Can I ask you one other question?
I’ve just had a nice chat with a patient - maybe even one I’ve been seeing for a few years, my hand is on the door ready to leave and I get this question.
“Sure. What’s up?”
“Well, I’m not sure if I’ve ever had an orgasm before.”
Hand is off the door and we are headed back for the chair because this visit will not be over any time soon.
This isn’t an uncoomon expreience. And, while I don’t mind the question, I do wish that people weren’t worried about asking it. I got into this field to deliver babies, but if you don’t ever get to the sex part, the babies stop coming. So, let’s talk about orgasm - what it is, how it happens, how to know and how to get there.
I have one quick PSA - if you’ve never had this problem, but suddenly you can’t get there anymore, it is absolutely critical to tell your doctor and if she (or he) doesn’t immediately refer you to a neurologist, then tell them they need to and push until you get imaging of your spine. It’s often the first presenting symptom of MS (Multiple sclerosis) in young women.
Now, back to the big O. An orgasm is a part of the sexual arousal cycle when a large amount of sexual excitement is released at one time. For most poeple this is acutely pleasurable, but can cause alot of weird other things. Orgasm causes the activation of the sympathetic nervous system and the release in the brain of large quantities of dopamine, seretonin and oxytocin. While for most people, the dopamine hit creates an addictive desires to have the experience again, some people are overwhelmed with sadness caused by the oxytocin release. Some people experience the flood of neurotransmitters as somewhat painful and for some others, it may trigger something like a headache. You also get rhythmic contraction of the pelvic floor muscles during orgasm. Muscles throughout the body can do weird things due to the firing of the nervous system. Overall, it’s a fairly noticeable event.
So, how do we get one of these? Suprisingly, missionary intercourse isn’t the answer for most women, and by that I mean, almost no one. Approximately 70-80% of women cannot achieve an orgasm with vaginal penetration alone. If penetration alone doesn’t work for you, you are not broken. It’s the women that can do it that are the weird ones. Why so much confusion? Because most women who think they are having an orgasm from nonclitoral stimulation are often in sexal positions that involve alot of clitoral stimulation. If you are grinding, you are probably stimulating the clitoris.
So, the mysterious clitoris is where most women have to head to for an orgasm. The highest concentration of nerve endings - down there - is in the clitoris. That’s the”button” at the top of the vagina. This is erectile tissue that is a female correlate of the top of/glans of the penis. It has the highest concentration of nerve endings above all other tissues nearby.
The female sexual cycle starts with desire and arousal - though not necessarily in that order (and for many women, especially as we get older, arousal might not happen without an invitation from another - desire becomes a reaction not a state we are walking around the grocery store in). Arousal begins the process of increasing blood flow to the vagina and the labia and clitoris (the female erectile tissue) and this causes a color and size change of the external organs and a sensation of wetness inside the vagina. Because our entire bodies are affected by this process, there can also be an increased heart rate, flushing, erection of the nipples and increasing sensitivity of the skin. For most women, this stage can be harder to achieve, but once it’s been triggered, the rest works fine. When we talk about testosterone supplementation for peri and post menopausal women, this is the part of the cycle we are intervening in. I often joke that the best way to get a woman in the mood for sex is to clean the kitchen and do the laundry so she has less to worry about. That Mr. Clean commercial where he’s sexily mopping the floor in very tight pants is arousing on so very many levels. What I mean by this is that if we are focused on the to do list and all the things that need to get done - because let’s face it, if we don’t take care of all these little things, who will? Making time for your partner to focus on them may be a necessary step in the equation. Them making time to do the dishes or take you out on a date may also be part of the equation. The things that increase desire help to build toward the orgasm - kisses, caresses and of course, intercourse.
To complete the orgasm, most women will need direct clitoral stimulation. There is no hard and fast guide here. Do what feels good to you. If you have a partner and can’t seem to get what works, you will probably need to talk about it and there is a very good chance that working through the situation will increase intimacy and actually make an orgasm easier to achieve. Because of the concentration of hormones release and the size of the sexual tension release and the contractions of the pelvic floor muscles, you will likely be very aware of when the actual orgasm happens. If you aren’t sure if it happened, it probably didn’t. Options - keep trying, try again later. The thing is, no one has a string of 100% amazing sexual encounters - even on sex in the city, they all have their own weird struggles - that’s the basic plot line of the show. Generally though, I encourage partners to talk to each other. For women, the desire for sex is often a response to the desire for intimacy, which is not the same for guys. With 10x female levels of testosterone, there’s a reason men are caricatured as always having sex on the brain. Working on building intimacy with “foreplay” - the touchy feely stuff - will help improve the experience while working towards the orgasm.
The aftermath. The final phase is “resolution.” It’s essentially the body’s vitals and tissues returning to normal. The clitoris can become uncomfortable to touch after orgasm and that’s normal too. For some women, they can immediately reenter the arousal/orgasm phase and have multiple orgasms in the same sexual encounter. No one is exactly sure of the percentages, but based on my experience talking to women, it’s probably less than most people think. (A note about the guys - there is often a “refractory” period, but how long it lasts is highly variable and gets longer as you get older.)
So, are there some things that can get in the way? Absolutely. Here’s a noncomprehensive list of medications:
Antidepressants - especially SSRIs - zoloft is probably the number one offender in my patient population
Beta blockers - taken for BP and anxiety
Spironolactone - used to treat acne and hirsutism - it lowers testosterone levels
Birth control pills - this isn’t their intended mechanism of action, but … also lowers testosterone levels
Anti-siezure medication
Chemotherapy Agents/Radiation
If you are taking one of these drugs and think it may be causing a problem, don’t stop your meds immediately. Work with you docor(s) to come up with an alternate regimen that has fewer sexual side effects. I encourage you not to be embarassed about this. Usually when someone brings up a problem, the first thing I say is, “let’s look at what medications you are taking” because it is such a common thing for people to be on one of these medications.
Are there some conditions that can prevent sexual arousal or make achieving orgasm more difficult? Absolutely. Here’s a list:
Breastfeeding
History of sexual abuse or trauma - this is so common and there are treament options. Be prepared for a process, but we can get your there
Unplanned pregnancy (current or previous)
Relationship difficulties
Painful intercourse - kills desire faster than anything else I can think of and is caused by most things on this list
Autoimmune conditions that affect mucus membranes - sjogrens, lupus, Behcets
Autoimmune conditions that affect the external vagina - lichen sclerosus beign the most common
Sexually Transmitted Illnesses.
There are alot of things. If you know of a trigger, it’s even easier to help root out the problem. I will again make a PSA that if you have a sudden change in your ability to have an orgasm (in the downward direction) and there is nothing you can pinpoit like medications or one of the above conditions, it is crucial you report this to your doctor. That’s not normal and there are serious underlying problems that can be.
I hope this has been a helpful overview. Books have been written on the subject and I would bet more books will be written in the future. If you are finding issues you want to work on, more than anything, I don’t want you to be embarrassed to ask. You are not alone and we can help make things better!