Sexual Wellness

Understanding Female Orgasmic Disorder

Female Orgasmic Disorder (FOD) is a bit more complex than simply not achieving orgasm. We can break it down into three main stages: pre-orgasm, orgasm, and post-orgasm. Within these stages, there are several ways FOD can show up, like not getting excited enough, having trouble with inhibition, experiencing delayed or "muted" orgasms, finding no pleasure at all, or even feeling unwell after orgasm.

Let's dive into what some of these mean.

Failure to Excite

This is when you just don't feel that "climb" of sexual excitement, and afterward, you don't feel satisfied. It's like the arousal never really takes off.

Failure to Inhibit

Sometimes, orgasm might happen too quickly, or it's not pleasurable, or you might even feel some discomfort during that "climb" to climax. It's about a lack of control over the process.

Delayed Orgasm

As the name suggests, this involves a significant delay in reaching that peak of excitement. Often, women report feeling fatigued, the pleasure might be muted, and they might or might not feel satisfied afterward.

Premature or Muted Orgasm

This can feel like repeated "blips" of muted, premature orgasms, with minimal muscle tension, muted pleasure, and no real feeling of satisfaction.

Orgasmic Anhedonia

This is when there's simply no pleasure experienced at all during orgasm.

Post-Orgasmic Illness Syndrome

This final sub-category is quite challenging. It involves a prolonged period where you just don't return to your normal baseline after orgasm. Women often describe feeling unwell, fatigued, mentally sluggish, low on energy, lacking motivation, and extremely frustrated.

When it comes to treatment, the idea of using medication for FOD has been suggested, but there's not yet a complete consensus on the best approach. Currently, doctors might recommend existing drugs that are already on the market or use other medications "off-label" (meaning for a purpose not officially approved by regulatory bodies).

It's important to note that Selective Serotonin Reuptake Inhibitors (SSRIs), commonly used for depression and anxiety, are actually a frequent cause of delayed or absent orgasm in women, rather than a treatment for it. They work by increasing serotonin levels in the brain, which, while beneficial for mood, can unfortunately dampen sexual desire and the ability to achieve orgasm. Additionally, oral contraceptives decrease testosterone levels which can also contribute to lack of desire or arousal.

It's clear that FOD can manifest in many ways, and understanding these nuances is key to finding the right support. Physical therapy

can help address pelvic floor or other muscle related issues while sex and psychological therapists can offer cognitive behavioral and

or sensate focus therapy. There are several validated questionnaires available which can be used to start the process of self-discovery and communication with your provider.

Pharmacologic Treatments for Women

Arousal & whole body/pelvic muscle contractions

Failure to Excite Delayed orgasm, Minimal excitation

Caffeine 100 mg orally 1 hour before
Flibanserin 100 mg qhs
Bremelanotide 1.75 mg (0.3mL) subq 1 hour before
Bupropion 75 mg QAM
Estrogen (estradiol, estriol, estrone)
Testosterone 5mg TD 2 hours before
Sildenafil topical 1 hour before
Tadalafil topical 1 hour before
Oxytocin 500 IU 1 hour before
Buspirone 10 mg BID

Insignificant
Low blood pressure, sleepiness
High BP, nausea
Contraindicated seizure disorder/bulimia
Progesterone required w/ intact uterus

Peak of excitation

Orgasm not pleasurable

Low dose naltrexone 4.5 mg 1 hour before

Start 1.5 mg daily weekly up to 4.5 mg to reduce vivid dreams

Return to baseline

Post-Orgasm

Illness Syndrome

Caffeine 100 mg orally 1 hour before
Bremelanotide 1.75 mg (0.3mL) subq 1 hour before/after repeat 4x monthly
Bupropion 75 mg QAM
Buspirone 10 mg BID
Testosterone 5mg 2 hours before and daily
Hydroxyzine 25-50 mg start after and daily

Insignificant
High BP, nausea
Contraindicated seizure disorder/bulimia

Understanding HSDD Treatments:
How They Work and What to Expect

Caffeine

Flibanserin (Addyi®)

Bremelanotide (Vyleesi®)

Summary

Female Orgasmic Disorder (FOD) encompasses various challenges beyond simply not achieving orgasm, categorized into pre-orgasm, orgasm, and post-orgasm difficulties. These manifestations include lack

of excitation, premature/muted or delayed orgasms, anhedonia, and post-orgasmic illness. While some medications like SSRIs can negatively impact orgasm, various pharmacologic treatments are employed,

often off-label, targeting different stages of FOD.

Treatments for pre-orgasm issues, like failure to excite, include caffeine, flibanserin, bremelanotide, bupropion, buspirone, estrogen, testosterone, topical sildenafil/tadalafil, and oxytocin, each with specific mechanisms and considerations. For unpleasurable orgasms, low-dose naltrexone is hypothesized to enhance natural opioid release and pleasure. Post-Orgasmic Illness Syndrome, theorized to involve immune or neurological dysregulation, may be managed with hydroxyzine. Comprehensive treatment involves understanding these nuances, alongside non-pharmacological options like physical therapy and psychological counseling.

References