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."

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.

Sex Talk Begins with What We Say to Ourselves

One of the advantages of having an advisory board is the different perspectives we bring to the same set of problems. In our last conversation with Mary Jo Rapini, the issue of body image came up: the fact that we women are sometimes our own worst enemies when it comes to nurturing our sexuality. The topic clearly hit a chord with Mary Jo--she'd also been coming across examples of it--and she offered to write this blog post.  

I was recently at a meeting that explored the literature and dealt with issues of sexuality, dysfunction, and relationships. The most popular theme in each educator’s presentation, no matter what their field of study, was the importance of body image in influencing women’s libido. Although many of the diagrams and graphs were complicated, the message was not. How women feel about their bodies influences their libido.

It makes sense, especially if you are a woman yourself or are close to one. You know how it feels when you feel bloated or fat and your partner wants to get naked. There is a sense of dread and duty; either you acquiesce or you find an excuse. It doesn’t matter how beautiful your partner tells you they believe you are, or what you’re wearing; if you don’t feel good about your body you don’t look forward to being vulnerable or wanting pleasure. Both of these are important when making love.MiddlesexMD_Rumi

When I see women who are struggling with their body image I find myself reciting things I have heard or read that help. For example, experts tell women to focus on an area they like and to appreciate and dress in to flatter that feature. For many women, this may be helpful, but my practice is full of women who can only admit to liking a very small limited area. Let’s face it; if you tell me your favorite area is your eyebrows, I'm going to struggle with how to help you build a better body image using your eyebrows--any expert would.

Body image can include areas that aren’t exactly body related. For example, many professional women boast a high body image and self esteem due to their careers. They may not like their body or parts of it, but they don’t let it hold them back sexually.

What we say to ourselves is much more important than what others say. A recent report I read said that women routinely say over twenty derogatory things about their bodies each day. These same women suffer from how they view their body emotionally, physically, and sexually. It doesn’t matter if their husbands love their bodies, comment on the beauty of their bodies, or tell them how attractive they are: These women are destroying their concept of themselves from within. Media is an easy target to blame, but media is not the entire problem. What we say to ourselves is the problem. What we think to ourselves is the problem. What we say to our friends about our inadequacies is a problem. All sex talk begins with what we say to ourselves. No sex talk will make women feel sexier, hotter, or more desired if they have destroyed their sense of sexiness from within. Hormone therapy can make you feel more like having sex, but if you don’t feel good about your body, you will be reluctant to act on your feelings.

Since this is an inside job we do to ourselves, the work to stop perpetuating a poor body image is also up to us. It means you have to take a stance and begin by advocating for yourself, for your intimacy/sex life with your partner. That means sitting down with your partner and directly addressing what happens to you when you talk to yourself. Usually loving men will do anything to help their partner if they understand the mission.

  1. If you are highly suggestive and seeing a photo of a taut, scantily dressed woman with sex appeal makes you feel and talk badly about yourself, then rid your home of these types of magazines, TV shows, or whatever you are currently seeing.
  2. Movement is linked to many sensory areas of our brains. Movement makes our mood better, our affect more animated, and our sense of sexuality healthier. You don’t need to run marathons to feel and be sexy, but you do need to exercise each day. Ten minutes is better than no minutes. An hour a day split up any way you want is best!
  3. Begin a journal to yourself listing derogatory comments you remember being said to you prior to the age of eight. These comments may have been made as "jokes" by warped people, but they weren’t jokes. They are wired into your brain, and you may be repeating these to yourself as part of your negative mantra.
  4. Catch yourself. Whenever you make a derogatory comment about some part of your body, picture a stop sign and say aloud, “No.” Ask yourself, “What right do you have to abuse anyone including yourself?” Then think of who in your life made you think this was okay. Sometimes you will remember things your dad said, but more likely your mom used to insult herself as well.
  5. If anyone in your life right now insults your body, that is a huge red flag. Tell them they are waving a red flag, and abusing you with negative comments is not okay. If your kids hear this message, they will begin early protecting their body image.
  6. Women are much more critical of their bodies than men are. Part of this is due to the fact that women are more sensitive and do not abuse men’s bodies with negative comments to the degree men do with women. One way men will learn how to treat women is if a woman stands up to them when they make a derogatory comment instead of joining them in their taunts.
Couples will spend money to enhance their sex life with products, medications, and exotic vacations. However, the least expensive and perhaps most effective is to begin changing how we talk to ourselves. The first sex talk you get is not the one you get from mom or dad during a formal birds and bees lecture. It’s the mini body image lectures we give ourselves when we are children. These mini body image insults we say each day to our bodies are more potent than any sex product, medication, or exotic vacation we could ever afford.

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!

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!

Hardwired for Sex?

Critics of the quest for “pink viagra” -- the elusive drug to increase female sex drive -- often argue that depressed libido isn't medical condition (like erectile dysfunction) that can be “fixed” with pharmaceuticals.

But a recent study by medical doctors at Wayne State University suggests that there may be measurable physiological differences between women who suffer from what researchers term “a distressing lack of sexual desire” and those who have a “normal” sex drive.

MRI scans of women viewing video clips that alternated between erotic scenes and nonsexual content found that areas of the brain that normally light up when thinking about sex remained dark in women with low sex drive, while other areas that usually don’t show activity lit up.

According to Wayne State’s Dr. Michael Diamond, who presented the findings at the annual meeting of the American Society for Reproductive Medicine last month, these brain pattern differences may provide the first “significant evidence” that, for some women, lack of sexual desire is a physiological disorder. One that could possibly be treated by meds -- pink or otherwise.

Although the study sample was small, and researchers have yet to understand exactly how these different regions of the brain relate to sexual arousal and response, for me these findings support the need for further research in this area. And raise hope that there eventually may be a medical option for women suffering from chronically low levels of desire.

We may find that some women are just wired differently and can benefit from a drug that improves their interest in sex, the way some people with ADD benefit from drugs like Ritalin and Adderall that improve their level of focus and concentration. Of course, some ADD patients prefer not to use medication and are able to make other adjustments that allow them to function well in their daily lives. And, if we do develop a “pink viagra,” it won’t be the solution for every woman. I’ve found that pain-free sex and a communicative partner can do wonders for the libido.

But I’d love to see the day when taking a desire-enhancing medication is a choice that a woman can make for herself. And studies like this one and the further research it will inspire move us closer to that goal.

Want Better Sex? Mark Your Calendar.

It’s interesting to me how many patients who come to me with concerns about diminishing libido are there because of their husbands or long-time partners. These lucky women have a great relationship with a great person, and they don’t want anything, including their own lack of sexual desire, to jeopardize it.

I respect that. I think that the desire to keep a long and satisfying relationship intact is a good reason to want to want to have sex.

I also believe that a lot of women in this situation sell themselves short. They think that because their partners want to have sex more often than they do themselves, there is something “wrong” that they need to “fix.” Often, it’s just a matter of timing.

Being “in the mood” for sex comes more easily to men. A man who is physically healthy and capable of an erection is almost always in the mood. Men are wired to go from zero to sixty on nothing more than a flash of leg or a lingering kiss. Women, on the other hand, tend to rely more on emotional or intellectual stimuli to reach a state of physical desire. And that takes time.

My advice? Get out your trusty planner and schedule a date for sex. Think of it as extended foreplay. If you schedule a week in advance, you’ll have days to think about your date night--what you’ll wear, what he might say about what you’ll wear, how he will want to take whatever you’ll wear off you. You’ll have time to buy some candles, choose a new aromatic massage oil.

Most importantly, because you’ll have to synch your calendar with your lover’s, you’ll have time to anticipate and talk about sex with each other, to make the crucial emotional and intellectual connection that helps both of you get in the mood for physical intimacy.

Some people dismiss scheduled sex as unromantic or think that deep physical attraction has to be “spontaneous.” I think it’s important to distinguish between sex that happens spontaneously (which can be very nice!) and sex that includes creativity and spontaneity in the act of making love (also very nice!). Think of scheduling sex as a way of insuring that you and your partner have a space and time where spontaneous acts of love and erotic play can occur.

Missing Orgasm: Is It Me or My SSRI?

Are the medications you're on behind your loss of interest in sex? Are they making it more difficult for you to reach orgasm? These are tough questions. On one hand, the answer is almost always "yes": So many of the medications we take--including pain meds and sleeping aids--list lower libido as a potential side effect. On the other hand, the answer is also usually "no": In my experience, the meds aren't usually the primary cause.

With one exception. If a patient reports a notable change in her ability to reach orgasm and is taking medication for depression or anxiety, I ask if she's on an SSRI.

The most commonly used antidepressants today, SSRIs--selective serotonin reuptake inhibitors (I know it's a tongue twister)--are very effective in treating depression and anxiety disorders. Unfortunately, they also tend to dampen a woman's ability to experience orgasm.

SSRIs--some of the most commonly prescribed are Prozac (fluoxetine), Paxil (paroxetine), and Zoloft (sertraline)--work by raising levels of serotonin in the brain, enhancing neurotransmission and improving mood. The "selective" part of the name is because SSRIs affect only one type of neurotransmitter--serotonin. But higher serotonin can lead to lower libido--and missing orgasms.

Of course, depression and anxiety all by themselves often lead to reduced interest in sex, so it can be hard to tease out cause and effect. But when a patient tells me she has lost desire or orgasmic function since beginning antidepressants, I often suggest that she consider switching medications.

Other types of antidepressants, like Wellbutrin (buproprion), act on dopamine neurotransmitters and typically have fewer adverse sexual side effects. In fact, studies suggest that increased levels of dopamine in the brain may actually facilitate sexual functions including libido and orgasm.

Sometimes bupropion is prescribed in addition to an SSRI, sometimes as a replacement. Doctors can often try different combinations and dosages until they find the prescription that treats the depression without robbing patients of their orgasms.

If switching isn't an option or if changing the prescription doesn't do the trick, there are other options. Even on SSRIs, a sluggish libido or elusive orgasm will respond to increased lubrication and stimulation.

Dealing with depression is hard. We don't have to make it harder by accepting the loss of an important part of ourselves. If you've struggled with the trade-offs, let us know how it's worked out for you.

Dean Martin. Found.

My libido woke up.

This week we shoveled out a room to make room for a new hobby. In the unearthing, my husband found my long-lost, autographed picture of Dean Martin:

Autographed photo of Dean Martin

Oh, be still, foolish heart!

My grandmother snagged two of these, one for my sister, and one for me, in Rome, when Martin was shooting there on location. She sent them to us when we were still too young to really understand what Dean could do for us.

But at the time, we were living on a naval base in the tropics, where it was hot, hot, hot. We spent most of our time in the base movie theatre, which had a sound track that ran the same songs over and over and over again between films. That track included “Everybody Loves Somebody, Some Time.” That voice could tease desire out of even a 10 year old. It turns out.

We fell a little in love then, but a lot in love later when we returned to the States and snuck around to watch Dean Martin on his television shows, and Dean Martin movies and listened even more to Dean Martin records. We have loved him ever since.

A quick quiz among a gathering of girlfriends suggests we are not alone. Dean still does it for a remarkably wide age demographic, doesn’t he? I know it included my mother, who would be in her late 70s now. And it extends to friends in their 40s…. I wonder if he could have ever known what lust he could inspire?

Anyway. Dean’s there for you on YouTube, whenever you want him. Here’s hoping he still works for you the way he does for me:

Especially for my sister:

That’s Amore:

Innamorata, sizzle

That’s just a sampling, friends. Happy memories…

Sex: Deciding to Just Do It

We are learning more and more about what motivates women to have sex -- enough to know that we still don't know that much.

We do know that our motivations 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 long-standing 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? And 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.

For us, having sex is less an urge than a decision. One we can choose to 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.
* It bolsters the immune system.
* Sex before bed helps us get to sleep.
* Of course, 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.
* Good sex reduces stress and increases self-esteem.
* Sex with your significant other stimulates feelings of affection, intimacy and closeness.

Making sex a focus in your life as you get older doesn't make you unusual. A study by AARP found that 66% of women age 45-59; 48% of women age 60-74 and 44% of women over the age of 75 believe that a satisfying sexual relationship is important to their quality of their life.

We think those numbers would be higher if women knew they could engage in thoroughly satisfying sex without waiting around for desire. Just by using their heads.