Posts Tagged ‘libido’

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.

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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!

And 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.

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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.

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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.

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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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Overall, estrogen is helpful to libido and sexual desire. Oral (systemic) estrogen can have the unintended effect of decreasing testosterone, which is linked to libido in women as well as men. The reason is complicated, but has to do with liver metabolism and a binding protein that reduces circulating testosterone.

The approach I take with patients is to use non-oral, transdermal (systemic) estrogen, which bypasses the liver and therefore doesn’t affect testosterone levels. I’ve had patients who couldn’t experience orgasm on oral estrogen but could with non-oral estrogen.

And for some women, I do consider adding testosterone. There isn’t a product for women, so I use a very low level of male testosterone “off-label” and then monitor blood levels during use. Sometimes, as an alternative, Wellbutrin (buproprion), an anti-depressant, helps restore libido by affecting the neurotransmitter dopamine.

I’m afraid we women are complicated! There are, though, a number of options to experiment with until you’ve achieved the sex life that makes you happy.

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For years, the dominant theory among anthropologists and evolutionary biologists has been that men are lusty, sexual creatures, primed by eons of evolution to spread their seed far and wide, assuring the propagation of their genes.

Women, on the other hand, mind the hearth and home. They trade sex for security and protection, saving the sweetest honey for the most viral suitor, who is also the one most likely to provide, protect, and produce robust offspring. Thus, women prefer monogamy and fidelity over sexual exploits.

That theory fits the predominant cultural paradigm. It’s a comforting, unthreatening explanation of how things are.

Except that it may not be accurate. Exactly.

Lately, this tried-and-true evolutionary theory has come under fire. Maybe the sexes don’t fall so neatly into “his” and “her” categories. Maybe previously overlooked research casts a different light on how humans interact sexually.

Maybe, for example, women aren’t so monogamous and passive. Maybe, despite even their own self-described diffidence, women are just at lusty and promiscuous at heart as men. That’s the thesis behind the new book What Do Women Want? Adventures in the Science of Female Desire by Daniel Bergner.

“Women’s desire—its inherent range and innate power—is an underestimated and constrained force, even in our times,” writes Bergner.

Consider that passion is one of the first casualties of long-term, committed relationships. According to Bergner, “flagging sex drive is not just an inevitability for women—it is specifically the result of long-term monogamy. Even [effects of] the hormonal decrease of menopause can be entirely overridden by the appearance of a new sexual partner.” (qtd. in this article in The New York Times. My italics)

So, dangle some studly dude before a menopausal lady, and she’ll be giggling like a teenager, but serve up the same old spouse and watch the sizzle drizzle.

Bergner references several studies that underscore the raw lust of the “gentle sex.” Female subjects were hooked up to a machine that measures vaginal blood flow. Then they were shown images of heterosexual and homosexual sex and even pictures of sex between bonobos—a species of ape. Women were turned on by all of it—even the apes—according to their vaginal reaction.

When heterosexual men were shown the same images, the response was predictable: they were slightly turned on by photos of men masturbating and male homosexual scenes, but they were overwhelmingly aroused by heterosexual and homosexual images of women.

But the really interesting thing?

In this study, both men and women also self-reported their levels of arousal as they watched the images. The men’s written responses were completely consistent with their physical responses—body and mind told the same story.

Not so with the women. Even though the instruments showed wide-ranging arousal at all the images, the women’s self-reported assessments were very different. The heterosexual women said they were turned on by the men but not by sex between apes or women. Right in line with cultural expectations and maybe their own idea of how they ought to feel.

Except that their bodies were telling a different story.

This female dichotomy between self-reporting and physical arousal has been repeated in several experiments that indicate women are turned on a lot more and by a wider range of sexual situations than previously thought, and also that women either aren’t aware of their own arousal or consciously under-report it.

Why is this? Why is the suggestion that women are naturally lusty such a shocking and forbidden topic? Why does this rattle the cage of cultural morés and expectations?

Women have, since time immemorial, been the kin-keepers, the caretakers, the foundation of the family, the social glue. But at what cost? Denial of their own primal sexual urges? Settling for sexual repression and boredom for the greater good?

No one is suggesting that monogamy, commitment, and long-term relationships ought to be tossed out, or that women should act on their urges. Clearly, stability, attachment, and intimacy create strong societies and families. Despite whatever sexual frustration it entails, monogamous relationships work for raising children and also perhaps for long-term psychological contentment.

But repression doesn’t work very well. So long as women feel they ought to ignore, deny—or to be puzzled or embarrassed by—urges that seem unacceptable or culturally unsanctioned, they will continue to be confused by and out of touch with their most primal urges. And maybe lose out on some healthy sexual energy as well.

No one has to act on their impulses, but acknowledging and accepting that they exist might be a healthy psychological choice, and one that puts women in touch with their sexuality.

How do men feel about all this female sexual sturm und drang? Well, “this scares the bejeesus out of me,” said one man in this article. The notion that, roiling beneath the domestic façade of the little woman tending hearth and home, may lie scary sexual urges has always been deeply unsettling, especially to men. Who’ll mind the children and navigate the social contract? Who’ll be the faithful one?

The growing scientific suspicion that women have a lot more going on beneath the surface than we let on or the culture sanctions is an interesting theory. While it may not be the whole story, I think somewhere we recognize it as at least partly true.

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Ever since Flibanserin was shelved after FDA rejection, the search for the next drug to treat lack of libido in women has been mighty low-key. To be sure, there were legitimate concerns about Flibanserin’s effectiveness, but as I’ve said before, we need more treatment options for women who suffer from hypoactive sexual desire disorder (HSDD).

Now, three years later, initial trials on another pink Viagra drug, which are actually two drugs (Lybrido and Lybridos), are just winding down. The results look “very, very promising,” according to Adriaan Tuiten, the drugs’ developer. If all goes well in the next phase of clinical trials, a pink Viagra could be on pharmacy shelves by 2016.

And that would be something to celebrate.

As I mentioned in my last post, HSDD is common; it’s complex; and it has confounded therapists and researchers for decades. Unlike pills for erectile dysfunction, low libido in women isn’t just a matter of hydraulics—increasing blood flow to the genitals (although it’s partly that).

Therapists and physicians have debated long and hard over female sexual desire—what creates it; what kills it; even what it is. Sexual desire probably has as much to do with our brains and our emotions as it has to do with our plumbing. And, possibly, desire may even be connected to the way women are hard-wired for sex, commitment, and monogamy.

It appears that women like novelty maybe even more than men. And while women don’t tend to be more promiscuous than men, they do tend to fizzle out, sexually speaking, more quickly and persistently within long-term relationships. They just lose interest.

“Sometime I wonder whether it [HSDD] isn’t so much about libido as it is about boredom,” says Lori Brotto, a therapist who has worked extensively on female libido, in this article in the New York Times magazine.

It’s also about loss of hormones that we experience—right about now.

This doesn’t mean that women who suffer from loss of libido don’t love their mates. It doesn’t mean that they can’t become aroused or even experience orgasm. It does mean that the sexual attraction, the heat and fizz, the interest in being sexual has waned or disappeared.

You know, the old “not tonight, dear. I have a headache” routine.

Every night.

Make no mistake, for many women this is a real heartbreak. “How much easier it would be if we could solve the problem by getting a prescription, stopping off at the drugstore and swallowing a pill,” writes Daniel Bergner, author of the forthcoming book What Do Women Want?

This next frontier may be attained if Tuiten’s sister-drugs for HSDD —Lybrido and Lybridos—continue to be as effective as early trials suggest.

The two drugs affect three chemicals thought to be involved with sexual desire and arousal in women: testosterone, dopamine, and serotonin. But each drug takes a slightly different approach.

Both have a testosterone coating that melts in the mouth and enters the bloodstream quickly. Lybrido then works something like Viagra, increasing bloodflow to the genitals, which may heighten a woman’s awareness of her own arousal, releasing a resultant cascade of dopamine, the neurochemical of passion, in the brain.

Lybridos, on the other hand, use an anti-anxiety drug, called Buspirone, instead of the Viagra look-alike. After the testosterone rush, Buspirone temporarily suppresses the production of serotonin, a “higher order” neurochemical that creates feelings of well-being and self-control. Squash the voice of reason (serotonin) and perhaps passion (dopamine) will gain the upper hand. Or so the thinking goes.

Preliminary results from these trials were recently published in The Journal of Sexual Medicine. The next round will involve a much larger study.

“Perhaps the fantasy that so many of us harbored, consciously or not, in the early days of our relationships, that we have found a soul mate who will offer us both security and passion, till death do us part, will soon be available with the aid of a pill,” writes Bergner in the Times article.

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Libido is a tender blossom. A cold blast of hormonal change. A whiff of illness or the wrong medication. Even routine and long-term sexual ho-hum can cause libido to wither like a sweet pea on a frosty morning.

The whole notion of female sexual desire and what causes it to bloom or to die on the vine isn’t well understood (like a lot of female sexuality, actually). But low libido in women is extremely common, according to the few studies done on it. Low libido conservatively affects between 8 and 12 percent of older women—those of us who are in the midst of or beyond the “change.” Other experts say that all women experience low libido at some point in their lives, and I wouldn’t quibble with that statement.

It even has a not-very-sexy name: hypoactive sexual desire disorder (HSDD).

To be clear, the textbook definition of HSDD goes like this: “a deficiency or absence of sexual fantasies and desire for sexual activity. The disturbance must cause marked distress or interpersonal difficulty.” (My italics.)

In other words, it ain’t a problem until you (or your partner) say it’s a problem. Low libido isn’t a disorder per se unless it’s making you or your partner feel distressed, dissatisfied, guilty, or otherwise unhappy.

Interestingly, while sex drive does tend to diminish as we age, most older women are less distressed about it, “resulting in a relatively constant prevalence for HSDD over time,” according to this report by Dr. Sheryl Kingsberg, a friend of MiddlesexMD.

To some extent, women expect to lose their sexy juice after a certain age because that’s what our American culture tells us to expect, according to Mary Jo Rapini, a therapist and MiddlesexMD advisor in this article for Fox News. Older women aren’t expected to be sexy. They’re expected to be invisible.

Yet, says Mary Jo, women shouldn’t passively accept this state of affairs just because they’re reaching midlife. “Accepting low sex drive because you’re getting older is the same as accepting drugs to control your diabetes when you could change your diet, exercise, and lifestyle regimen.”

For many women, however, low libido is a problem, causing all kinds of guilt, distress, and relationship disturbance, which may either be intense and unrelenting or intermittent and mildily distressing.

If good sex is correlated with general sense of well-being and higher quality of life and self-esteem, it’s not surprising that ongoing sexual frustration can negatively affect health and well-being. Dr. Sheryl mentions several studies that associate HSDD with health problems. In one such study, for example, “women with HSDD experienced large and statistically significant declines in health status, particularly in mental health, social functioning, vitality, and emotional role fulfillment.”


HSDD can be caused by a whole bunch of physical conditions, ranging from certain medications to certain illnesses to, yes, age-associated hormonal changes. But many women struggle with HSDD because of emotional issues, and that’s the focus of Mary Jo’s article. In her experience, the emotional causes of low libido are often relied to stress, relationship and intimacy issues, or to problems with self-esteem and body image.

“Addressing the emotional causes of low libido should be the first step you take in addressing why you no longer desire sex, your partner, or your intimate life,” she writes.

Mary Jo suggests some honest exploration, perhaps with a therapist, to get at the root of these emotional problems:

Are you stressed or depressed? Are you struggling with self-esteem or poor body image? Do you feel emotionally connected to your partner? Can you talk about sexual issues? Is there a history of abuse or infidelity in your relationship?

As with so many sexual matters, the causes of HSDD are complex, intertwined, and challenging to unearth. The cause could be as straightforward as adjusting a medication or as difficult as changing an unhealthy lifestyle or honestly assessing emotional issues.

If loss of libido is troubling you, tackling the underlying causes may also be a journey toward greater overall emotional and physical health, because just as sexuality is woven into the very fabric of emotional and physical well-being, you can bet that what affects sexuality is also affecting other parts of life as well.

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According to a recent New York Times article, women now have available a plethora of products meant to boost “feminine arousal.” And they’re appearing not behind the pharmacist’s counter, but in over-the-counter products in major pharmacies, right beside the Vaporub and Ace wraps.

Yahoo—I think.

Many of these products contain blends of botanicals and oils and “secret-recipe” ingredients designed to boost a woman’s sexual response. I wish some of them would carry more information for the user so that, for example, some oils aren’t unintentionally used internally when they’re best only for external massage. As with many beauty products, some strike me as setting unrealistic expectations (or even sending unfortunate messages), as with “anti-aging creams” for the vagina, clitoris, and inner thighs.

Few of these products have been objectively tested for efficacy or safety, so it’s a “buyer beware”—or, I’d rather say, “buyer be informed” marketplace.  Zestra’s oil is the only arousal product that has been subjected to a randomized clinical trial in which it “significantly” outperformed a placebo. Too many products are promoted with only survey results, which are not the same thing as a clinical trial.

As the Times article noted (and we’ve stated many times), the trouble with female libido is that it’s complicated. Everything from mood to culture and personal beliefs to hormonal imbalances can affect a woman’s ability to “get it on.”

And in fact, a woman’s lack of libido also affects her partner’s sexual pleasure. Dr. Michael Krychman, gynecologist and MiddlesexMD advisor, notes that men often neglect to fill their Viagra prescriptions because their partner’s sexual issues remain unaddressed.

Finding a one-size-fits-all silver sex bullet is like looking for fairy dust. Most of us have to develop a multi-pronged regimen to keep our sex drive functional, especially as we get older. We could abide by the Hippocratic principle to “do no harm,” and given that these products are, by-and-large, indeed harmless, and that they may do some good, why not give them a trial of your own? Use a site like ours to inform yourself about what might be worth looking for or avoiding (we have this advice, for example, about choosing a lubricant), and then make some room for some playfulness.

“Do they work for serious issues? No. But do they work to make your sex life more fun? Maybe. There’s certainly no harm in trying,” says Dr. Bat Sheva Marcus in the Times article.

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