Anorgasmia (Difficulty Reaching Orgasm)

What anorgasmia is

Orgasm depends on desire, arousal, nerve and blood supply to the genitals, hormones, and the brain's ability to relax and focus. A problem in any of these can make orgasm difficult. Doctors diagnose female orgasmic disorder or delayed ejaculation in men when the difficulty is present on most occasions for at least 6 months and causes distress. Difficulty that does not bother you or your partner is not a disorder.

Many women do not reach orgasm through penetration alone; most need direct clitoral stimulation. This is normal, not anorgasmia.

Types of anorgasmia

Causes

Medicines

• SSRIs and SNRIs (such as sertraline, fluoxetine, paroxetine, venlafaxine): a very common cause, affecting a large proportion of people who take them
• Antipsychotics, some anti-seizure medicines, opioids, benzodiazepines and some blood pressure medicines
• Hormonal contraception in some women, by lowering free testosterone

Psychological and relationship factors

• anxiety, including performance anxiety, and depression
• stress and fatigue
• relationship conflict, poor communication or lack of trust
• negative beliefs about sex from upbringing, culture or religion
• body image concerns
• past sexual trauma or abuse

Physical and medical factors

• Menopause: lower estrogen reduces genital blood flow and sensitivity and causes vaginal dryness and pain
• Pain during sex (dyspareunia) and vaginismus
• Diabetes: damages nerves and blood vessels
• Multiple sclerosis, spinal cord injury and peripheral neuropathy
• Pelvic surgery, including hysterectomy and prostate surgery, and pelvic radiation
• Pelvic floor dysfunction: muscles that are too weak or too tight
• Low testosterone, thyroid disease and high prolactin
• Alcohol, cannabis and other drugs
• Aging, which can make orgasm take longer and feel less intense

Insufficient stimulation

Not enough time, the wrong kind of touch, or lack of knowledge about one's own body is one of the most common and most treatable causes, especially in lifelong anorgasmia.

Diagnosis

A doctor, gynecologist, urologist or sex therapist will ask about:

• whether you have ever had orgasms, and in which situations
• desire, arousal, lubrication or erection, and pain
• relationship and emotional factors
• medicines, alcohol and drugs
• medical history including diabetes, surgery, childbirth and menopause

A physical exam may look for vaginal atrophy, pain points, pelvic floor tension or nerve problems. Blood tests for hormones, thyroid and blood sugar are used when a physical cause is suspected. There is no single test for anorgasmia.

Treatment

Education and self-help

• Learning about your body, including the role of the clitoris, and what kind of stimulation works for you
• Directed masturbation: a structured program of self-exploration, highly effective for lifelong anorgasmia in women
• Vibrators, which provide stronger, consistent stimulation and help many people reach orgasm
• Sensate focus: exercises with a partner that remove pressure to perform and rebuild pleasurable touch
• Communicating with your partner about what feels good, and allowing more time for arousal

Therapy

• Sex therapy with a certified sex therapist, alone or as a couple
• Cognitive behavioral therapy for anxiety, negative beliefs and body image
• Couples therapy for relationship problems
• Trauma-focused therapy when past abuse is a factor
• Pelvic floor physical therapy for muscle tension, pain or weakness

Medicine-related anorgasmia

Do not stop an antidepressant suddenly. Ask your prescriber about:

• lowering the dose
• switching to an antidepressant with fewer sexual side effects, such as bupropion or mirtazapine
• adding bupropion
• timing doses around sexual activity, for some medicines

Medical treatments

• Vaginal estrogen, DHEA or ospemifene for menopausal dryness and atrophy, which can improve sensation and comfort
• Lubricants and moisturizers for dryness
• Testosterone for some postmenopausal women with low desire, under specialist supervision
• Treating erectile dysfunction, diabetes, thyroid disease or pain that contributes
• Clitoral vacuum devices help some women with arousal difficulty

No medicine is approved in the US specifically to treat anorgasmia.

Outlook

Anorgasmia is very treatable. Women with lifelong anorgasmia have high success rates with directed masturbation and sex therapy. Acquired anorgasmia often improves once the cause, such as a medicine, menopause changes or relationship stress, is addressed.

Frequently asked questions

What causes anorgasmia?

Common causes include antidepressants, anxiety, stress, relationship problems, not enough clitoral stimulation, menopause, diabetes, nerve damage, pelvic surgery and alcohol. Often several factors combine, so treatment works best when it addresses both physical and emotional aspects.

Is it normal not to orgasm during intercourse?

Yes. Most women need direct clitoral stimulation to reach orgasm, and many do not reach it through penetration alone. This is a normal variation, not anorgasmia. Adding clitoral stimulation by hand or a vibrator during sex often helps.

Can antidepressants cause anorgasmia?

Yes. SSRIs and SNRIs commonly delay or block orgasm in both women and men. Talk to your prescriber, who may adjust the dose, switch to a different medicine such as bupropion, or add one that counteracts the effect. Do not stop your medicine abruptly.

Can men have anorgasmia?

Yes. In men it is often called delayed ejaculation or anorgasmia. It is linked to SSRIs, diabetes, nerve damage, low testosterone, prostate surgery, alcohol and psychological factors. A urologist or sex therapist can help.

How is anorgasmia treated?

Treatment includes sex education, directed self-exploration, vibrators, sex therapy, couples counseling, pelvic floor therapy, medicine changes, and treating conditions such as menopause symptoms, diabetes or pain during sex. Many people regain orgasms with these approaches.