When you can’t have an orgasm, it may seem like you’re missing out on the holy grail of sex. There are plenty of other reasons to engage in some horizontal (or vertical, if that’s your jam) cardio with another person or with yourself, but it can still feel like you’re barred from some exclusive club everyone else can’t stop talking about.

“Women sometimes come into my office scared out of their minds because they can’t reach orgasm,” Dr. Alyssa Dweck, a gynecologist in New York and assistant clinical professor at the Mount Sinai School of Medicine, tells SELF.

Although medical issues like heart trouble that cause diminished blood flow to the vulva or clitoris can make it hard to orgasm, they’re rare. Here, Dweck explained five much more likely things that may be blocking you from getting off and how to increase your chances of making it happen.

1. You’re not getting enough clitoral stimulation.

The clitoris is usually the real star of the orgasm show.

“Around 70 percent of women orgasm through direct clitoral stimulation rather than vaginal penetration,” Dweck said.

That means two things: First, that you’re in good company if you’ve never had a vaginal orgasm, and second, that direct focus on your clitoris might be what you’re missing. You can go for the gold easily enough when you’re masturbating, but things can get more complicated with a partner. Dweck recommends trying different positions that can provide extra stimulation (like the Coital Alignment Technique) or introducing sex toys for some seriously good vibes.

2. You’re getting too much clitoral stimulation.

On the flip side, sometimes your most sensitive spot would prefer a little less attention. That’s no surprise since, as Dweck notes, the clitoris is packed with 8,000 nerve endings!

“There’s definitely a group of women who can’t orgasm because there’s too much stimulation,” she said.

In that case, you can put a piece of soft or silky fabric on top of your clitoris before you start touching yourself, or ask your partner to try lighter pressure.

3. You’re dealing with anxiety or depression.

There’s absolutely nothing wrong with you if you have a mental illness, but one of the side effects can be trouble reaching orgasm, especially if you’re taking medication.

“Neurotransmitter chemicals like serotonin, dopamine, and norepinephrine are involved in sexual response and orgasm, but they’re also influenced by medications that treat anxiety and depression,” Dweck said.

Try talking to your doctor about whether there are options that will target your anxiety or depression without causing unwelcome sexual side effects, and most important, try not to feel embarrassed about any of it.

“Women should be able to enjoy sex and ask questions without feeling ashamed,” Dweck said.

Being brave enough to do so is an awesome thing.

4. Your hormones are out of whack.

This may be due to the Pill, which is kind of annoying since one of birth control’s major draws is the theoretical ability to have tons of worry-free orgasms. 

“The Pill prevents ovulation by changing your levels of estrogen, progesterone, and testosterone,” Dweck said.

Those adjustments can affect your libido, eventually resulting in you either not wanting to have sex or not feeling the urge to do what it takes to orgasm. Chatting with your gynecologist can help you figure out if it makes sense to switch to a different method of contraception. 

Perimenopause, or the time in your late 30s or 40s when your body prepares to go into menopause, can also cause a hormonal shift.

“Again, it’s those three hormones, estrogen, progesterone, and testosterone, that decrease and cause a weakened orgasm response that can be more like a drizzle than a thunderstorm,” Dweck said.

This is another time when a gynecologist can help you figure out a potential plan of action. 

5. Your mind is all over the place.

It’s hard to orgasm if sex doubles as your chance to ponder such questions as, “Should I splurge on the ‘rose gold’ iPhone if it’s actually just pink?” Paying attention to what’s going on is an essential part of climax! 

“For women, much of the sexual response starts in the brain,” Dweck said.

Luckily, the fix for this one is fun: focus on how good everything feels, then take it to the next level. You know how mindful eating involves relying on all your senses to really savor your food? Adapting the technique for sex can work wonders for helping you stay present and have as much fun as possible.

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