Loss of Desire Is Real

The conversation about women’s sexual health has continued, sometimes with heat, sometimes with light. For the first time I can remember, the International Society for the Study of Women’s Sexual Health, of which I’m a member, responded directly to a New York Times op ed piece, calling it false and demeaning (The New York Times published a number of responses this weekend).

I’m grateful to my colleagues who are setting the record straight.

As a practicing physician, I have conversations every day with women who are navigating changes in and challenges to the intimacy they want.

Some women have no problem wanting sex. They may encounter pain with intercourse, diminished capacity, or more difficulty experiencing orgasm. As a doctor, I have plenty of treatments options I can recommend and see what works best. Many of the options are neither prescription-only nor pharmaceutical: moisturizers and lubricants, dilators, and vibrators can do a lot. If those don’t work, there are some drugs that could.

Other women, though, come to me because while they love their partners, they no longer get the sexual urge. They find it difficult to respond when their partners initiate. If I close my eyes, I can see their faces, hear the grief in their voices. They’ve told me about their own sense of loss, of incompleteness; they’ve told me their concerns about the unintended messages their partners are receiving; they’ve told me about their fears for their relationships.

And of course I do the obvious assessments, ask them the obvious questions, make the obvious suggestions. I check their overall health to see if there’s an underlying condition that could explain their loss. I check out—and ask them about—medications they’re taking, which sometimes have unintended consequences. I probe for signs of depression. I inquire about their relationships, alert to any clue that it may not be a healthy one.

And sometimes, I do find an underlying cause. I’m able to treat a medical problem, make a referral for counseling, provide compassion to a woman who acknowledges that a relationship is over.

But other times, there’s no apparent reason for a loss of desire. And for those women, it doesn’t occur to me to say “Nothing is wrong with your sex drive,” which is what the New York Times op ed piece asserted. If nothing were wrong, they wouldn’t be in my office, asking—sometimes pleading—for help.

There’s not a lot in my toolkit to respond to those women. And I’d like some options, because I think #womendeserve them. There have been very few silver bullets in my line of work—solutions that work all the time for every woman. I don’t expect that. I do firmly believe that women—with support from their health care providers—can make decisions about what might help them and the trade-offs that affect their quality of life.

Each woman can decide. For herself. From among options not limited by lack of priority or double standards at the FDA. And not limited by the opinions, however well-intentioned, of other women or men.

Stuck without Solutions

If you’re a regular reader of the MiddlesexMD blog, you might think I’m a broken record on the topic of the dearth of pharmaceutical tools to address hypoactive sexual desire disorder (HSDD). That’s because I am. I don’t know how else to respond to where we are, except to keep talking about it, to make sure we’re all sufficiently aware—so we can all be clear, when the subject arises, about what we want and need.

As I encourage us all to recognize, women’s sexuality is complicated from the start, and becomes more so as we enter perimenopause and menopause. Our sexuality is an intermixing of the physical, psychological, and emotional. It often takes some experimentation for women to get back on sexual track, sometimes because it’s not clear whether a physical problem is in the lead or it’s really stress or a relationship issue that’s diminished desire.

In that experimentation, I prefer, as a physician, to start with the simplest steps first. That may mean adding a lubricant or a vibrator to a woman’s bedside table; it may mean using dilators for a time. But also as a physician, I appreciate knowing that there are pharmaceutical options in my repertoire, too, to help a woman get unstuck.

So I follow the news about drugs in development, and about their progress in getting approved for use by the FDA. Earlier this summer, I received an update from the Board of Directors of the International Society for the Study of Women’s Sexual Health (ISSWSH). They wanted to be sure that we’d seen an ABC News story on Flibanserin, which is still stalled out on appeal, subject to additional study.

“No single drug will ever be a cure-all in sexual or most other conditions, let alone effective for 100% of appropriate patients,” the ISSWSH statement read. “But that is never the standard by which biopsychosocial drugs are approved.” The news story also questions whether the standards for drugs for women’s sexuality are different from those for men. It compared side effects of dizziness, sleepiness, and anxiety to those listed in “iconic Viagra commercials, such as nausea, diarrhea, and the risk of erections lasting over four hours.” The reporter suggests that the bar seems higher for drugs for women.

I’m not in the room for the FDA discussions, so I don’t pretend to know whether there’s bias at play. I simply point out that there are 25 FDA-approved medications for men’s sexual dysfunction, and none that address HSDD for women. None. As a physician, I’m conscious of that void whenever I’m talking to a patient who misses her sexual self.

What do we do? Keep talking about it, even if we sound like broken records. And, if you haven’t already, you can sign on to the ISSWSH Wish Petition. The number of names listed does help to communicate the importance of this issue to women and the men who love them—as well as to the health care providers who serve them!

Q: Can I regain my desire?

I wish there were a "secret sauce" that worked for all of us to restore libido. Not surprisingly, it's more complicated than that.

It's somewhat unusual to have an abrupt change to libido; for most women, it's a "slow drift." The first thing to consider with a dramatic change is any new or different medications. There are quite a few that have effects on desire: blood pressure, pain, and mood medications (antidepressants) to name a few. If you have had a change, you can work with your doctor to experiment with dosage or medications; let him or her know of this unintended side effect.

You ask about Cialis and similar products. They can help with orgasm (as they do for men), by arousing blood supply to the genitals, but they don't have an effect on libido or desire.

One option to consider is testosterone. While it's thought of as a male hormone, it's also present in women and is linked to libido. Some physicians aren't willing to prescribe it for women because it's an "off-label" use, but 60 percent of women report significant improvement in libido with testosterone replacement, and 20 percent of U.S. prescriptions for testosterone are now for women.

The other factor important to consider is mindfulness--which we might also call intentionality. While you may not feel desire that motivates you to be sexual right now, you know your long-time partner does. You can make the decision (together) that you will continue this activity together, including foreplay. (And I note a recent study that linked frequency of sexual activity with the quality of relationships, which confirmed my intuition.) When you make that decision, sex is a "mindful" activity: You anticipate and plan it and prepare physically and emotionally for an optimal experience with your partner.

Many women grieve the loss of a part of their lives that was once so important and fulfilling. It's most often an unnecessary loss, and staying sexually active has many health benefits as well as giving us feelings of both individual wholeness and connection to our partners.

Less Urge, More Decision

As a menopause care provider, I have lots of conversations with women about sex. I’ve heard confirmation that our motivations to have sex change with our situations. What motivates us when we’re young and single is very different from what motivates us when we’re older and in longstanding relationships, or older and single.

So when we suffer from lack of desire—are we missing the sort of drive we had when we were teenagers? Or is it possible we just haven’t found a new motivation for sex? The more we learn from women, the more it seems that for us sex doesn’t always begin with lust, but instead starts in our hearts and minds. We engage in our heads first, decide to have sex, and then with enough mental and emotional stimulation, our genitals respond. The older we grow, the more this is true. Age and maturity bring a new game into the bedroom. MiddlesexMD_Christie

For us, having sex is less an urge than a decision, one we can make and then act upon. When we decide to say yes instead of no, decide to schedule sex instead of waiting (perhaps for a very long time…) for our body to spontaneously light on fire, decide to engage with media or methods that will put us in the mood rather than wait for romantic moments to happen along, we’re using our heads to keep sex in our relationships.

Deciding to be intimate unlocks the pleasure. And the more sex we decide to have, the more sex we will feel like having. That’s the secret to regular bonding.

Why just decide to do it? This much we know:

  • Sex leads to a longer life.
  • Sex, like all exercise, helps protect us against heart attack and possibly stroke.
  • Hormones released during sex may decrease the risk of breast cancer and prostate cancer.
  • Sex bolsters the immune system.
  • Sex before bed helps us get to sleep.
  • Sex burns calories.
  • Sex can help relieve chronic pain, including migraines.
  • An active sex life is closely correlated with overall quality of life.
  • Good sex can protect us against depression, reduces stress, and increases self-esteem.
  • Sex with your partner stimulates feelings of affection, intimacy, and closeness.

That last point is what I hear most often in my practice: Women want to keep or already miss the intimacy with their partners that mutually satisfying sex communicates. While they also miss the feelings of power and wellbeing that sex gives them, it’s the loss of connection that impels them to take action.

And you can take action, too. We don’t need to wait around for “desire” to lead to thoroughly satisfying sex. We can use our heads.

Q: Can love lead back to desire?

First, let me assure you that you're not alone in feeling a loss of libido: It's common for women to lose desire, even in great, emotionally supportive relationships.

Low desire is challenging to treat, because we women are complex sexual creatures. I prescribe testosterone for some of the women in my practice; about 60 percent of those who've tried it have found that it does boost libido. I wish it were 100 percent, but it's not! And some physicians are reluctant to prescribe testosterone for women because it's "off-label."

Given what we know about women's sexuality, I advise women to engage "mindfulness" when it comes to sex. Often, we feel desire somewhere in the process of being intimate; we may not be driven to intimacy by desire. We need to choose to be sexual! I encourage women to plan for sex, committing to a frequency that is comfortable for both partners. It might be once a week, once a month, on Friday evening or Sunday morning—whenever you're least likely to be distracted, stressed, or tired. When we have been sexual, we've typically found it pleasurable and we're glad we did!

Finally, you mention being self-conscious about your breasts, which are no longer like they used to be. We are our own worst enemies when it comes to body image, and we pay the price when we rob ourselves of pleasures! I'll bet your partner doesn't look like he used too, either, and that he loves every inch of your body, as you love his. You might reread this blog post on body image and try some of the suggestions to "send your body some luv."

Models of Desire

Women are not men. No surprise, right? In many parts of our lives, we know that.

When it comes to sex, though, many of our expectations—and those of the experts who advise us—are still based on expecting that men and women are more alike than not. And women are not men.

There’s an important implication from the model for women’s sexuality I’ve shared before, the one developed by Rosemary Basson, of the University of British Columbia. Women are not men: While men quite predictably experience desire and then arousal, women don’t. Sometimes, actually, women don’t experience desire until midway into lovemaking.

No big deal, you’re thinking? I wish.

Unfortunately, the messages we’ve internalized affect the way we behave and what we believe about ourselves. I’ve talked about hypoactive sexual desire disorder (HSDD) before, and it’s something I regularly talk about with women in my practice. There are hormonal changes, reactions to prescriptions, and other factors that can lead to HSDD, which is real and deserves attention from researchers and pharmaceutical companies.

But sometimes what we wish we could fix with a pill is actually the fact that we’re women, not men. If we, as women, expect to respond sexually as men respond, we’re more likely to misread our reality as “lack of libido.”

Which leads to the other reason I think understanding Rosemary’s model is a big deal. I talk to women who are at some point in a vicious cycle: They don’t experience interest as they used to; some physical changes have made intimacy uncomfortable or even painful; they begin to avoid sex; the physical changes continue; and intimacy becomes even more uncomfortable. How do we reverse this sequence? Or avoid the slide into it?

We can start with the reasons—beyond the hormones that drove us at 27—that we might want to be sexually intimate with a partner: to please him, to experience closeness, to cement our relationship, as an apology, a thank-you—or because we want to feel our own liveliness, sensuality, and power!

Kama Sutra Massage OilsAnd then we can trust that desire will come into the picture, if we’re having the kind of sex that arouses us. Michael Castle wrote about this in Psychology Today: “Sex that fuels desire is leisurely, playful, sensual…. based on whole-body massage that includes the genitals but is not limited to them.” Castle says women often complain that men are “too rushed, and too focused on the breasts, genitals, and a quick plunge into intercourse.” That kind of lovemaking doesn’t allow space for women to experience desire.

He points out, too, that leisurely, sensual sex is also recommended by sex therapists to men dealing with premature ejaculation or erectile dysfunction. Happily, the kind of sex that fuels women’s desire is also good for their partners.

Women are not men. We can recognize, internalize, and celebrate our difference. We can be sure we’ve communicated with our partners what we like when we make love. We can let go of any expectations except our own. We are women.

Disincentives: Sex Is Boring

“I can tell you the movements he’s going to make step-by-step. He can get me off, but it’s sex. It’s not making love.”

--quoted by Marta Meana, Ph.D., University of Nevada, Las Vegas, “When Feeling Desire Is Not Enough: Investigating Disincentives to Sex”

If I had a nickel for every woman with this complaint, I could retire tomorrow. According to Dr. Meana and others who study female sexuality, boredom is the second biggest disincentive to sex in married women. But of all the sexual challenges, this one is the most fun—because the cure requires creativity, lightheartedness, and the willingness to play.

No matter how red-hot the passion once was, over time it’s bound to cool to glowing embers. Left unattended for years, however, that flame will begin looking more like gray ash. Doctors and counselors—and your girlfriends—all have recipes for bringing the romance back into your relationship. I’m not trying to reinvent the wheel, but here are some suggestions I’ve gathered from various sources that look like fun to me. I would, however, encourage you to take the initiative in this endeavor to reinvigorate your sex life. It’s too easy to take a passive “hurry up and get it over” attitude. You’re half the partnership, so you bear some of the responsibility for your love life. You can be more forthcoming with what feels good to you and what you’d like to try. I’m betting that your partner will be pleasantly surprised and willing to try.
  1. Spend time together doing nonsexual things. For women “it's not what happens in the bedroom—their desire arises when they are interacting with their partner, just touching, talking, when they go on a hike or a picnic, that starts to get them sexually interested,” said Patricia Koch, Ph.D., Associate Professor of Biobehavioral Health & Women's Studies at Pennsylvania State University in a recent article. The first step, then, in rekindling the flame is to become romantically reconnected outside the bedroom.
  2. Try self-stimulation. This may sound counterintuitive, but the idea is to “get your head in the game,” not to create a substitute for sex as a couple. Sometimes masturbation can reignite that spark of sexual interest that leaves you wanting more.
  3. Talk about what you like and what you want to try. As a more mature woman, you know what you want; you’re more confident in asking for it. Maybe your partner has some idea to try as well.
  4. Break the mold. No doubt, routine is boring. New places, positions, accessories, and techniques are an antidote to routine. Check out our website for suggestions or this list of romantic movies. Read an erotic book together. You’re only limited by your imagination.
  5. Keep it light. This should be a fun exploration, not a do-or-die ordeal. The goal is to expand your sexual repertoire as a couple, to pleasure each other, to reconnect both sexually and emotionally. You aren’t trying to become sexual athletes or to experience orgasm every time.
So—boring sex? Not to be glib, but what a great problem to have. Its solution lies at least fifty percent in your hands.

Make Your Own Love Potion

“I just want to want sex again.” I can’t tell you how many of my patients have expressed -- in one way or another -- this simple desire for the desire they experienced in their 20s and 30s, when their bodies were flooded with procreative hormones.

Wouldn’t it be great if I could mix up a love potion to send home with them and to share with you here? Some powerful concoction of roots and herbs perhaps, a magic elixir guaranteed to bring it all back?

Well, here’s the next best thing. A recipe you can use to produce your own personal, all-natural love potion. For free.

Oxytocin, a hormone produced by the pituitary gland, has long been recognized for its role in childbirth and lactation and mother/child bonding. Women in labor are sometimes given a synthetic oxytocin to stimulate contractions. And mothers and babies both experience the pleasurable effects -- calmness, trust, contentment -- of the natural oxytocin that is released into their brains and blood streams during breast-feeding.

Recently though, research has been identifying the significant effects that “the cuddle hormone” have on men as well as women -- and on their desire for (and enjoyment of) sex that isn’t about making babies.

Both men and women experience rising oxytocin levels in response to being touched anywhere on their bodies. The effects promote a bond of closeness that increases sexual receptiveness -- and the desire for even more touching. Even more touching leads to even more oxytocin which leads to even more arousal and even more desire for even more touching. Isn’t it beautiful how that works?

There’s more: high levels of oxytocin cause nerves in the genitals to fire spontaneously, triggering powerful orgasms. And during orgasm the body releases -- you guessed it -- more oxytocin. (Which, as it turns out, is good for you in all kinds of ways. Research indicates that oxytocin helps people sleep better, enhances feelings of well being, and counteracts the stress hormone, cortisol.)

The best thing about this amazing hormone for women our age is that -- unlike estrogen and other sex hormones -- you can make it yourself. Caressing your partner, enjoying a massage, bringing yourself to orgasm are all ways to get more oxytocin into your life. In fact, many women find that self-pleasuring is the best way to boost a sagging libido. More orgasms = more oxytocin = more desire.

Check out our website for information and products that can help you get this wonderful pleasure cycle up and running!

Q: Should I worry if I found an erotic video arousing?

Absolutely not! As we grow older, it takes more stimulation for us to arouse and lubricate, and that stimulation can come in many forms--physical or mental.If watching an erotic video provided visual stimulation for you... well, you're not alone!

It's sometimes a challenge to find the right material--arousing but not offensive--but it sounds like you found it! Don't feel guilty or embarrassed. Most women need to change things up a bit and adding erotica is a perfectly acceptable option.

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!

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