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Improving Sexual Function in Women with Cognitive Behavioral Therapy

In a previous post on The Pelvic Rehab Report, Sagira Vora, PT, MPT, WCS, PRPC explored the impact that pelvic floor exercises can have on arousal and orgasm in women. Today we hear part two of the conversation, and learn what factors can impact a woman's ability to achieve orgasm.

Mindfulness“An orgasm in the human female is a variable, transient peak sensation of intense pleasure, creating an altered state of consciousness, usually with an initiation accompanied by involuntary, rhythmic contractions of the pelvic striated circumvaginal musculature, often with concomitant uterine and anal contractions, and myotonia that resolves the sexually induced vasocongestion and myotonia, generally with an induction of well-being and contentment.”

Wow, that sounds like paradise! The question is--how to get there? Many of our cohorts and many our female patients have not experienced this or orgasm happens for them rarely. Findings from surveys and clinical reports suggest that orgasm problems are the second most frequently reported sexual problems in women. Some of the reasons cited for lack of orgasm are orgasm importance, sexual desire, sexual self-esteem, and openness of sexual communication with partner by Kontula el. al. in 2016. Rowland found that most commonly-endorsed reasons were stress/anxiety, insufficient arousal, and lack of time during sex, body image, pain, inadequate lubrication.

One factor that comes up consistently, is the ability of women to focus on sexual stimuli. This point has been brought up by various studies and presented in different ways. Chambless talks about mindfulness training and improvements in orgasm ability noted equally in women who practiced mindfulness vs. women who engaged in Kegels and mindfulness. Rosenbaum and Padua note in their book, The Overactive Pelvic Floor, “women who do not have a low-tone pelvic floor and who seek to enhance sexual arousal and more frequent orgasms have not much to gain from pelvic floor muscle training. Actually, a relaxed pelvic floor and mindful attention to sexual stimuli and bodily sensations seem a more effective means of enhancing sexual arousal and orgasm.” Various studies specifically studying the effect of mindfulness training have demonstrated both improved arousal and orgasm ability in women who practiced mindfulness. Brotto and Basson found their treatment group, which consisted of 68 otherwise healthy women, who underwent mindful meditation, cognitive behavioral training and education, improved in sexual desire, sexual arousal, lubrication, sexual satisfaction, and overall sexual functioning.

Cognitive-behavioral therapy appears to play a significant role in improving sexual function in women. Meston et. al. notes, “cognitive behavioral therapy for anorgasmia focuses on promoting changes in attitudes and sexually relevant thoughts, decreasing anxiety, and increasing orgasmic ability and satisfaction. To date there are no pharmacological agents proven to be beneficial beyond placebo in enhancing orgasmic function in women.”

Alas, there are no magic pills to create the above described “state of altered consciousness,” allowing women a sense of “well-being and contentment.” However, mindfulness training and cognitive behavioral therapy are both accessible and attainable for women who want to improve their ability to enjoy this much desired state. Many Pelvic floor therapist incorporate cognitive behavioral and mindfulness approaches in their practice.

The studies above mention pain as one of the factors for inability to experience arousal and orgasm. Hucker and Mccabe even noted that their mindfulness treatment group demonstrated significant improvements in all domains of female sexual response except for sexual pain. Dealing with sexual pain is a daily battle pelvic floor therapist face each day. So, how do women with sexual pain dysfunction differ from women who are experiencing sexual dysfunction but not pain? Let’s explore this in our next blog…


Chambless DL, Sultan FE, Stern TE, O’Neill C, Garrison S. Jackson A. Effect of pubococcygeal exercise on coital orgasm in women. J Consult CLin Psychol. 1984; 52:114-8
Bratto LA, Basson R. Group mindfulness-based therapy significantly improves sexual desire in women Behav Res Ther. 2014 Jun; 57:43-5
Hucker A. Mccabe MP. Incorporating Mindfulness and Chat Groups Into an Online Cognitive Behavioral Therapy for Mixed Female Sexual Problems. J Sex Res. 2015;52(6):627-33
Kontula O., Mettienen A. Determinants of female sexual orgasms. Socioaffect Neurosci Psychol. 2016 Oct 25;6:31624. doi: 10.3402/snp.v6.31624. eCollection 2016
Meston CM1, Levin RJ, Sipski ML, Hull EM, Heiman JR. Women’s orgasm. Annu Rev Sex Res. 2004;15:173-257. Review
Rosenbaum, Talli Y., Padoa, Anna. The overactive Pelvic floor. 1st ed. 2016
Roland DL, Cempel LM, Tempel AR. Women’s attributions on why they have difficulty reaching orgasm. J. Marital Therapy. 2018 Jan 3:0

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Feeding the Microbiota-Gut-Brain Axis

Anxiety and depression are frequently encountered co-morbidities in the clients we serve in pelvic rehabilitation. This observation several years ago in clinical practice is one of many that prompted me down the path of exploring the connection between the gut, the brain, and overall health. In answering the question about these connections, I discovered many nutritionally related truths that are being rapidly elucidated in the literature.

A recent study by Sandhu, et.al. (2017) examines the role of the gut microbiota on the health of the brain and it’s influence on anxiety and depression. The title of the study, “Feeding the microbiota-gut-brain axis: diet, microbiome, and neuropsychiatry” gives us pause to consider the impact of our diets on this axis and in turn, on the health of our nervous system. The authors state:

It is diet composition and nutritional status that has been repeatedly been shown to be one of the most critical modifiable factors regulating the gut microbiota at different time points across the lifespan and under various health conditions.

With diet and nutritional status being the most critical modifiable factors in the health of this system, it becomes our responsibility to seek to understand this system and its influencing factors. We need to learn how to nourish the microbiota-gut-brain axis.

While anxiety and depression are common co-morbidities we encounter, we also commonly detect imbalance between the sympathetic and parasympathetic nervous system in our patients leading to, for example, pelvic floor muscle tension. In light of this study we must first and foremost ask: what is the microbiota? How can it influence our nervous system? How does this correlate to anxiety and depression? The answers to these questions provide clinical insight with far-reaching impact. We also consider: which circumstances disrupt the health of this system and which improve it? Finally, could understanding of this axis, among other nutritional correlates, provide a novel approach to bowel dysfunction, bladder dysfunction, chronic pelvic pain?

Be a part of the paradigm shift to integrative understanding as we explore these and many other burning questions. Please join us for insightful discussion in White Plains, NY March 31-April 1, 2017 for our next offering of Nutrition Perspectives for the Pelvic Rehab Therapist.


Sandhu, K. V., Sherwin, E., Schellekens, H., Stanton, C., Dinan, T. G., & Cryan, J. F. (2017). Feeding the microbiota-gut-brain axis: diet, microbiome, and neuropsychiatry. Transl Res, 179, 223-244. doi:10.1016/j.trsl.2016.10.002

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