Sexual Arousal Disorder: "I Just Can't Get Excited"

Think of sexual arousal as the second phase of lovemaking. First, you want to have sex and then, through foreplay and intimacy, you become aroused. But if your mind is saying "yes" and your body isn't listening, you could be suffering from sexual arousal disorder (SAD).

Medically speaking, SAD is defined as the persistent or recurring inability to maintain adequate genital lubrication, swelling or other responses, such as nipple sensitivity, during the excitement stage of sexual activity.

Vaginal lubrication is dependent on the swelling of blood vessels in the genital region, so any impediment to blood flow could potentially cause SAD, including:

  • Pelvic surgery like hysterectomy of which 600,000 are performed each year. Drs. Jennifer and Laura Berman report that the research on hysterectomy is contradictory: Some studies indicate sex improves after surgery, and some show negative results, such as decreased vaginal lubrication and a loss of genital sensation. Even if the surgery spares your ovaries, you can still experience these symptoms. The Bermans say removal of the cervix and injury to the nerves during surgery can severely compromise blood flow, thereby setting the stage for SAD.
  • Childbirth trauma (vaginal tearing) from suction or forceps sometimes causes nerve and vascular damage to the vagina, resulting in problems with vaginal and clitoral sensation. Decreased lubrication can also occur during breast-feeding; it is not uncommon in postpartum women due to an elevation of the hormone prolactin.
  • Blood flow diseases: Coronory heart disease, high blood pressure, diabetes, and high cholesterol all can impede blood flow to the pelvic region and reduce a woman's ability to become aroused. Ironically, some drugs used to treat high blood pressure, known as beta-blockers, actually cause sexual dysfunction; calcium channel blockers, also used in the treatment of heart disease, have become more popular, say the Bermans, because of their reduced impact on sexual function.
  • Hormonal changes: Fluctuations can be instigated by the onset of menopause, childbirth or medications. For instance, some women who take progestin-dominant birth control pills complain of a loss of libido and vaginal dryness. Medications to prevent recurrence of breast cancer, such as Tamoxifen, also can cause vaginal dryness. But by far, the most dramatic change is the drop in estrogen, which occurs with menopause and causes decreased vaginal lubrication as well as many other unpleasant symptoms.

Overcoming Sexual Arousal Disorder

Until the Bermans and other advocates of women's sexual health arrived on the scene, all women had to combat SAD were vaginal lubricants like KY-jelly, which eases symptoms but does not address the underlying problem.

Now, clinical trials are underway to evaluate the efficacy of medications like Viagra to successfully treat SAD and some other types of female sexual dysfunction. The Bermans have worked tirelessly to help determine the best candidates for the trial.

Notes Dr. Jennifer Berman: "In the studies, probably 80 to 90 percent of women with arousal problems noted enhanced sensation, lubrication and engorgement" with Viagra.

Two Approaches to Sexual Arousal Disorder

Basically, there are two approaches to treating SAD: hormone replacement therapy (HRT) and increasing blood flow to the pelvic tissues.

  • HRT: Conventional hormone replacement therapy—estrogen combined with a synthetic version of the hormone progesterone—is typically used to treat decreased estrogen levels associated with dryness, thinning and irritation of the vagina. You don't have to take Premarin, the best-selling drug in the United States for estrogen; in fact, for SAD you may want an estradiol vaginal ring (Estring), which is placed in the vagina for 90 days at a time. Another local vaginal delivery system is Vagifem, a tablet that you insert into your vagina daily for two weeks, followed by twice a week thereafter. These two options are easiest to use and less messy than vaginal creams, note the Bermans.
  • Increasing blood flow: To help increase blood flow and improve genital sensation, the Bermans often prescribe 2 percent testosterone cream, which you apply at least three times a week at bedtime to the clitoris and inner labia. (Libido problems associated with hypoactive sexual disorder are better treated with oral testosterone.) The Bermans also often recommend the prescription drug Viagra. Viagra helps to engorge the vagina with blood, causing it to become properly lubricated, much the same way it causes the blood vessels in a man's penis to become engorged, which produces an erection.

The Story of Lucy

In their book For Women Only: A Revolutionary Guide to Reclaiming Your Sex Life, the Bermans tell the story of Lucy, a 43-year-old mom with very low genital sensation and lubrication. The Bermans suspected that Lucy's vaginal nerves and arteries had been injured during her hysterectomy 13 years earlier. They prescribed Viagra and sexual counseling. With the help of Viagra, Lucy was able to experience powerful orgasms for the first time in years.

In addition to Viagra, there are number of other medications that enhance arousal by causing blood vessels to expand, thereby increasing blood flow to the genitals. You'll have to work closely with your doctor if you want to try any one of the following medical treatments. Currently, there is no FDA-approved pharmaceutical product for treating any form of female sexual dysfunction.

  • Phentolamine, marketed as Vasomax for men and Vasotem for women, has been shown to improve arousal, lubrication and sensation in post-menopausal women with SAD.
  • The Eros-CTD(clitoral therapy device): Approved in May 2000 by the FDA for treatment of FSD, the CTD is a small cup with a pump that fits over the clitoris. When it is turned on, a gentle vacuum is created, increasing blood flow to the genital area. The device is designed not unlike the penile pump that was created for men many years ago. Says Jennifer Berman: "It can be used as part of foreplay. It can be used on its own. It's recommended to be used as sort of an exercise to maintain the health of your genital area...It's sort of a variation of a vibrator." What's the advantage of the CTD over a stimulator or vibrator? The CTD is intended for women who typically have problems becoming sexually aroused with manual and/or vibratory stimulation. If you find that you can become aroused with other kinds of stimulation (e.g. manually or with a vibrator), then your arterial system is indeed functioning and enough blood is traveling to the genital area to create engorgement, lubrication, and sensation, and you probably don't need this device, says Jennifer. To learn more about the CTD, go to, or call this toll-free number: 1/866-774-3767.
  • Other Alternatives: The Bermans say results are promising for L-arginine, an amino acid sold in health food stores and yohimbe, a West African herb used for centuries to enhance libido. L-arginine is essential for the formation of nitric oxide, which relaxes smooth muscles and widens blood vessels, leading to better circulation. You can take L-arginine orally, and some companies offer nonprescription topical creams that, when applied to the clitoris, may increase blood flow by dilating clitoral blood vessels. The standard dose is 1,500 mg per day.

Given the size of the market, many new drugs are likely to emerge in coming years to treat SAD, hypoactive sexual disorder, orgasmic disorder and sexual pain disorder. The Bermans are keeping a watch on the development of topical genital creams based on prostaglandin E-I, a factor that helps enlarge blood vessels, and the drug apomorphine. A new tablet form of apomorphine is being developed by Tap Pharmaceuticals. It could be the first medication to target the brain for improved sexual arousal.

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