) and to rule out pregnancy, which turns the cervix blue. Many nerve conditions are associated with low libido, so your doctor must test your reflexes and muscle strength.

As you recline on the examination couch, your doctor inserts a clean clamp (speculum) to hold your vagina open and shines a bright light on your perineum to see well. If you have not had a Pap smear in the past year, the doctor scrapes your cervix with a wooden popsicle stick, smears the sample on a slide, and sends it to the pathology lab for expert examination.

You may refuse the internal pelvic exam without an anesthetic if you have vaginismus, which is involuntary contractions of the pubococcygeus (PC) muscle surrounding the vagina. It makes the vaginal opening so tight that penetration is either very painful (secondary vaginismus) or impossible (primary vaginismus). Sometimes, vaginismus is caused by
physical damage from a difficult childbirth, a motor vehicle accident, or rape. Vaginismus can also have a psychological cause. If you are afraid of an internal exam, ask for a referral to a gynecologist who is skilled in treating vaginismus. Remind your family doctor to state in the referral letter that you require an anaesthetic before the examination.


Sexual Response Review

Your doctor needs to discuss with you the normal sequence of sexual arousal in women to determine:
When during sexual activity your problem starts
How long you have experienced this problem
Its frequency and persistence
The normal sequence of sexual arousal is:

1. Slight breast enlargement

2. Nipple erection

3. Vaginal lubrication

4. Swelling labia and clitoris
Women with sexual arousal disorder cannot follow this sequence, even when they have sufficient sexual stimulation for a long period and are willing sex partners.

If you have always had sexual arousal disorder, but have some sexual desire, then your problem may be simple naivety about how your genitals function. This can be easily corrected with a couple of hours of training in different techniques to stimulate them. You may be inhibited by your religious background, feel guilty about cultural taboos, or you may have a negative self-image. Talk to an accredited sex therapist.

If sex education does not fix your sexual arousal disorder and it has been present since puberty, then you should be screened for: diabetes, thyroid gland deficiency (hypothyroidism), genetic disorders (e.g. Turner and Kallmann syndromes), and muscular dystrophy. Screening is especially important if you lack sexual desire and your vagina is unable to lubricate. The above conditions cause sex hormone deficiency (hypogonadism), which can be controlled with hormone replacement therapy.

If you once had good sexual function and only recently developed sexual arousal disorder, then you must be screened for: early menopause, hormone deficiency, vaginitis, cystitis (bladder inflammation, usually due to infection), endometriosis, multiple sclerosis, and diabetes.

If you recently had a mastectomy (breast removal), or hysterectomy (uterus removal), then your body image may have changed. You may need group therapy or psychotherapy to regain self- acceptance or help you deal with trauma if you had a cancer scare. If your ovaries were also removed (oophorectomy), then you will need hormone replacement therapy (HRT) to prevent your vagina from thinning and drying out.

Did you recently begin taking prescription medication, street drugs, or traditional herbs? Your doctor may consult a pharmacist to find out if any of these are lowering your libido. Some known culprits that cause sexual arousal disorder are: birth control pills, antidepressants,
antihypertensives (to control high blood pressure), and sedatives. The solution may simply be changing your birth control method or switching to another prescription. Also, some over-the-counter herbal medicines for women’s problems can depress your libido (e.g. Chasteberry). Consult your doctor about discontinuing these.

If you have sexual arousal disorder because of nerve or blood vessel damage in your groin, then you can increase feeling with alprostadil, a drug invented to treat male impotence.

One in ten women never have an orgasm (sexual climax), which is known as anorgasmia. Your doctor may review your sexual technique to find out if you realize half of all women cannot attain orgasm through vaginal penetration alone, and require direct stimulation of the clitoris. The frustration resulting from anorgasmia can cause low libido.

Orgasmic disorder is persistent, frequent absence of sexual climax, or one that is greatly delayed, even if the woman has intense, prolonged sexual stimulation. Orgasmic disorder may be present at puberty, or may develop later in life as the result of a disease such as diabetic neuropathy. It should not be confused with occasional inability to reach orgasm due to tiredness, acute physical illness, or stress. Known causes of orgasmic disorder include depression and taking SSRI antidepressants to alleviate it, such as fluoxetine. Orgasmic disorder is only a problem if lack of orgasm distresses you.

If you seek treatment for orgasmic disorder, encourage your regular sex partner to participate. Your therapist will ask if you have been able to achieve orgasm with another partner. If so, it may be your current partner does not provide you with sufficient foreplay, or is a premature ejaculator, or you both were not taught how genitals operate. Once a woman has been taught to achieve orgasm, she does not lose that ability unless there is pelvic damage, post traumatic stress disorder, psychiatric disease like depression, or conflict in her relationship. You may also have feelings of guilt, religious or cultural taboos regarding pleasure, or a fear of losing control in front of another person.
If you avoid sex because it causes your vulva to burn unbearably, then your doctor will suggest lifestyle changes to minimize your vulvodynia episodes. You must: avoid tampons, modify the clothes you wear and how you wash them, watch what you eat and drink, stop swimming in chlorinated pools for exercise, and change when and where you have sex.

Dyspareunia is pelvic pain during or after intercourse. Both men and women can have dyspareunia. It can have an acute physical cause, such as an ulcerated vagina or severe yeast infection (candidiasis), or a psychological cause such as past rape or sexual trauma.

If you have dyspareunia after a hysterectomy, ask for an ultrasound to look for a remnant of an ovary left behind by the surgeon. The remnant can develop painful cysts.

Dyspareunia often results from chronic diseases that cause pelvic pain, such as interstitial cystitis; endometriosis; varicose veins in the pelvis, also called pelvic congestion syndrome; fibroid tumors; inflammatory bowel disease; pelvic inflammatory disease (PID); long-standing sexually transmitted infection; and muscle spasms that tense the pelvic floor.


Understand more on low libido in women:

What is Low Libido?

Why and who develops low libido?

Signs and Symptoms of Low Libido in women. When should I be concerned?

Treatment options for low libido in women

Female Sexual Function Questionnaire

The information in this article has been taken with permission from the official Lawley booklet on Understanding Low Libido in Women.