Q: What can I do about my husband’s and my mismatched sex drive?

Oh, I feel for you. You say you have pain (and no doubt other symptoms—like fatigue and depression) from lupus, fibromyalgia, and Sjogren’s syndrome. You see your lack of interest in sex becoming a larger problem in your marriage as the difference between your sex drive and your husband’s increases.

The first order of business is to find a health care provider with whom you can discuss this aspect of your health. The pain you mention may be generalized pain from the autoimmune conditions you have, or it may be pain with intercourse. Painful intercourse is nearly always a treatable condition, so addressing that if you experience it is critical.

You asked. Dr. Barb answered.The harder issue is the “desire discrepancy” you describe in your marriage. While the situation is not uncommon, your additional health issues add a degree of difficulty. Assuming any issues with painful sex have been addressed, there are some medications that can be helpful for low libido: Addyi, testosterone, and Wellbutrin, to name a few. Your health care provider can help you understand if any of these can be an option for you depending on your health history and other medications you’re taking.

For more about low libido, you can read this blog post on the emotional component and this one that includes an overview of the condition and common causes. It could be helpful to read these to have some terminology in mind when you meet with your health care provider.

The situation you describe might best be addressed with a (sex) therapistperhaps not a dedicated sex therapist but one who has expertise in health-related relationship concerns. (Here are two blog posts on sex therapy: one I hoped would demystify it and one that explains how it works.) Your health care provider is likely to be able to direct you to someone with experience to assist you and your husband as you navigate this significant challenge.

Best of luck in reaching some common ground! 

 

September 29, 2016

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desire ›   libido ›   women's sexual health ›  


Q: Does exercise help libido?

You asked. Dr. Barb answered.Yes, exercise helps libido in a number of ways, both directly and indirectly. It improves general health and energy levels. It improves sleep and blood supply. And it improves self-image, too, which can make us feel more desirable and more in touch with our sexual selves.

I recommend that women add Kegel exercises to their exercise habits. Increased muscle tone in the pelvic floor increases orgasm response, as well as keeping our organs where they belong and preventing or minimizing incontinence. It’s a complete win!

So yes, get active or stay active. Your body will thank you.

Q: How can I boost my desire and arousal?

You asked. Dr. Barb answered.You say you find your partner attractive, you have a good relationship, and your gynecologist gives you a clean bill of health. And yet, you’re having trouble getting aroused. This is the exact situation for which the Fiera Arouser for Her was designed. It’s not a vibrator; you use it as “before-play”; the gentle suction and vibrations increase blood flow to your genitals, which increases responsiveness--and lubrication, as well.  

Another consideration may be Stronvivo, a nutritional supplement that has been shown to improve sexual function for women (and men), including improved libido/desire and ability to arouse and orgasm.

Some women with libido concerns benefit from supplementing testosterone. This requires an assessment and monitoring from your physician or nurse practitioner, since it’s prescription only. Use of testosterone in women is considered “off label”, or non-FDA approved, and not all practitioners are willing to prescribe it for their patients.

At the same time, you say you’re experiencing less moisture. This is critical to address, because painful intercourse is, of course, not an incentive to desire! There are varieties of lubricants that can add playfulness as well as immediate increased comfort; regular use of a vaginal moisturizer can help you through perimenopause.

The Fiera may be your best bet. I do know this issue can test relationships, and wish you the very best in finding a way forward! Be assured it’s possible.

March 14, 2016

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HSDD ›   libido ›   testosterone therapy ›  


Testosterone Therapy: Another Set of Socket Wrenches

I love options. Moose Tracks or Mackinaw Island Fudge? Mocha or machiatto? Phillips screwdriver or allen wrench?

Mostly, I like having options for my patients. At this awkward middle-age time of life, issues are complex and solutions are rarely straightforward. So I like to have a toolbox of treatment options to choose from. If one method doesn’t work, maybe another will.

To be clear, I always start with the most natural, straightforward treatment possible, postponing pills, prescriptions, and hormones. To this end, a healthy lifestyle is the first and most important contributor to a good sex life. Along with lavish use of moisturizers, lubricants, toys, and imagination.

But when these things fall short, it’s nice to have options.

Healthy lifestyle first and most important contributor to good sex lifeThat’s what testosterone therapy offers—another tool. Another treatment regimen that might fan a faltering libido and fading intimacy in an otherwise healthy relationship. Like any treatment, this isn’t a silver bullet or a magic pill. In fact, it’s controversial. There just isn’t a lot of research on long-term use or even on how testosterone functions in women. (Spoiler alert: a lot different than in men.) It isn’t FDA-approved, although it’s been prescribed “off-label” for decades in the US and is prescribed legally in Europe and elsewhere.

In women, testosterone is produced at much lower levels than in men, mostly in the ovaries and adrenal glands. As we age, and especially if our ovaries have been removed, testosterone levels drop sharply. This isn’t the only reason for diminishing sexual desire but it may be part of the picture. (In medicalese, a distressing loss of libido is called hyposexual desire disorder—HSDD.)

Since declining testosterone levels, menopause, and HSDD tend to happen in tandem, maybe a causal link exists among them, so the thinking goes. Obviously, it’s more complicated than that, but for some women, a little testosterone boost just seems to work. As a recent bulletin from Harvard Medical School states: “…in some but not all studies, testosterone therapy has been shown to be an effective treatment for HSDD in carefully selected postmenopausal women.” In my clinical experience, testosterone therapy improves libido, desire, and/or the ability to orgasm in about 60 percent of the women who take it.

So, what are those “carefully selected” qualities that make a patient a good candidate for testosterone therapy?

First, testosterone won’t cure difficulties in a relationship that may be contributing to intimacy problems. Other libido-killers include depression, fatigue, anxiety, certain medications, and the usual menopausal suspects: loss of estrogen, night sweats.

In the absence of physical or psychological factors, women who are distressed by their lack of libido (the classic definition of HSDD) might find relief with a little extra testosterone in their system. I monitor blood levels during treatment with the goal of restoring testosterone to the level you probably had when you were 25 years old.

Some women (about 20-30 percent of my patients) experience some added benefits, such as improved mood and more energy, while another 10 to 15 percent have less positive side effects, like unwanted hair growth or acne. And for about 40 percent of my patients, testosterone therapy isn’t helpful at all.

Testosterone can be safely applied topically; I usually prescribe a gel, the same FDA-approved topical gel that is used by men, but at one-tenth the dose, which I find offers a safe and consistent delivery of the medication.

For some women, testosterone is a game-changer and for others, not so much. Since the potential benefit is so positive and the detriment is minimal, in my opinion, testosterone therapy is a solid treatment option. A woman who’s tried it will tell her story in our next blog post.

The Lowdown on Libido

Once upon a time, you may have felt sexual desire hit with the force of a tsunami—no mistaking the intensity of that jump-your-bones drive. These days, it passes like a gentle drizzle. If it comes at all.

Meanwhile, back at the doctor’s office, one of the most frequent questions this gynecologist hears (and I would agree) is: What happened to my sex drive?

Loss of libido is common. The numbers are all over the map, and I’m not sure that they’re particularly helpful anyway, but many women—and men, too—experience a loss of sexual desire. And this state of affairs can stir up a lot of consternation and unhappiness in the bedroom and beyond.

Lack of sexual desire has a couple of dry, scientific names: hyposexual desire disorder (HSDD) or hypoactive sexual interest and arousal disorder (this one, HSIAD, is relatively new, coined in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM]; can you imagine the discussion at the recent FDA forum?). Despite studies exploring its frequency, causes, and symptoms, no pharmaceutical silver bullet has been found to fix it—yet. And, believe me, having tasted the commercial success of erectile dysfunction drugs like Viagra, pharmaceutical companies are extremely keen on finding a similar blockbuster drug for women.

Loss of libido all by itself isn’t the problem—exactly. If you are content to let your sexual self recede with your youth, and this isn’t disturbing to you or anyone else, then by definition you don’t have HSDD/HSIAD.

If, however, loss of libido is distressing to you or to your partner; if you want to continue enjoying sex with your partner and you mourn the loss of your old sexy self, then you have a problem. According to medical diagnostic manuals, in order to meet the criteria for HSDD/HSIAD, you not only have to lack desire for any form of sexual activity, but this also must cause you or your partner “personal distress and/or interpersonal difficulties.”

Loss of sexual desire is a tough nut to crack. There’s no “on” switch for libido; there’s no one-size-fits-all therapy; there’s no FDA-approved drug. So rather than searching for a quick fix for a waning libido, you may have to take a patient, holistic, experimental, long-distance view of the situation. You (and your partner) may have to adjust your expectations: sex can still be close and satisfying, but it may be different.

Additionally, you may have to take a clear-eyed assessment of your overall health and lifestyle because, like so many things, sexual response doesn’t happen in a vacuum. It’s intimately connected with other parts of your physical and psychological health.

With this in mind, loss of libido can be affected by:

  • Loss of hormones—the loss of both estrogen associated with menopause and testosterone associated with aging. Low libido is a frequent complaint of post-menopausal women and those with surgically induced menopause due to removal of ovaries.
  • Some medications, for cancer and depression, for example, are known to depress libido, as are some recreational drugs.
  • Some illnesses, such as diabetes and kidney disease, can disrupt hormone levels and damage nerves in the genital area.
  • Relationship problems. If you have a rocky relationship with your sexual partner, disinterest in sex is a likely side-effect. Stir in some menopausal changes and you have a discouraging environment for sex.
  • Stress and anxiety. Financial worries, career challenges, family problems. It’s hard to feel open to sex with major life issues on the brain.
  • Abuse, whether physical, sexual, or emotional, especially if the abuse is still ongoing.
  • Obesity, which for the women I meet in my practice has most effect on self-image.

We’ve mentioned before that good sex is good for your health. So, how does losing your libido impact health and well-being? A 2009 study conducted by a team of researchers at University of North Carolina at Chapel Hill sought to answer those questions.

In a survey of almost 2000 women, the researchers found that women with HSDD/HSIAD were more likely to be depressed and dissatisfied with their home lives and their partners, and that they were more likely to have other health issues, like heart disease and thyroid problems. In fact, the effect of HSDD/HSIAD on quality of life measures was comparable to that of other chronic health conditions, such as back pain or arthritis.

Ouch.

So what’s to be done with a case of lost libido? How do you begin to tackle this very real and very frustrating condition?

Fortunately, there’s a lot you can do, from lifestyle changes, like exercising and losing weight, to pharmaceutical regimens, which, while limited, might include estrogen replacement or using testosterone off-label. And while you may have to experiment, in the end, you can be every bit as intimate, sexy, and feminine as ever.

I’ll dig into those details in a future post. In the meantime, your recommended reading is my new book, Yes You Can: Dr. Barb’s Recipe for Lifelong Intimacy. Because that’s what we’re all about here—believing that we can.

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.

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.

You're Not Alone

It’s going on eight years since I transformed my medical practice. I studied and became certified by the North American Menopause Society as a menopause care provider, and while welcoming patients into my practice, used their questionnaire — a thorough document that makes it easy for new patients to give me a comprehensive view of their symptoms and health histories.

On that eight-page-long form there are just a few questions for women to answer about their current and past sexual experiences:

  • Do you have concerns about your sex life?
  • Do you have a loss of interest in sexual activities (libido, desire)?
  • Do you have a loss of arousal (tingling in the genitals or breasts; vaginal moisture, warmth)?
  • Do you have a loss of response (weaker or absent orgasm)?
  • Do you have any pain with intercourse (vaginal penetration)? If yes, how long ago did the pain start? Please describe the pain: Pain with penetration? Pain inside? Feels dry?
I continue to be amazed by the responses from my patients. Sixty percent of my patients have experienced a loss of interest in sexual activities, 45 percent have a loss of arousal, and 45 percent a loss of sexual response. And when I talk to them, they are
  • Perplexed—because they don’t understand what’s changed.
  • Disappointed—because they expected there to be more.
  • Frustrated—because they don’t know what to do about it.

And when you carry those numbers from my practice to the rest of the country–well, more than 44 million women are aged 40 to 65 in the US alone. Some 6,000 of us reach menopause every day. And at least half of us experience sexual problems with menopause. Probably more.

That’s a lot of disappointed women. And a lot of disappointed men, too.

But you know what it means? Those symptoms you think are setting you apart, making you the odd woman out? They’re not unusual. You’d be more unusual if you sailed through perimenopause and menopause without symptoms.

So speak up! Talk to your health care provider about what you’re experiencing. Read sites like ours to learn more about your options for compensating for changes that aren’t making you happy. Talk to your friends and sisters about your experiences.

We don’t give up reading when our eyesight weakens—we snag some cheaters from the drugstore. We don’t have to just accept the changes if we don’t want to. We’re smart, resourceful, and can do what it takes to live the lives we want to live.

Still Seeking Options

We’ve been following the development of Flibanserin, also called “pink Viagra,” since 2010, when its developer shelved it after hitting a bump in the road to FDA approval. Several years later, we were talking about alternatives, Librido and Lybridos, which were moving forward with clinical trials (and have not yet been approved).

We’ve just learned that the manufacturer that now owns Flibanserin has filed an appeal of the FDA denial, saying that other drugs have been approved with less data and more extreme side effects. And that’s reignited discussion about whether pharmaceutical products targeting women’s sexual disorders are evaluated on a level—or relevant—playing field.

Flibanserin, Librido, and Lybridos (and a small handful of others) are all drugs designed to play a part in awakening libido for women. They counter hypoactive sexual desire disorder (HSDD), in physicians’ terminology (the rest of us call it “not tonight—or tomorrow night, either” syndrome). There are, for context, a couple of dozen FDA-approved drugs for the comparable problem among men, including Viagra.

I don’t have the insider information I’d need to assert a double standard, although people I know and respect—like my colleague Sheryl Kingsberg—suggest there is one. Women’s health psychologist at University Hospitals MacDonald Women’s Hospital, Sheryl said, “There’s a double standard of approving drugs with a high risk for men versus a minimal risk for women.” The side effects for Flibanserin, for example, were reported as dizziness and nausea; Sheryl compares those to side effects of penile pain, penile hematoma, and penile fracture—all from a drug that was approved.

That does sound like some extra protectiveness of women. Given my focus on sexual health for women, I run into a lot of cultural expectations and hesitations; we Americans are still just a bit prudish when it comes to, especially, older women having sex. That’s in spite of what I see in my practice every day: Women themselves want to live whole lives, which means being physically active, emotionally engaged, and sexually active within their relationships.

I recognize that sexuality for women is complex, and there won’t be a “magic bullet.” For women, arousal and desire is a mix of emotional intimacy, biological responses, and psychological responses; a drug won’t address all of the components. But because I’m often working with patients to untangle interlocking causes of problems with sex, I’m eager for as many tools as possible, including pharmaceuticals.

As a physician, I also see the need to evaluate trade-offs and risks. I’ve talked before about the pros and cons of hormone therapy. For some women, living longer doesn’t really count if they’re not able to be active—including being actively sexual. “Pink Viagra” drugs may well require the same kind of close collaboration between women and their doctors to evaluate risks and benefits. Again, Sheryl: “Give women a chance to decide for themselves, within reason. There is no drug out there that has no risk.” In the case of Flibanserin, only 8 percent of testers said the side effects were bad enough to make them want to drop the drug.

These decisions by the FDA are also important because pharmaceutical research is done by businesses, businesses that can decide that one problem or another is too expensive or too complicated to take on. Sheryl sees this, too, saying, “My worry is that research in this area will dry up and will leave many women without a pharmacological option.”

One way to make your voice heard about the importance of continued research is by signing the International Society for the Study of Women’s Sexual Health (ISSWSH) WISH petition. Our sexual health is integral to our overall health, and we need more investigation and even-handed, common-sense consideration of therapies for women.

Q: Is there a trade-off between hot flash relief and libido?

You're wondering whether your hormone therapy, designed to address your hot flashes, is having an unintended negative effect on your libido. The good news is that adding estrogen is better for sex, in general terms. So you don't have to take back your hot flashes to get your libido back!

The less good news is that libido is sometimes a puzzle to solve. I've found that non-oral estrogen addresses hot flashes with fewer unintended effects on sexual desire. The reason is that oral estrogen enters our systems in ways that affect metabolization in the liver and resulting circulating testosterone levels. And testosterone, though not entirely understood, is as important to women's sexuality as it is to men's!

You might start by changing to non-oral or transdermal estrogen; it will likely take up to 12 weeks to see whether there's an effect. And if that doesn't make enough difference, there are other options you can explore with your health care provider.

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