Symptoms

An orgasm is a feeling of intense physical pleasure and release of tension, accompanied by involuntary, rhythmic contractions of your pelvic floor muscles. But it doesn't always look — or sound — like that famous scene from "When Harry Met Sally." Some women actually feel pelvic contractions or a quivering of the uterus during orgasm, but some don't. Some women describe fireworks all over the body, while others describe the feeling as a tingle.

By definition, the major symptoms of anorgasmia are inability to experience orgasm or long delays in reaching orgasm. But there are different types of anorgasmia:

• Primary anorgasmia. This means you've never experienced an orgasm.
• Secondary anorgasmia. This means you used to have orgasms, but now experience difficulty reaching climax.
• Situational anorgasmia. This means you are able to orgasm only during certain circumstances, such as during oral sex or masturbation. This is very common in women. In fact, most women experience orgasm only from stimulation of the clitoris.
• General anorgasmia. This means you aren't able to orgasm in any situation or with any partner.

When to see a doctor Talk to your doctor if you have questions about orgasm or concerns about your ability to reach orgasm. You may find that your sexual experiences are normal. Or your doctor may recommend strategies to reduce your anxiety and increase your satisfaction.

Causes

Despite what you see in the movies, orgasm is no simple, sure thing. This pleasurable peak is actually a complex reaction to many physical, emotional and psychological factors. If you're experiencing trouble in any of these areas, it can affect your ability to orgasm.

Physical causes A wide range of illnesses, physical changes and medications can interfere with orgasm:

• Medical diseases. Any illness can affect this part of the human sexual response cycle, including diabetes and neurological diseases, such as multiple sclerosis.
• Gynecologic issues. Orgasm may be affected by gynecologic surgeries, such as hysterectomy or cancer surgeries. In addition, lack of orgasm often goes hand in hand with other sexual concerns, such as uncomfortable or painful intercourse.
• Medications. Many prescription and over-the-counter medications can interfere with orgasm, including blood pressure medications, antihistamines and antidepressants — particularly selective serotonin reuptake inhibitors (SSRIs).
• Alcohol and drugs. Too much alcohol can cramp your ability to climax; the same is true of street drugs.
• The aging process. As you age, normal changes in your anatomy, hormones, neurological system and circulatory system can affect your sexuality. A tapering of estrogen levels during the transition to menopause can decrease sensations in the clitoris, nipples and skin; blood flow to the vagina and clitoris also may be impeded, which can delay or stop orgasm entirely.

Psychological causes Many psychological factors play a role in your ability to orgasm, including:

• Mental health problems, such as anxiety or depression
• Performance anxiety
• Stress and financial pressures
• Cultural and religious beliefs
• Fear of pregnancy or sexually transmitted diseases
• Embarrassment
• Guilt about enjoying sexual experiences

Relationship issues Many couples who are experiencing problems outside of the bedroom will also experience problems in the bedroom. These overarching issues may include:

• Lack of connection with your partner
• Unresolved conflicts or fights
• Poor communication of sexual needs and preferences
• Infidelity or breach of trust

Appointment

If you rarely or never experience orgasm from sexual activity and it's causing you distress, make an appointment with your doctor. You may feel embarrassed to talk about sex with your doctor, but this topic is perfectly appropriate. Your doctor knows that a satisfying sex life is very important to a woman's well-being at every age and stage of life.

You may have a treatable, underlying condition, or your may benefit from lifestyle changes, therapy or a combination of treatments. Your regular doctor may diagnose and treat the problem or refer you to a specialist who can.

Here's some information to help you prepare for your appointment, and what to expect from your doctor.

Information to write down in advance

• Your symptoms. It will help your doctor to know whether you've ever had an orgasm, and if so, under what circumstances.
• Your sexual history. Your doctor likely will ask about your relationships and experiences since you first became sexually active. He or she may also ask about any history of sexual trauma or abuse.
• Your medical history. Write down any medical conditions with which you've been diagnosed, including mental health conditions. Also note the names and strengths of all medications you're currently taking or have recently taken, including prescription and over-the-counter drugs.
• Questions to ask your doctor. Creating your list of questions in advance can help you make the most of your time with your doctor.

Basic questions to ask your doctor The list below suggests questions to raise with your doctor about anorgasmia. Don't hesitate to ask more questions during your appointment at any time that you don't understand something.

• What may be causing my difficulty to orgasm?
• Do I need any medical tests?
• What treatment approach do you recommend?
• If you're prescribing medication, are there any possible side effects?
• How much improvement can I reasonably expect with treatment?
• Are there any lifestyle changes or self-care steps that may help me?
• Do you recommend therapy?
• Should my partner be involved in treatment?
• Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

What to expect from your doctor Your doctor may ask a number of very personal questions and may want to include your partner in the interview. To help your doctor determine the cause of your problem and the best course of treatment, be ready to answer questions such as:

• When did you first become sexually active?
• For how long have you had difficulty reaching orgasm?
• If you've had orgasms in the past, what were the circumstances?
• Do you become aroused during sexual interactions with your partner?
• Do you experience any pain with intercourse?
• How much are you bothered by your lack of orgasm?
• How satisfied are you with your current relationship?
• Are you using any form of birth control? If yes, what form?
• What medications are you taking, including prescription and over-the-counter drugs as well as vitamins and supplements?
• Do you use alcohol or recreational drugs? How much?
• Have you ever had surgery that involved your reproductive system?
• Have you been diagnosed with any other medical conditions, including mental health conditions?
• What were your family's beliefs about sexuality?
• Have you ever been the victim of sexual violence?

What you can do in the meantime While you wait for your appointment, be open with your partner about the situation. Continue to be active with intercourse, and also explore other ways of being intimate. Shifting the focus from orgasm to pleasure may be a helpful strategy in treating anorgasmia.

Tests and diagnosis

A medical evaluation for anorgasmia usually consists of:

• A thorough medical history. Your doctor may also inquire about your sexual history, surgical history and current relationship. Don't let embarrassment stop you from giving candid answers. These questions provide clues to the cause of your problem.
• Physical examination. Your doctor will probably conduct a general physical exam to look for physical causes of anorgasmia, such as an underlying medical condition. Your doctor may also examine your genital area to see if there's some obvious physical or anatomical reason for lack of orgasm.

Treatments and drugs

It can be difficult to treat anorgasmia. Your treatment plan will depend on the underlying cause of your symptoms, but your doctor may recommend a combination of lifestyle changes, therapy and medication.

Lifestyle changes and therapy For most women, a key part of treatment includes addressing relationship issues and everyday stressors. Understanding your body and trying different types of sexual stimulation also can help.

• Understand your body better. Understanding your own anatomy and how you like to be touched can lead to better sexual satisfaction. If you need a refresher course on your genital anatomy, ask your doctor for a diagram or get out a mirror and look. Then take some time to explore your own body. Masturbating or using a vibrator can help you discover what type of touching feels best to you, and then you can share that information with your partner. If you're uncomfortable with self-exploration, try exploring your body with your partner.
• Increase sexual stimulation. Many women who've never had an orgasm aren't getting enough effective sexual stimulation. Most women need direct or indirect stimulation of the clitoris in order to orgasm, but not all women realize this. Switching sexual positions can produce more clitoral stimulation during intercourse; some positions also allow for you or your partner to gently touch your clitoris during sex. Using a vibrator during sex also can help trigger an orgasm.
• Seek couples counseling. Conflicts and disagreements in your relationship can affect your ability to orgasm. A counselor can help you work through disagreements and tensions and get your sex life back on track.

• Try sex therapy. Sex therapists are therapists who specialize in treating sexual concerns. You may be embarrassed or nervous about seeing a sex therapist, but sex therapists can be very helpful in treating anorgasmia. Therapy often includes sex education, help with communication skills, and behavioral exercises that you and your partner try at home.

  For example, you and your partner may be asked to practice "sensate focus" exercises, a specific set of body-touching exercises that teach you how to touch and pleasure your partner without focusing on orgasm. Or you and your partner may learn how to combine a situation in which you reach orgasm — such as clitoral stimulation — with a situation in which you desire to reach orgasm, such as intercourse. By using these techniques and others, you may learn to view orgasm as one pleasurable part of sexual intimacy, not the whole goal of every sexual encounter.

Medical treatments Hormone therapies aren't a guaranteed fix for anorgasmia. But they can help. So can treating underlying medical conditions.

• Treating underlying conditions. If a medical condition is hindering your ability to orgasm, treating the underlying cause may resolve your problem. Changing or modifying medications known to inhibit orgasm also may eliminate your symptoms.
• Estrogen therapy. Systemic estrogen therapy — by pill, patch or gel — can have a positive effect on brain function and mood factors that affect sexual response. Local estrogen therapy — in the form of a vaginal cream or a slow-releasing suppository or ring that you place in your vagina — can increase blood flow to the vagina and help improve desire. In some cases, your doctor may prescribe a combination of estrogen and progesterone.
• Testosterone therapy. Male hormones, such as testosterone, play an important role in female sexual function, even though testosterone occurs in much lower amounts in a woman. As a result, testosterone may help increase orgasm, especially if estrogen and progesterone aren't helping. However, replacing testosterone in women is controversial and it's not approved by the Food and Drug Administration for sexual dysfunction in women. Plus, it can cause negative side effects, including acne, excess body hair (hirsutism), and mood or personality changes. Testosterone seems most effective for women with low testosterone levels as a result of surgical removal of the ovaries (oophorectomy). If you choose to use this therapy, your doctor will closely monitor your symptoms to make sure you're not experiencing negative side effects.

Alternative medicine

Natural products are available that may help some women who have difficulty reaching orgasm. These oils and supplements work by increasing sensation in the clitoris and surrounding tissue.

The following products may benefit some women with anorgasmia:

• Zestra. This botanical massage oil helps warm the clitoris and may increase sexual arousal and orgasm.
• ArginMax. This oral nutritional supplement contains L-arginine, a substance that relaxes blood vessels and increases blood flow to the genital area, and the clitoris in particular.

Talk with your doctor before trying any natural therapies. These products can cause side effects and may interact with other medications. Your doctor can help determine if they are safe for you.

Coping and support

If you're experiencing difficulty reaching orgasm, it can be frustrating for you and your partner. Plus, concentrating on climax can make the problem worse.

Most couples aren't experiencing the headboard-banging, van-rocking intercourse that appears on TV and in the movies. So try to reframe your expectations. Focus on mutual pleasure, instead of orgasm. You may find that a sustained pleasure plateau is just as satisfying as real climax.