Q: Can antidepressants have caused my husband’s loss of desire?

I’m so sorry that you’re experiencing this loss in your relationship. Both depression and the medications used to treat it can be culprits in a loss of desire, and given the relatively short time frame in which you noted the change (one or two weeks), the antidepressant is the likely explanation for your husband.

The situation that you describe is probably best addressed with the help of a therapist; someone who does sex therapy would be most helpful (you can find one certified by the American Association of Sexuality Educators, Counselors, and Therapists through their website).

You asked. Dr. Barb answered.As you’ve begun to experience, the longer this dynamic goes on, the more anger and resentment builds. Having a therapist to help you navigate the conversations is extremely helpful. And your suggestion of a therapist sends your partner the clear message that intimacy is really, really important for you and your relationship.

There’s some evidence that Stronvivo, a nutritional supplement for cardiovascular health, can improve both libido and function in both men and women; that could be a consideration as well.

Good luck!

Baby Blues and Menopausal Depression: Part Two

Many women go through menopause with little more than irritability and hot flashes. In our last blog post, we reviewed research that suggests, though, that if you've experienced postpartum depression or hard-core premenstrual syndrome, you may be at higher risk for depression during perimenopause or menopause. Awareness and perhaps some preparation for this challenging transition might be prudent. It’s like an athlete training for a race. You want to be in shape before you hit the tarmac.

And even if you’ve never had a down day in your life, some commonsense lifestyle adjustments as you approach your “window of vulnerability” might ease the transition. What you absolutely do not want is to be taken by surprise at the intensity of your emotions, as this couple, tragically, was.

Forewarned, as they say, is forearmed.

So here are some suggestions for greater awareness and healthy lifestyle changes that, honestly, are never too late (or early) to adopt:

Nutrition. Eating sensibly is a good foundation for the inevitable metabolic changes that happen during menopause. Go heavy on whole grains and fresh fruits and veggies, ideally from local, organic sources. Lighten up on fats and sugar. Take your vitamins.

If you need to lose some serious weight, now’s the time to get serious about it, before menopausal changes really kick in.

Get moving. Lack of social connection and daily activity intensifies a sense of isolation and lethargy. Create a routine of exercise and involvement. Volunteer for a few organizations you believe in or enjoy. Exercise regularly. Get outdoors—don’t just walk from house to car. Surround yourself with healthy activity and people you like.

Explore treatment options. Some studies indicate that, for perimenopausal depression, hormone replacement therapy, sometimes in conjunction with antidepressants, can ease the mood swings, hot flashes, and insomnia, especially during the early stages of menopause.

St. John’s wort may also relieve mood swings and anxiety during menopause. (But don’t take any natural remedy without talking to your doctor first.)

Build your network. It’s comforting to know that people you trust have your back. And it’s a lot easier to find helpers before you’re in the thick of things.

Maybe find a therapist you like. Maintain connections with good friends.

And if you find yourself overwhelmed with feelings of unworthiness, or are unable to get out of bed or to function normally, for heaven’s sake, tap into that support system. Call your therapist or doctor. Call someone you love.

Menopausal depression is treatable and usually resolves itself once you’re through the change. Then you’ll be back to your sunny, even-keeled self.

In the meantime, it’s just your hormones talking.

Baby Blues and Menopausal Depression: A Connection?

We’ve talked about depression during menopause. It’s a common, joy-sapping beastie that rears its ugly head during this time of whacked-out hormones and middle-age adjustment.

After all, what with hot flashes, insomnia, loss of libido, mood swings, who wouldn’t feel depressed?

While we may not exactly sail through menopause, most of us make it through “the change” relatively unscathed. But for a few, the hormonal fluctuations that may precede menopause by a number of years is part of a larger picture—sort of a déjà vu experience that we ought to be aware of so as not to be blindsided by it.

Episodes of depression are common, and they are more common for women than for men. About 20 percent of women—one in five—will experience major depression at some point in life, and that’s twice the rate at which men become depressed, according to this report in “Dialogues in Clinical Neuroscience.”

Why this happens is unclear, but one obvious culprit is the normal hormonal fluctuations that occur at predictable points in a woman’s life: puberty, menstrual cycles, childbirth, and menopause. Some women appear to be more sensitive to these hormonal changes, and depression—sometimes crippling in its intensity—can result. These predictable points at which female hormones are on a roller coaster may be considered “windows of vulnerability.”

Perimenopause—the years immediately preceding active menopause—seems to be the point at which depressive episodes are more frequent. Even before a woman’s menstrual cycle is changing, her hormones may be dancing the rhumba. Perimenopause can last for five years, on average, and 95 percent of women enter it between the ages of 39 and 51.

“These periods are not only marked by extreme hormone variations but may also be accompanied by the occurrence of significant life stressors and changes in personal, family, and professional responsibilities,” writes researcher Claudio Soares in this report for Biomedcentral.com.

The thing to be aware of, however, is that the biggest predictor of perimenopausal or menopausal depression is a prior episode of depression. And the “reproductive life cycle event” most strongly correlated with perimenopausal depression is postpartum depression—the “baby blues.”

“We also found, however, a correlation between perimenopausal mood ratings and ratings at other reproductive cycle events, especially between perimenopausal depression and postpartum depression,” write the authors of this study published in the Journal of Clinical Psychiatry. “This suggests that there may be a subgroup of women who have a specific vulnerability to developing reproductive cycle event–related depression.”

Other well-regarded studies have confirmed these correlations.

What this means for you, as you head into your final and very challenging “reproductive life cycle event,” is that if you’ve experienced postpartum depression or hard-core premenstrual syndrome, you may be at higher risk for depression during perimenopause or menopause.

In fact, if you’ve had one prior incident of depression, your chances of having another are one in two (fifty percent). If you’ve had three previous depressive episodes, your likelihood of experiencing another is 95 percent, according to The Massachusetts Health Study cited in this report.

But that doesn't mean you're without resources: Forewarned, as they say is forearmed. In our next blog post, we'll talk about what you can do to increase awareness and keep yourself healthy—in body, heart, and mind.

More from the Trenches

In a previous post Dr. Susan Kellogg Spadt, a MiddlesexMD medical advisor, described some of the impediments to sexuality that she sees affecting women as they age. The list, which began with internalized ageism, sexual scripts from our families of origin, and low self-esteem, continues in this post…

Performance anxiety. Men aren’t the only ones who worry about “performing.” All those physical changes to our sexual apparatus that are discussed on MiddlesexMDvaginal dryness, pain, reduced sensation, lack of interest—can contribute to performance anxiety for women, too.

As one 52-year-old woman said, “I can no longer tell how my body is going to behave. It makes me nervous in bed.” As with men, this inability to trust or predict how your body will respond can affect your ability to enjoy or your desire to have sex. Some women (and some men) just decide not to be sexual anymore.

Women need to know that there is help for these physical changes—again, all the things discussed on the blog and the website—such as moisturizers, lubricants, vibrators, and dilators. These tools can help us remain comfortable and familiar with our changing bodies, so that we’re less anxious when we’re with our partner.

Depression. Older women get depressed at somewhat higher rates than younger women. That’s what the research says. Not only that, but the side effects of some antidepressants include decreased desire, vaginal dryness, and delayed orgasm.

So what’s a woman to do?

Talk to your healthcare provider. You need counseling for the depression, and if medications are affecting your libido, discuss alternatives with your provider. It’s not easy, but you could end up feeling better and enjoying sex again.

Lack of attraction to partner. Yes, I hear this from women—the spark is gone. They just aren’t attracted to their partner anymore.

Maybe the relationship was always difficult or lacked physical intimacy, and the couple stayed together for practical reasons. Or maybe physical changes due to the partner’s aging or illness have affected the woman’s physical attraction. According to the literature, this happens in both women’s heterosexual and lesbian relationships.

Fantasy is one way to mitigate the “turnoff.” Use your imagination to turn the frog into a prince. Sex therapy may be another aid to establishing intimacy.

Lack of partners. There’s no sex without a partner. Duh! Demographics and life expectancies being what they are, the older we get, the fewer our options for partners.

Some of us may be able to date casually or to self-pleasure for sexual release, but for others, this may not be an option. Again—no easy answer.

Making peace with the situation. “Normal” covers a lot of ground. And while we clinicians are always seeking to define it, the fact is that “normal” for one patient may be very different for another.

Despite all the impediments and changes, I’ve found that women generally find their way to a sense of equilibrium with regard to their sexuality. And we clinicians have to respect that.

You define what’s normal for yourself. If you are at peace with your decision to abstain from sex, then abstinence is normal for you. Likewise, if you choose to be sexually active well into your nineties, then that’s also normal.

However, if you experience frustration, anxiety, discomfort, or pain regarding your sexuality, then you should bring this up with your healthcare provider. We can help, and sometimes the solutions are simple.

Sex and Depression: A Tricky Combination

Even if you’ve been an emotional Rock of Gibraltar throughout your life, menopause can brew up a perfect storm for jittery moods, anxiety, and depression. And in addition to its psychological punch, depression and anxiety can put a definite crimp in your sex life.

According to the North American Menopause Society, “Women suffering from depression (which is associated with a chemical imbalance in the brain) report symptoms of prolonged tiredness, loss of interest in normal activities [like sex], weight loss, sadness, or irritability.”

Who feels like sex when the rest of you feels like this?

Menopause and depression make such cozy bedfellows because:

  1. hormonal and endocrine-related turmoil are the very hallmarks of menopause, and they are intimately related to our moods. And
  2. certain predictable but challenging life events tend to coalesce during this period.

Ever since puberty, you’ve made a sometimes uneasy peace with the normal hormonal fluctuation of your monthly cycle. But now your hormones are all over the map. And in this case, a hormone like estrogen affects the functioning of a whole lot of other stuff.

For example, estrogen affects serotonin levels in your brain, and serotonin is the happy juice that regulates sleep, mood, energy, and libido. “It’s central to our well-being,” writes Colett Dowling, psychotherapist and author of The Cinderella Complex in an article on her website.

Dowling is no stranger to the emotional and physical punch of those hormonal changes. “It was only when I was a year past menopause that I began to address the sleep problems I was having, as well as the loss of energy and libido.… It took far longer than it should have for me to learn that menopausal depression, related to a drop in estrogen, was causing my symptoms, and to get the treatment that put me back on track.… I was stuck in this pattern for many many months, and it became hard not to think: Is this it, the end of my vitality and productivity?”

Research also suggests that women with depressive bouts in the past or who suffer from more severe or prolonged hot flashes are also more susceptible to depression during menopause.

And don’t count on life giving you a break during this stormy period. You may have to adjust to your children leaving, maybe to the death or disability of a parent, maybe to health issues of your own or of your partner. You may struggle with the emotional transition of a changing self-image or the inevitable and final loss of youth. Cultural stereotypes being what they are, you have to make peace (or not) with different social roles and perceptions.

Given these hormonal and psychological transitions, is it any wonder that depression often dogs the menopausal years? Is it any surprise that our sex life is an early casualty?

To get a handle on this dance between depression and loss of libido, begin by understanding how common and treatable it is. Give yourself a break and don’t be embarrassed to ask for help. Dowling writes, “Women at mid-life often feel guilty about their mood changes and avoid seeking treatment. ‘This will pass,’ they think, and while that may be true, depression can seriously affect the quality of life, including one's ability to make a living.”

Loss of libido is another of those quality-of-life issues. It can strain a relationship and affect your sense of well-being. You don’t have to compromise either your happiness or your sex life. And you shouldn’t suffer in silence.

A few additional issues with regard to depression and libido:

  • Antidepressants that affect serotonin levels (SSRIs and norepinephrine reuptake inhibitors) also affect libido, and not in a good way. If you’re on an antidepressant and have lost any interest in sex, talk to your doctor about a change in medication.
  • Low thyroid function (hypothyroidism) looks a lot like depression. It might be beneficial to have your thyroid levels checked. Also check your iron levels for anemia.
  • Consider whether unresolved relationship issues might be involved with your lack of interest in sex. Many doctors think a multi-pronged approach to depression and loss of libido is a more effective treatment. This may involve antidepressants as well as psychological counseling and perhaps lifestyle changes.
  • Ask your doctor about trying testosterone therapy to boost your sex drive. The jury’s still out, but there’s some indication that it can be effective.
  • Don’t overlook the basics. Your salad years of hopping in the sack for a quickie in the afternoon may be over, but you can still enjoy long, slow evenings of sweet intimacy. Just don’t forget the lube—and maybe a few pillows to keep things comfy.

Sex and Depression

When a patient tells me that she no longer enjoys sex, one of first things I ask her is to tell me about something that she does enjoy.

If she isn’t able to come up with a fairly quick answer, in my experience it’s likely that depression is playing a part in her loss of libido.

Anhedonia -- the inability to gain pleasure from normally pleasurable experiences -- is a core clinical feature of depression. And because depression affects nearly twice as many women as men, and because recent studies suggest that midlife is a period of increased risk for depression in women, I am always on the alert when a patient mentions that she has stopped enjoying activities -- like sex -- that used to give her pleasure.

The cause-and-effect relationships between menopause and depression and between depression and loss of libido are complicated -- to say the least!

Some studies suggest that changes in hormonal levels, such as those that occur during the transition to menopause, may trigger depression. The production of mood-enhancing neurotransmitters is boosted by estrogen. Lower levels of estrogen that accompany menopause can mess with the brain’s chemical balance, leading to depression. Other biochemical changes that come with age, such as those that result from decreased thyroid function, have also been linked to the onset of depression.

But the pressures and stresses associated with midlife surely play a role as well. The loss of our youthful looks, of our reproductive and mothering roles, and sometimes even of our jobs or life partners -- all make us vulnerable to depression as we move into and through our menopausal years.

Whatever the cause -- and at whatever age -- depression has a significant impact on sexual function and enjoyment. Nearly half of all women -- and men -- diagnosed with depression report that it interferes with their sexuality.

The good news: If depression is behind your loss of interest in and enjoyment of sex, there is an array of proven treatments to relieve the underlying cause and its symptoms. Your doctor can help identify and treat medical causes, such as thyroid problems. In some cases, hormone replacement therapy that elevates estrogen levels may be effective. Antidepressants that help correct chemical imbalances in the brain help many (although these may have their own sexual side-effects). Regular exercise, improved sleep habits, and dietary changes can help to counteract depression, and counseling and support groups are other options to explore.

Don’t let depression drain the pleasure from your life. Talk to your doctor. See our website for more information on hormonal changes and therapeutic resources. And if you have experienced and overcome anhedonia in your own sex life, we’d love to hear your story!