Many things shape whether and how easily a woman reaches orgasm, and this chapter sorts them into clear groups. It starts with biological factors, such as hormonal changes across the menstrual cycle and differences in anatomy. It then looks at the mind, including how stress, anxiety and body image can get in the way of relaxation and arousal. The chapter also considers the link between relationship satisfaction and orgasm, the effect some medications can have, including certain antidepressants and birth control pills, and how sexual response may change with age and around menopause, when issues like vaginal dryness can appear.