She looked tense and agitated.
'I have been married for three years and have a good relationship with my husband,' my patient told me. 'It took me a long time to realise that I was not achieving climax during sex. I get aroused easily but I do not get the pleasurable orgasmic sensations that my close friends have experienced. The frustration is indescribable.
'My husband is feeling the stress too. We discussed different approaches such as more foreplay and going away on short holidays, which might help us feel more relaxed. It was all to no avail. I am afraid that this may affect our relationship in the long run."
F, a 32-year-old, is suffering from a common female sexual disorder called anorgasmia in which she is unable to reach orgasm when sexually excited and is distressed by the problem.
Orgasm is a phase of sexual response where there is a feeling of intense physical pleasure and release of tension, accompanied by involuntary, rhythmic contractions of pelvic muscles. Sexual response is a complex coordination of the mind and the body and both need to be functioning well for orgasms to occur.
Anorgasmia affects between 15 and 40 per cent of women. It can be divided into a primary disorder, in which a woman has never experienced orgasm, as in F's case, and a secondary one, when the ability to reach climax is lost.
Inability to reach orgasm is usually a result of sexual inexperience, performance anxiety, past sexual trauma or a strict upbringing that led to an inhibition of sexual response.
In F's case, she was brought up in a very strict and traditional family where the subject of sex was never brought up.
Other causes include diabetes, neurological diseases, blood pressure medications and antidepressants - particularly selective serotonin reuptake inhibitors (SSRIs).
Women who have relationship issues such as a lack of emotional connection with their partner, unresolved conflicts, poor communication of sexual needs and preferences and infidelity or breach of trust may also suffer from anorgasmia.
An evaluation of this condition usually consists of reviewing a patient's thorough medical history and physical examination to rule out underlying medical conditions.
Like many sexual dysfunctions, diagnosis is somewhat subjective and depends a great deal upon the thoughts, emotions and desires of the patient.
A treatment plan includes sex education, communication training and behavioural exercises.
For many Asian women, socio-cultural influences and family upbringing (as in F's case) often lead to inhibitions and difficulty in receiving pleasurable sexual stimuli. It is important to educate the couple on the anatomy and physiology of sexual intimacy.
The couple should also be counselled on the emotional or situational factors that might contribute to the lack of orgasm.
Women who are suffering from the side effects of SSRIs may benefit from a change to alternative medication (like Bupropion). Older women can be helped by the use of vaginal lubricants or female hormonal cream. This may improve blood flow to the vagina and make intimacy more pleasurable. Clitoral vacuum pump devices that improve clitoral blood flow and sexual sensations are helpful. Herbal supplements and testosterone (male hormone) have been used with varying degrees of success.
If there are other sexual dysfunctions (such as lack of interest and pain during intercourse) present at the same time, these need to be addressed as well.
F and her husband were taught the mechanisms of sexual arousal and the differences in the male and female sexual response. To help her achieve orgasm, sensate focus (specific sexual exercises) and Kegel exercises (contracting and relaxing of the pelvic floor muscles) were recommended to improve the tone of her pelvic muscles. Through the body-awareness programme and comfort with orgasm, F slowly took charge in directing her husband during intimacy.
Last Christmas, I received a card from F. She wrote: 'Dear Doc, thanks for your help, my marital life is more fulfilling and I feel more complete as a woman now."
Dr Peter Chew is a senior consultant gynaecologist and obstetrician at Gleneagles Medical Centre. He is the founder chairman of aLife (www.alife.org.sg), a charitable organisation with a mission to nurture and promote healthy family life.
This article was first published in Mind Your Body, The Straits Times on Jan 22, 2009.