• Coronary heart disease: We are frequently informed by the media about the risks of coronary heart disease. One aspect of this disease they do not mention is that the same plaque that builds up in the arteries of the heart also builds up in the arteries of the pelvis. This can restrict the flow of blood to the pelvic and genital organs. It may also lead to thickening and scaring within of the muscles of the vagina and the smooth muscles tissues of the clitoris. This can lead to a lack of lubrication and pain during foreplay and intercourse.

• High blood pressure: The affects of high blood pressure on female sexuality are not fully understood at this time. What is know is, high blood pressure can damage the blood vessels resulting in an increased risk for coronary heart disease, described above. The medications used to treat it may directly affect female sexual response as well. These medications are discussed on the Health page.

• Smoking: While we have all been made aware of the damage cigarette smoking can do to our bodies, few would expect it to affect our sexuality. Smoking causes the blood vessels to constrict. This can affect the blood flow to the pelvic organs. Toxins in cigarettes can also damage the walls of the arteries leading to coronary heart disease.

• Bicycle riding: The use of standard narrow bicycle seats can result in damage to the blood vessels and nerves that lead to the clitoris. This can result in clitoral numbness, at first it is just temporary but may become permanent. Women, and men, should only use wide bicycle seats. You can learn more about this at: Institute for Sexual Medicine: Bike Riding and Your Sex Life. An interesting medical article abstract can be read here. Medical Quote, "Handlebars positioned lower than the saddle were significantly associated with increased perineum saddle pressures and decreased genital sensation in female cyclists." Read More

• Menopause: The decreased production of estrogen that occurs during menopause can result in hot flashes, vaginal dryness or irritation, incontinence, a thinning or loss of elasticity of the skin, mood swings, and depression. A corresponding decrease in androgen hormones like testosterone can result in reduced muscle strength, appetite, energy, memory, sexual desire, and responsiveness. Testosterone appears to be the main controller of sexual desire. A medical article abstract says the sexual functioning of the brain changes after menopause, possibly the result of hormonal changes. There was a medical study done to see if the changes that occur in the female genitals during menopause could be observed by Magnetic Resonance Imaging (MRI) and they were successful, which provided some information on how they change. Read that article.

• Endocrine disorders: The endocrine glands are spread throughout the body and are responsible for controlling the body's internal functions by producing numerous hormones. Diseases and illnesses that affect such glands as the pituitary, hypothalamus, thyroid, and adrenals can have a significant affect on a woman's sexuality. Hormones control the production of other hormones so a chain reaction of events may lead to sexual dissatisfaction.

• Postpartum hormone deficiencies: While a short-term loss of libido flowing pregnancy and childbirth is normal, it should not last for years. When a woman is breast-feeding her body produces oxytocin and prolactin that suppress the production of testosterone. As a result, breast-feeding women may experience a decreased desire for sex for as long as they nurse. (The benefits of breast-feeding still greatly outweigh the negatives.) Women who do not breast feed, and after others stop doing so, may also experience a chronic decrease in sexual desire and this may be the result of a decrease in or total absence of testosterone. The reason why testosterone production ceases is not known.

• Diabetes: A diabetes related disorder called diabetic neuropathy can affect the nervous system and blood vessels. More than fifty percent of diabetics develop neuropathy. This condition often results in a loss of feeling in the feet, hands, and legs. The small arteries in the pelvis may also be affected by the resulting vasculogenic problems.

Neurogenic Problems: Any medical condition that affects the nervous system can have a major impact on a person's sexual function.

• Spinal cord injury: Paralysis often results in a significant sexual impairment but not a decease in sexual desire. Women may experience a loss of genital sensitivity and may not be able to experience orgasm following a spinal injury. New research though has shown some women with paralysis are able to experience orgasm by using non-conventional means. Some experience orgasm while stimulating the cervix or vagina. Others experience orgasm by using a standard vibrator. Still others find other areas of their body become erogenous zones, like the nipples, neck, and ears. Disabilities are often only as debilitating as a person allows them to be.

• Endometriosis and fibroids: Women with endometriosis and fibroids may suffer sexual dissatisfaction as a direct result of medical treatments they receive; like D&C (dilation and curettage), hysterectomy, or uterine embolization. The effects these procedures may have on a woman's sexual satisfaction have been addressed above.

• Vaginal and urinary tract infections: The symptoms associated with vaginal and vulvar infections like vulvitis, vulvadynia, urinary tract infections, and cystitis can result in a woman's vulva and vagina being too sensitive or irritated to permit any form of sexual contact. Some of these infections result in unpleasant smells as well. While most of these infections are easily treated and have a limited impact on a woman's sexuality, others are chronic and debilitating. Unfortunately, all of these diseases are not fully understood and as a result there is no known treatment for some of them.

• Interstitial cystitis: This is a chronic inflammation of the bladder. It is indicated by a frequent urge to urinate, lower abdominal, vaginal, and rectal pain. This disease can be hard to detect and often requires the visual examination of the bladder using a cystoscope, to look for hemorrhages. This condition often becomes debilitating and leads to sexual dissatisfaction. It can result in labial, vaginal, and pelvic pain and difficulties with arousal and orgasm. Researchers are still searching for a cause and developing new medications to treat it.

• Pelvic floor disorders: These disorders result in the relaxation and loosening of the muscles and connective tissues that support the pelvic organs; like the uterus and bladder. Women who experience this may also experience vaginal pain, loss of sensitivity within the vagina, and arousal and orgasmic impairment. New and better surgeries are being developed to help protect a woman's sexual functioning, to protect her vital nerve and blood supplies when surgical treatments are undertaken.

• Depression and dysthymia: Depression affects twice as many women as men. It has many causes, chemical imbalances within the brain, severe stress, grief, family history, emotional conflict, or any combination of factors. Dysthymia is a less severe form of depression that usually goes undetected. A woman with dysthymia may feel sad and unattractive. Both forms of depression can lead to sexual dissatisfaction and avoidance of sex.

• Stress: Many women have two careers, they perform the tasks required of a mother and a businesswoman at the same time. Today's working mother often times does not have the support of multiple nuclear family members to the degree they once did. The responsibilities associated with both careers results in women who are under much more stress than the average man. Stress can lead to emotional and medical problems and as a result sexual difficulties. Women who find they are feeling stressed need to ask for, if not demand, assistance from others. If you cannot relax in the arms of your partner you are very unlikely to be able to experience sexual arousal and orgasm, if you are able to attempt intimacy at all.

• Sexual or emotional abuse: The potential ways in which sexual and emotional abuse can affect a woman's sexuality are enormous. Women who have been exposed to this may experience one or more of the four types of sexual dissatisfaction listed above. It can cause women to avoid sex or be unable find it pleasurable. A woman may find herself unable to develop a committed and lasting emotional relationship with someone; she may seek pleasure through frequent sex, perhaps with multiple partners that have no emotional attachment to her. For a woman to heal from abuse it often takes a sizeable investment of time and a very supportive partner. I want to point out that just because a woman has a strong interest in sex or has no interest in sex at all, that does not automatically mean she was abused as a child. In addition, a woman who was abused may still have a healthy sex life as an adult. Women should be careful not to become the victims of suggestion.

• Drug and alcohol use: Women may abuse drugs and alcohol as a result of a preexisting emotional conditions. While the drugs and alcohol may allow them to hide from their problems, it only adds to them by creating new ones. Women who are always intoxicated or under the influence of drugs when they engage in sex may be unable to relate to their partner on an emotional level when they are sober. Once a woman is no longer addicted she often finds herself unable to have a fulfilling sexual relationship with her partner, in part because the emotional problems come to the forefront once again. Some women use sex as a form of distraction, as a means of avoiding their problems. Sex becomes the drug; hormones produced during sex may result in a natural high or peaceful state-of-mind. Women who have been treated for alcohol or dug abuse often need extensive counseling and a supportive partner if they are to find sexual happiness.

• Sexual addiction: This is a controversial subject. Women in the past were labeled nymphomaniacs if they expressed any outward interest in sex. Now if they express "too much" interest they may be called a sex addict. Is it possible that only the label applied to a sexual woman has changed with time, rather than our opinion of her? Who exactly is defining what is too much? What is sexual addiction and what is a strong yet normal sex drive? If your desire for sex precludes all else, specifically work and family, then it is unhealthy emotionally. If the only thing you and your partner(s) do while together is have sex, then you may be using sex as a means of avoiding emotional and intimacy issues. Sex is just one spoke in the wheel of life, if all the other spokes are broken or weak, the wheel will collapse when jostled.

• Body image and self-esteem problems: Women often compare their body to an unrealistic and unhealthy ideal created and propagated by the mass media. Women often expect they should naturally look like the underweight or surgically modified models frequently shown on the covers of magazines, television, and in movies. Women who are considered very attractive by those around them often find significant fault with their body; especially those very women who adorn the covers of magazines. As a result, many women are uncomfortable showing their body to their partner. They never allow their partner to see them undressed, with the lights on. They may not allow their partner to look at or touch certain areas of their body, specifically their vulva. If a woman cannot undress fully in front of her partner with the lights on and allow them to examine her entire body with their eyes and hands, she is not going to be able to fully enjoy her sexual interactions with them. How a woman values herself in her work and relationship also affects her sexuality. If a woman feels she has no skills or qualities others value, she will likely find she unable to express herself sexually. If a woman believes her partner will not listen to or respect what she has to say she will never make her sexual needs known. If she does not feel comfortable with herself and her partner she is less likely to be able to relax and have an orgasm. Having an orgasm may cause a woman to feel very vulnerable, if she does not have confidence in herself or the relationship she may not allow herself to have an orgasm, consciously or unconsciously. See Body Image section of website for more information on this subject.

• Relationship problems: The state of a couple's sexual relationship is often a direct indicator as to the state their entire relationship. If a couple is having sexual difficulties, those difficulties usually have a negative impact on their entire relationship, and vise versa. If the relationship is in turmoil then no form of treatment that involves only the woman will solve their sexual difficulties. If the woman's sexual dissatisfaction is the result of her partner's sexual difficulties or lack of sexual skills, treating her alone will most surely result in failure. If a couple does not trust one another and have good communication skills, achievement of sexual satisfaction is unlikely. Some couples have trouble accepting the natural changes their relationship undergoes with the passing of time. Many relationships start out as the result of mutual infatuation that is intense and often accompanied by sexual passion. Once the newness of the relationship has worn off the relationship becomes mellower and less exciting. If the couple has good communication skills and there is mutual trust and respect the relationship will survive the transition, the couple discovers love. If a person expects to maintain that initial emotional and physical intensity throughout the relationship they often find themselves bouncing from one relationship to the next. Many couples have false expectations as to what their sex life should be like, ignoring all the other things that have changed within the relationship. Having children for example will usually require a couple's sexual relationship to change. A healthy relationship is essential to enjoyable sex. Love is not an essential quality of a healthy sexual relationship, but mutual respect and trust, and the ability to communicate effectively are. Unfortunately, society is to blame for much of the mutual distrust that exists between the sexes.

• Full gynecological and urological exam: This involves the thorough examination of the internal and external structures; including an examination of the clitoris, which is not normally done during pelvic examinations. A woman's medical history is also taken. The doctor needs to know about past surgeries, illnesses, family history, and treatment of emotional problems.

• Determination of the vaginal pH level: A small flexible probe is inserted into the vagina to measure its acidic level. A reading of 4.5 to 5.1 is considered normal for premenopausal women. Post-menopausal women who are not on estrogen replacement therapy experience an increase in acidity. A measurement of 0-7 is considered acidic, 7-14 is considered alkaline. A measurement of 7 is neutral. More about vaginal pH can be learned here.

• Measurement of clitoral and labial sensitivity: This is done using a biothesiometer; a device that measures the sensitivity of the skin to high and low frequency vibration. It is used to determine the sensitivity of the clitoris and labia to stimulation, and the condition of the nerves.

• Determination of vaginal compliance: This test is done to measure the ability of the vagina to relax and lengthen. A small balloon like device is inserted into the vagina and slowly inflated. A woman is asked to indicate when she first feels a sensation of pressure within the vagina and then when the dilation begins to become uncomfortable.

• Examination using ultrasound: Using a small matchstick sized ultrasound probe, the anatomy and blood flow of the clitoris and labia is examined. The doctor is able to observe the anatomy and blood flow on a television screen. A tampon sized ultrasound probe is then inserted into the vagina to do a similar examination of the vagina and uterus.

• Assessment of arousal: This is perhaps the type of procedure women would least expect to occur in a doctor's office. In order to measure a woman's ability to become sexually aroused she needs to be aroused sexually. Dr. Berman gives the women a pair of 3-D surround sound video glasses and a vibrator. The glasses fill the woman's full range of vision and allow her to watch an erotic video, designed for and produced by women. (One would hope they also have videos for use by their lesbian clients.) The woman is then asked to engage in self-stimulation (masturbation) for fifteen minutes using the vibrator to achieve a high degree of arousal. The doctor is not present while the woman is engaged in this activity. When the doctor returns she repeats the three prior steps to determine the level of lubrication, blood flow, sensitivity, and the elasticity of the vagina when the woman is aroused. If the expected changes do not occur, it could be a sign that there are physical factors involves in the woman's sexual dissatisfaction. If a woman is not able to become aroused because of the situation she currently is in, she needs communicate this to her doctor.

• Assessment of arousal when Viagra is used: On a subsequent visit a woman may be give a dose of sildenafil (Viagra) and the above step is repeated. This is done to see if this prescription medication will have the desired beneficial affects on the woman's sexual response. An increase in blood flow and sensitivity are the desired results. If emotional issues are at play, even if a woman is highly aroused physically, orgasm may still be unachievable. The Berman's have found that if careful screening is done before hand, prescribing Viagra can be very beneficial for women. This is not true for all women. Viagra is not an effective treatment option for all or most forms of sexual dissatisfaction. It usually works best for women who once had a fulfilling sex life but due to physiological changes is no longer able to experience the necessary level of sexual arousal required to achieve orgasm.