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REVIEW
The Effects of Exercise on Sexual Function in Women
Amelia M. Stanton, BA, Ariel B. Handy, BA, and Cindy M. Meston, PhD
ABSTRACT
Background: Acute exercise is associated with transient changes in metabolic rate, muscle activation, and blood
flow, whereas chronic exercise facilitates long-lasting adaptations that ultimately improve physical performance.
Exercise in general is known to improve both physical and psychological health, but the differential effects of
brief bouts of exercise vs long-term exercise regimens on sexual function are less clear.
Aim: The purpose of this review was to assess the direct and indirect effects of both acute and chronic exercise on
multiple domains of sexual function in women.
Methods: A literature review of published studies on exercise and sexual function was conducted. Terms
including “acute exercise,”“chronic exercise,”“sexual function,”“sexual arousal,”“sexual desire,”“lubrication,”
“sexual pain,”and “sexual satisfaction”were used.
Outcomes: This review identifies key relationships between form of exercise (ie, chronic or acute) and domain of
sexual function.
Results: Improvements in physiological sexual arousal following acute exercise appear to be driven by increases
in sympathetic nervous system activity and endocrine factors. Chronic exercise likely enhances sexual satisfaction
indirectly by preserving autonomic flexibility, which benefits cardiovascular health and mood. Positive body
image due to chronic exercise also increases sexual well-being. Though few studies have examined the efficacy of
month-long exercise programs for the treatment of sexual dysfunction, exercise interventions have alleviated
sexual concerns in 2 specific clinical populations: women with anti-depressant-induced sexual dysfunction and
women who have undergone hysterectomies.
Conclusions: This review highlights the positive effects of acute and chronic exercise on sexual function in
women. Directions for future research are discussed, and clinicians are encouraged to tailor specific exercise
prescriptions to meet their patients’individual needs. Stanton AM, Handy AB, Meston CM, et al. The Effects
of Exercise on Sexual Function in Women. Sex Med Rev 2018;XX:XXXeXXX.
Copyright 2018, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Female Sexual Function; Acute Exercise; Chronic Exercise; Sexual Dysfunction
INTRODUCTION
The benefits of exercise on both physical and mental health are
well documented in the scientific literature and are frequently
conveyed by popular media. According to the American College of
Sports Medicine, exercise and physical activity decrease the risk of
developing congenital heart disease, stroke, type 2 diabetes, and
some forms of cancer.
1
Exercise also contributes to the prevention
and improvement of mild to moderate depressive and anxiety
disorders, enhances cognitive function, and improves quality of
life.
1
However, the relationship between exercise and sexual
function has received significantly less attention than the effects of
exercise on physical and mental health. Though the connection
between sexuality and exercise is perhaps less intuitive, many of the
physiological mechanisms involved in exercise are also implicated
in female sexual function. If there is a significant relationship be-
tween exercise and improvements in sexual health, exercise could
be a particularly appealing form of treatment for sexual concerns,
as it does not carry the stigma that is often associated with sex
therapy and pharmacotherapy. Individuals may avoid seeking help
for a sexual concern due to discomfort, shame, or fear of not being
taken seriously by their providers. Primary care providers often
find it challenging to talk about sexual matters in the exam room,
which could result in missed opportunities for prevention and
intervention.
2,3
Given these challenges, exercise may be an
attractive treatment option, either as a stand-alone intervention or
as a complement to other forms of treatment.
Exercise has both an acute phase, during which homeostatic
adjustments occur, and a more chronic phase, which is
Received September 12, 2017. Accepted February 12, 2018.
Department of Psychology, University of Texas at Austin, Austin, TX, USA
Copyright ª2018, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.sxmr.2018.02.004
Sex Med Rev 2018;-:1e10 1
accompanied by long-term physiological adaptations. During
and immediately following a bout of exercise, there are metabolic
and neuromuscular changes that are proportional to increases in
metabolic rate. Oxygen consumption, an index of metabolic rate,
can increase from around 3 mL oxygen/kg/min at rest to between
50 and 70 mL oxygen/kg/min, depending on an individual’s
average level of physical activity.
4
A few hours after exercise,
oxygen consumption returns to baseline. These metabolic
changes are transient. Other changes that occur in order to meet
the demands of increased metabolic rate include altered blood
flow to the active muscles, increased heart rate, increased
breathing rate, secretion of stress hormones (eg, adrenocortico-
tropic hormone, cortisol, catecholamines), and increased body
temperature.
5
These changes maintain the constancy of the
body’s internal state during exercise.
4
When exercise is repeated regularly, chronic changes occur as
early as a few weeks following the start of a new regimen.
4
The
nature of these more long-term changes depends on the type of
exercise. A long-distance runner, for example, will experience
different neuromuscular changes following months of training
than will a wrestler. The chronic effects of exercise are also
influenced by an interaction of several other important factors,
such as previous exposure to the activity, the type of muscle
action, and duration of the activity. Individual differences in
responses to the same exercise stimulus affect the speed at which
long-term adaptations occur.
6
Variations in the timing and
composition of food intake and the absorption of nutrients may
also impact chronic adaptations. For example, eating carbohy-
drates or a combination of carbohydrates and protein reduces the
expression of genes involved in lipid metabolism,
7
and there have
been significant differences in training adaptation following
dietary interventions.
8
Acting together, these factors influence
the pathways that are involved in protein synthesis or degrada-
tion, leading to changes in performance.
Chronic exercise regimens typically emphasize either endur-
ance (aerobic) training or strength (resistance) training. Endur-
ance training improves resistance to fatigue by increasing the
maximal oxygen uptake (V0
2max
).
4
Increases in V0
2max
result
from changes to muscle properties following training, enabling
individuals to take on an increased physiological “workload”
during subsequent exercise.
9
Unlike endurance training, strength
training increases muscle strength, or the amount of force that is
produced by a given muscle. Muscle strength improves over time
when individuals use resistance bands, machine weights, or free
weights to manipulate the intensity and number of repetitions as
well as the length of the recovery period between repetitions.
10
Given the differences in the effects of acute and chronic ex-
ercise, this review addresses both types of exercise in relation to
female sexual function. We pay particular attention to the do-
mains that appear to be most impacted by exercise: sexual
arousal, desire, and satisfaction. Sexual arousal has both a phys-
iological (ie, genital) and a subjective (ie, being mentally “turned
on”) component, both of which are associated with increased
engagement (physiological or cognitive) in response to a sexual
stimulus.
11
Desire is more indicative of motivation to engage in
or be receptive to a sexual event, and satisfaction reflects the
fulfillment of one’s sexual wishes, expectations, or needs.
11
This
review also highlights populations with specific types of sexual
dysfunction that may benefit from exercise interventions.
THE EFFECTS OF ACUTE EXERCISE ON
PHYSIOLOGICAL SEXUAL AROUSAL
Over the past 2 decades, research has demonstrated a strong
link between acute exercise and increased physiological (ie,
genital) sexual arousal in women. Acute exercise influences a
number of bodily systems that could feasibly impact women’s
physiological sexual arousal. Exercise has been shown to posi-
tively affect a variety of hormones such as cortisol,
12
estrogen,
13
prolactin,
14
oxytocin,
15
and testosterone,
16,17
all of which have
been linked to arousal, some more strongly than others. The
effects of exercise on hormonal responses in women vary based
on the type of exercise and, for pre-menopausal women, the
menstrual cycle. 1 Study found that moderate- to high-intensity
(60e80% V0
2max
) exercise provokes increases in circulating
cortisol levels, whereas low-intensity (40% V0
2max
) exercise leads
to a reduction in circulating cortisol levels.
12
In another study,
30 minutes of exercise at 60% V0
2max
during the luteal phase
resulted in significant increases in estradiol; this was not the case
during menses.
18
More recent work has demonstrated that an
exercise regimen of 150 minutes of moderate to vigorous aerobic
exercise over a 16-week period resulted in significant changes in
estrogen metabolism.
13
Prolactin also increases post-exercise. In a
small sample of women runners, prolactin concentrations
increased significantly following physical activity.
19
There is also
evidence for increased oxytocin following prolonged endurance
exercise; oxytocin levels do not increase following short bursts of
high-intensity exercise or steady runs on a treadmill.
15
The
effects of exercise on testosterone also depend on the type of
exercise. Testosterone does not tend to increase following
resistance exercise,
20,21
but it is elevated after aerobic exercise in
pre-menopausal women.
22
These hormones either have direct or indirect effects on sexual
arousal function in women. Hamilton and colleagues
23
found
that some women experience an increase in cortisol during sexual
arousal. Women who exhibited this pattern tended to have lower
scores on the arousal domain of the Female Sexual Function
Index. The authors of this study suggested that a laboratory test
of sexual responding might be more stressful for women who
have experienced arousal dysfunction. Estrogen is known to play
a significant role in the regulation of female sexual arousal
function. Estradiol levels influence nerve transmission and affect
cells in both the peripheral and central nervous systems. Chronic
decreases in serum estrogen levels result in the thinning of the
vaginal epithelium and the atrophy of vaginal wall smooth
muscle, which lead to a decrease in vasodilation and ultimately to
Sex Med Rev 2018;-:1e10
2Stanton et al
decreased genital sensations.
24
The relationship between prolac-
tin and arousal is more indirect than that of estrogen and arousal.
There are pronounced increases in prolactin levels following
masturbation-induced orgasm,
25
which may provide a negative
feedback signal controlling sexual arousal and thus decreasing the
likelihood of continued sexual activity.
26
Like prolactin, oxytocin
appears to be most related to orgasm function,
27
but recent data
indicate that oxytocin administration has more specific effects on
the orgasmic/post-orgasmic interval as well as on parameters of
partner interactions (eg, contentment after intercourse).
28
Though these effects are not specific to arousal, they may
contribute to a positive feedback loop that facilities sexual arousal
with a particular partner. Androgens, including testosterone and
dihydrotestosterone, may facilitate increased arousal through
aromatization to estrogens,
29
which are important for main-
taining the health and integrity of vaginal tissue. Androgens have
also been shown to influence attentional aspects of sexual func-
tion,
30
which contribute to arousal.
It is also feasible that sympathetic nervous system (SNS)
activation may be driving the association between acute exercise
and increased physiological sexual arousal in women. Biochem-
ical and physiological research indicates that diffuse SNS
discharge occurs during the later stages of sexual arousal in
women,
31
with marked increases in heart rate and blood pressure
occurring during orgasm.
32
Increases in plasma norepinephrine,
a sensitive index of SNS activity, have also been shown to
accompany increases in sexual arousal during intercourse.
33
A large body of literature supports the critical role of the SNS
in increasing sexual arousal following short bouts of exercise. In a
series of laboratory studies,
34,35
Meston and Gorzalka examined
the direct effects of acute exercise on physiological sexual arousal.
The first of these studies required sexually functional participants
to engage in 20 minutes of intense exercise (stationary cycling)
prior to viewing a non-sexual and erotic film sequence.
34
The
procedure consisted of an orientation screening, questionnaire
session, and a 20-minute bicycle ergometer fitness test, followed
by 2 counter-balanced experimental sessions (exercise, no exer-
cise), which took place on different days. During the fitness test,
the experimenters determined each participant’s maximum vol-
ume of oxygen uptake so that they could instruct the participants
to cycle at a constant 70% of their estimated maximum volume.
By ensuring that all participants worked at equivalent levels of
their V0
2max
, differences in physiological responses resulting
from variations in fitness levels were minimized. During the
exercise session, participants cycled for 20 minutes and then
watched a non-sexual film followed by an erotic film while their
genital arousal (recorded as vaginal pulse amplitude [VPA]) was
measured with a vaginal photoplethysmograph.
36
In the no-
exercise condition, participants sat for 20 minutes, inserted the
vaginal photoplethysmograph, and viewed a different non-sexual
and erotic film sequence. The results revealed that VPA was
significantly higher during the presentation of the erotic film
after exercise than it was during the erotic film in the no-exercise
condition. There were no significant differences between con-
ditions in VPA responses during the non-sexual film, indicating
that exercise did not simply increase blood flow to the genitals;
rather, it prepared the woman’s body for sexual arousal so that
when she was in a sexual context (eg, viewing the erotic film) her
body responded more intensely.
In a follow-up study using a similar methodology, Meston and
Gorzalka
36
examined the effect of timing on the relationship
between exercise and increased sexual arousal in women by
measuring physiological arousal in response to erotic films at
either 5, 15, or 30 minutes post-exercise. At both 15 and 30
minutes post-exercise, there was a significant increase in physi-
ological arousal (indexed by VPA) to the erotic films compared to
the no-exercise control condition. However, there was no sig-
nificant increase in VPA immediately following exercise. During
and immediately following exercise, a decrease in vascular resis-
tance of the working muscles typically causes a significant in-
crease in blood flow to those muscles.
37
Therefore, blood flow
may have shifted away from the genital region to temporarily
help restore the working muscles. The finding that exercise
inhibited genital arousal immediately following exercise but
facilitated genital arousal at 15 and 30 minutes post-exercise led
the authors to speculate that there may be an optimal time for
engaging in sexual activity following exercise.
To determine if there is indeed an ideal window of time post-
exercise for sexual activity, Lorenz and colleagues
38
performed a
secondary analysis of participants from the control conditions of
3 previously published studies.
39e41
SNS activity was assessed
using heart rate variability, which refers to the degree of vari-
ability in the lengths of time between successive heartbeats.
Heart rate variability is a useful non-invasive index of the relative
balance of sympathetic and parasympathetic forces acting on the
heart.
42
As predicted, the results revealed a curvilinear relation-
ship between SNS activity and women’s physiological sexual
arousal. That is, moderate increases in SNS activity were asso-
ciated with greater physiological sexual arousal responses, while
low and high SNS activation were associated with lower physi-
ological sexual arousal. These results suggested that there is an
optimal level of SNS activity from acute exercise for the facili-
tation of genital sexual arousal in women.
If exercise increases genital arousal via SNS activation, then
blocking SNS arousal during exercise should diminish the
enhancing influence of exercise on VPA responses. To test this
hypothesis, Meston and Gorzalka
43
administered either placebo
or 0.2 mg of clonidine, which acts centrally as a norepinephrine
antagonist and peripherally as an inhibitor of sympathetic
outflow, to 30 sexually functional women in 2 counter-balanced
sessions. Before viewing the experimental films, half of the par-
ticipants engaged in 20 minutes of exercise in order to elicit
significant SNS activation, and the other half did not exercise.
Following heightened SNS activation (via acute exercise), there
was a significant decrease in VPA responses to the erotic film in
the clonidine condition compared to placebo condition. Among
Sex Med Rev 2018;-:1e10
Exercise and Sexual Function in Women 3
the participants who did not engage in exercise prior to viewing
the film sequence, clonidine showed a non-significant trend to-
ward decreasing VPA responses compared with placebo. Given
that clonidine inhibited sexual responding only when partici-
pants were in a state of heightened SNS activity (ie, after acute
exercise), it is likely that the drug suppressed sexual arousal by
direct inhibition of sympathetic outflow. The fact that clonidine
has been reported to significantly inhibit SNS, but not hormonal
responses to exercise,
44
is consistent with the hypothesis that
clonidine acted to inhibit sexual responding via suppressed SNS
activity.
Taken together, the studies cited above demonstrate that there
is a direct relationship between acute exercise and increased
physiological sexual arousal in women.
THE EFFECTS OF CHRONIC EXERCISE ON SEXUAL
WELL-BEING
The effects of chronic exercise on female sexual function are
more challenging to assess than those of acute exercise. The only
study that has directly examined the impact of a longer exercise
protocol on some domain of sexual function tested the effects of
a 3-week exercise regimen on both arousal and desire.
45
It is
unclear if 3 weeks of exercise (in this study, the exercise program
was a combination of strength and endurance training, 3 times
per week) was enough to catalyze the physiological adaptations
that are associated with repeated exercise. The increases in muscle
size that are associated with strength training do not occur until
8e10 weeks after the start of a new regimen.
46,47
With respect to
endurance training, it may take 8e12 weeks of low-level aerobic
work to build a strong aerobic base.
48,49
There is also some in-
dividual variability in responsiveness to regular exercise training;
for example, genetic factors play an important role in deter-
mining sub-maximal exercise rate and blood pressure.
50
Although no studies have directly assessed the relationship
between chronic exercise and sexual function in women, chronic
exercise likely has a number of indirect effects on sexual well-
being. There are 3 variables that are positively influenced by
exercise that have also been related to different domains of sexual
function: cardiovascular health, mood, and body image. The
relationships between these variables and exercise, as well as
subsequent connections to sexual function, are reviewed below.
Cardiovascular Health
Chronic exercise and regular physical activity are protective
against cardiovascular disease.
51
Indeed, regular physical activity
has been shown to reduce the risk of cardiovascular disease by
one third to one half.
52
In a review of the effects of exercise
training on hypertension severity, exercise not only led to a
decrease in blood pressure, but also to significant reductions in
plasma low density, increases in high-density lipoprotein lipid
levels, and improvements in insulin sensitivity.
53
The protective
effects of exercise may be due to its impact on the autonomic
nervous system.
52
Altered autonomic function can have a large
effect on cardiovascular disease; reduced heart rate variability, a
marker of autonomic flexibility, has been associated with an
increase in the incidence of coronary heart disease and mortal-
ity.
54
Correspondingly, hundreds of studies in the past several
decades have demonstrated that individuals who are physically
active or trained in exercise have higher heart rate variably than
control groups that are comparatively sedentary. This effect
appears to be consistent across age and gender. Exercise may keep
the autonomic nervous system healthy by acting against
age-related reductions in baroreflex function,
55
which helps
maintain relatively low heart rate and decreased blood pressure.
If chronic exercise is improving cardiovascular health via
vascular mechanisms, then it follows that those improvements
will also be associated with enhanced sexual function. Athero-
sclerotic vascular disease interferes with the normal vascular
physiological processes that are associated with vaginal and
clitoral engorgement,
56
and hypertension is strongly linked to
female sexual dysfunction. In a sample of over 400 women,
42.1% of the hypertensive women were found to have sexual
problems, whereas only 19.4% of the normotensive women re-
ported sexual concerns.
57
Medications used to treat hypertension
(eg, lipid regulators, beta blockers) have also been linked to
sexual dysfunction.
58
Given the positive associations between
chronic exercise and cardiovascular health, developing a long-
term exercise regime may be an appropriate option for control-
ling hypertension, enhancing vaginal blood flow, and potentially
avoiding medication-induced sexual problems.
Mood
Exercise is well-known to boost mood
59
as well as decrease
depression and stress.
60
Moderate-intensity exercise programs
have led to improvements in affect,
61
and the anti-depressant
effects of exercise tend to outlast the length of the interven-
tion.
62
Aerobic exercise, in particular, influences mood by
stimulating serotonin activity in the brain, which increases
tryptophan in the blood. An enzyme found in tryptophan,
4-mono-oxygenase, facilitates the synthesis of serotonin.
63
Though most studies have examined the relationship between
aerobic exercise and improved mood, there is some evidence
indicating that resistance-based exercise has similar effects.
64
The
mood-boosting effects of acute exercise are small and short-
lived,
65
but long-lasting benefits are likely to result from chronic
exercise.
The direct impact of exercise on mood may be contributing to
an indirect effect of exercise on sexual satisfaction. A correlational
study revealed that, among sexually active university students, 20
minutes of physical activity at least 3 times a week was associated
with higher levels of sexual satisfaction.
66
Clinicians working
with patients who are experiencing sexual problems should
consider presenting them with this evidence, as this prescription
has a high degree of clinical utility. The authors of this study
suggest that the physiological benefits of exercise (eg, release of
Sex Med Rev 2018;-:1e10
4Stanton et al
endorphins) improve mood, which then leads to an increase in
satisfaction. It is also conceivable that factors other than mood,
such as body esteem, may be driving the relationship between
exercise and sexual satisfaction. Esteem about body parts that can
be physically altered through exercise (eg, thigh size, stomach
appearance, and weight) has been linked to greater sexual
satisfaction, as has esteem related to body parts that cannot be
easily changed through physical activity, such as the breasts and
the face.
67
Body Image
It is well known that chronic exercise improves body image.
Individuals who exercise regularly have a more positive body
image than those who do not, though the effect size is small.
68
Correlational research has shown that women who engage in
frequent exercise have lower levels of body dissatisfaction than
those who exercise less often.
69
Systematic exercise programs
have also led to improved body image post-intervention
compared to pre-intervention. Among women taking part in
either an aerobic exercise program or a social psychology course,
exercisers exhibited significant gains in body esteem over the
course of the 10-week study, whereas their counterparts in the
psychology course did not.
70
In general, exercise intervention
studies have documented significant improvements in body im-
age, though effects vary by type of exercise and by gender. There
appears to be a greater effect of exercise on body image for those
engaging in aerobic and anaerobic exercise (Hedges g¼0.45) vs
one or the other; stronger effects were also linked to strenuous
exercise (g¼0.45) compared to moderate (g¼0.36) or mild
(g¼0.04) exercise. It appears as though women reap greater
benefits from exercise than men (g¼0.43 vs g¼0.26).
68
Ac-
cording to Hausenblas and Fallon,
68
these results are due in part
to: (1) increased activity levels, which contribute to the devel-
opment of a lean and fit physique, one that resembles the
aesthetic ideal put forth by society; and (2) improvements in
psychological health, both of which enhance sexual well-being.
Positive body image is directly associated with greater sexual
well-being.
71
Possible mechanisms driving this association
include sexual objectification, hyper-attentiveness to one’s body,
and cognitive distraction. Sexual objectification (also known as
“self-objectification”) refers to valuing one’s body only for its
sexual usefulness to others. When a woman comes to view herself
as a sexual object, she may develop a habitual practice of
monitoring her body’s outward appearance.
72
This practice re-
inforces a hyper-attentiveness to bodily changes as well as
perceived physical flaws, both of which are particularly relevant
to the sexual domain. By definition, sexual activity involves
another person focusing attention on one’s body. Cognitive
distraction, or negative thoughts about one’s body during sexual
activity, contribute to a phenomenon known as “spectatoring”
73
;
spectators become distracted by thoughts about their own sexual
performance. Barlow model of sexual function
74
suggests that
intense focus on one’s own sexual performance distracts the
individual from other pleasurable aspects (eg, orgasm, enhanced
intimacy and emotional connection) of the sexual experience,
ultimately decreasing sexual pleasure and satisfaction. It is
reasonable to expect that women who feel more positively about
their bodies likely experience less distraction during sex, which
allows them to engage more fully in the sexual experience. This
was the case in 1 study that assessed sexual satisfaction, body
image, and cognitive distraction among college-aged women.
67
Results indicated that body image specific to sexual attractive-
ness, as well as appearance-based distracting thoughts, signifi-
cantly predicted satisfaction. That is, the more esteem women
had for their sexual body parts and the less they focused on their
bodies during sex, the higher their sexual satisfaction.
Poor body image is also associated with sexual avoidance.
Discomfort in intimate situations that arises from poor body
image leads to decreased desire to engage in future sexual activ-
ity.
75
Indeed, in a study of over 350 undergraduate students,
researchers found a significant relationship between negative
body image and sexual avoidance.
76
Seal and colleagues
77
also
examined the role of body image in predicting future sexual
activity. In their study, body esteem was positively related to
both self-reported sexual desire and desire in response to erotic
material. That is, feeling good about one’s body predicted greater
desire, likely leading to increased engagement with sexual stimuli
in the future. Notably, the link between body esteem and sexual
desire was unrelated to body mass index, suggesting that actual
body size is less relevant to sexual function than how one feels
about her body.
EXERCISE AS A TREATMENT FOR SEXUAL
DYSFUNCTION
Few studies have examined acute or chronic exercise protocols
as stand-alone treatments for sexual dysfunction in women.
There are 2 notable exceptions, and they are reviewed here.
These studies developed specific exercise-based interventions to
meet the needs of 2 clinical populations: women with anti-
depressant-induced sexual dysfunction and women who have
undergone hysterectomies.
Anti-Depressant-Induced Sexual Dysfunction
It is estimated that 1 in 6 U.S. women has been prescribed an
anti-depressant,
78
primarily selective serotonin reuptake in-
hibitors (SSRIs) and selective norepinephrine reuptake inhibitors
(SNRIs). Nearly all women taking anti-depressants (96%) report
at least 1 sexual side effect,
79
most commonly difficulties with
desire, arousal, or orgasm. Though both SSRIs and SNRIs are
associated with these sexual side effects, SNRIs appear to impair
arousal and orgasm at lower rates compared to SSRIs.
80
The
sexual side effects of SSRIs are most likely linked to peripheral
nervous system adrenergic pathways,
81
particularly to changes in
SNS activity.
80
It is thought that SSRIs suppress SNS activity
through norepinephrine release
82
as well as through sympathetic
Sex Med Rev 2018;-:1e10
Exercise and Sexual Function in Women 5
muscle and vascular nerve firing.
83
SNRIs may counter the in-
hibition of norepinephrine, which occurs alongside increases in
serotonin, by directly increasing the availability of norepineph-
rine.
84
Given that moderate SNS activity, as opposed to very
high or very low SNS activity, is associated with increased genital
arousal, it follows that SNRIs, which suppress SNS activity less
so than SSRIs, are associated with lower rates of genital arousal
problems than are SSRIs.
1 Study
45
examined potential differences between the acute
and chronic effects of SNS activation on sexual function in
women with anti-depressant-induced sexual problems. Partici-
pants were entered into a 9-week randomized cross-over trial.
Baseline levels of sexual activity were recorded for the first 3
weeks. Then, women were randomized to either 3 weeks of
exercise immediately prior to sexual activity, or 3 weeks of
exercise at a time unrelated to sexual activity. The exercise pro-
tocol involved 30 minutes of strength training and cardio with
resistance bands, 3 times a week. To standardize the protocol,
participants were instructed to maintain 70e85% of their
maximum heart rate by changing resistance during exercise. At
the end of 3 weeks, the women crossed over to the other exercise
condition.
Results from this study indicated that, overall, exercise
improved sexual desire and sexual function. There was also evi-
dence to suggest that exercising immediately prior to sexual ac-
tivity may be more beneficial than exercising in general. In
aggregate, these results revealed that exercise improves sexual
function in women with sexual problems due to anti-depressant
medication use, and exercising immediately prior to sexual
activity may provide additional benefit.
Sexual Dysfunction Following Hysterectomy
Hysterectomy is the most common form of gynecological
surgery. In the United States, 80% of hysterectomies are inten-
ded to treat benign conditions.
85
Reports of beneficial outcomes
of hysterectomies include the cessation of abnormal uterine
bleeding, relief from menstrual symptoms and pelvic pain, and
decreases in depression and anxiety.
86
However, a number of
women report negative symptoms post-hysterectomy, including
depression, fatigue, urinary incontinence, constipation, early
ovarian failure, and sexual dysfunction.
87
With regard to sexual
dysfunction, up to 40% of women report a decrease in sexual
activity following the surgery,
88
as well as a lack of vaginal
lubrication, loss of libido, and sexual pain. The uterine sup-
porting ligaments contain sympathetic, parasympathetic, sensory,
and sensory-motor nerve types, and they are considered a major
pathway for autonomic nerves to the pelvic organs. It is feasible
that the negative sexual outcomes following the procedure are a
result of damage to the pelvic autonomic nerves, which may be
affected by the excision of the cervix and the separation of the
uterus from the cardinal and uterosacral ligaments.
89
Given the possibility that hysterectomies may adversely affect
the autonomic nerves that facilitate arousal, 1 study tested the
effects of acute exercise on physiological sexual arousal in women
with a history of benign uterine fibroids who had and had not
undergone the procedure.
90
It was expected that women who had
the procedure would have impaired physiological sexual arousal in
response to erotic stimuli, and that this impairment would be most
apparent after exercise. Surprisingly, exercise significantly
increased VPA responses in women who had undergone hyster-
ectomy. This effect may have been due to the release of 2 specific
hormones, epinephrine and/or norepinephrine, during exercise,
both of which could have facilitated physiological sexual arousal.
Exercise could also have induced changes in other endocrine fac-
tors, neuromediators, or substances released by endothelial cells.
91
As such, exercise may serve as a non-invasive means of enhancing
sexual responding in women who experience sexual arousal diffi-
culties post-hysterectomy.
CONCLUSION
This review identified several domains of sexual function that
are improved by either acute or chronic exercise. Acute exercise
increases physiological sexual arousal in women, and the most
likely mechanism associated with this relationship is SNS acti-
vation, although the roles of hormonal and other potential
changes that occur with exercise cannot yet be ruled out. There
appears to be an optimal level of SNS activation for the
enhancement of genital arousal in women; moderate increases in
SNS activity have been associated with high physiological sexual
arousal responses, whereas both very low and very high SNS
activation are associated with lower responses. There are a
number of indirect effects of chronic exercise on sexual well-
being, such as benefits in cardiovascular health, mood,
and body image. Exercise-based improvements in self-esteem
and body satisfaction have been noted among adolescents
92
and adults.
93,94
Exercise has also been linked to increased en-
ergy and decreased fatigue,
95
which play a positive role in
women’s sexuality.
Although few studies have tested exercise protocols on women
who meet clinical criteria for sexual dysfunction, there are
some notable exceptions. In a series of studies, Meston and
Lorenz
45,90,96
examined the effects of acute exercise on sexual
desire and physiological sexual arousal in women with anti-
depressant-induced sexual dysfunction and women who have
undergone hysterectomies. Results indicate that exercise is an
effective treatment for these populations. Given the paucity of
studies that have tested exercise as an intervention for sexual
dysfunction, there are many variables that have yet to be
examined. These variables include type of strength training (eg,
number of sets and repetitions), type of cardiovascular training
(eg, cycling, walking, running, swimming), and participant age
(eg, pre-menopausal vs post-menopausal). Researchers might also
investigate the relationship between time spent training and
positive sexual health outcomes to determine the length of time
required for maximum benefit. Yet another variable that could be
manipulated in future exercise protocols is nutrition. Variations
Sex Med Rev 2018;-:1e10
6Stanton et al
in the timing and composition of food intake, as well as in the
absorption of nutrients, may also impact chronic adaptations to
exercise. To our knowledge, no studies have examined the rela-
tionship among exercise, food intake, and sexual function; this
may be an important area for future research.
3 Domains of sexual function were addressed in this review.
Studies that examined the relationship between either acute or
chronic exercise and some aspect of sexual function typically
focused on arousal, desire, or satisfaction, ignoring other
potentially relevant domains, such as orgasm, sexual pain, and
lubrication. There are anecdotal reports of exercise-induced
orgasm, with 1 study suggesting that these orgasms are more
common among women who endorse high levels of self-
consciousness during exercise,
97
but the impact of exercise
(either acute or chronic) on orgasm has not been thoroughly
addressed. Likewise, the relationship between exercise and sexual
pain has yet to be established. There is some evidence that a
program of chronic exercise decreases pain in bodily regions close
to but distinct from the genitals (eg, the lower back
98
), but there
has been little attention paid to the potential mitigating effects of
exercise on different types of genital pain.
This review also highlights a need for more exercise inter-
vention studies that target populations with specific types of
sexual dysfunction (eg, female sexual interest/arousal disorder,
female orgasmic disorder, genito-pelvic pain/penetration disor-
der). Researchers may also consider assessing the efficacy of
combination therapies that aim to increase both physiological
arousal and some other domain of sexual function. Developing
and testing exercise interventions for clinical populations will
enable clinicians to offer their patients exercise prescriptions for
their individual sexual concerns.
Corresponding Author: Cindy M. Meston, PhD, Department
of Psychology, University of Texas at Austin, 108 East Dean
Keeton Stop, A8000, Austin, TX, USA 78712. Tel: 512-232-
4644; E-mail: mestoncm@gmail.com
Conflict of Interest: The authors report no conflicts of interest.
Funding: None.
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Amelia M. Stanton; Ariel B. Handy; Cindy M. Meston
(b) Acquisition of Data
Amelia M. Stanton; Ariel B. Handy; Cindy M. Meston
(c) Analysis and Interpretation of Data
Amelia M. Stanton; Ariel B. Handy; Cindy M. Meston
Category 2
(a) Drafting the Article
Amelia M. Stanton; Ariel B. Handy; Cindy M. Meston
(b) Revising It for Intellectual Content
Amelia M. Stanton; Ariel B. Handy; Cindy M. Meston
Category 3
(a) Final Approval of the Completed Article
Amelia M. Stanton; Ariel B. Handy; Cindy M. Meston
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