Sex Drive and the Menopause
What is libido?
Your libido is your sexual interest and desire, otherwise known as your ‘sex drive’. Libido varies from woman to woman and can be influenced by a range of different factors. Loss or reduction of libido may be experienced by women of any age and may result in reduced desire to have sex and/or sexual experiences that are no longer satisfying or pleasurable. All women will experience low libido at some time in their lives – this may be prolonged or short term (e.g. after the birth of a baby, during a stressful life period or when a relationship is rocky). Low libido can become an issue in relationships when one partner wants sex more often than the other and this desire discrepancy can cause conflict and unhappiness.
What influences your libido?
Hormone levels can affect your libido. For example, breastfeeding women have an increased production of prolactin, which can reduce sexual desire, and women who have reached menopause experience a reduction in sex hormones which can reduce libido.
There are a range of illnesses and medical conditions that can affect your libido, including:
- kidney failure
- infections, e.g. thrush or urinary tract
- hypothyroidism (underactive thyroid gland)
- chronic pain
There are a range of sexual conditions that can also affect your libido, including:
- dyspareunia – painful sexual intercourse, due to physical or psychological causes
- vaginismus – intercourse is difficult or impossible due to involuntary spasm of pelvic floor muscles
- orgasm problems – inability to orgasm or reach orgasm in a reasonable amount of time
Libido can be affected by stress, depression, anxiety, resentment, poor body image and shame and guilt about sex.
Some medications have side-effects that may affect your libido. Antidepressants and some oral contraceptive pills can decrease libido (due to changes in hormone levels). If you feel a medication that you are taking is affecting your libido, speak to your health professional about alternative treatments for your condition. Taking drugs (e.g. marijuana, alcohol) may also affect your libido.
Rest, relaxation, recreation and suitable exercise can all have positive effects on your libido, as well as on your health, bones, mood and general wellbeing. Therefore, if you are not maintaining a healthy and balanced lifestyle, you may experience reduced libido.
State of your relationship:
There are a number of relationship factors that can affect libido, including:
- familiarity, i.e. ending of the early ‘honeymoon’ period of the relationship
- being time poor or feeling too tired/fatigued for sex
- poor sexual compatibility or partner sexual problems
- experiencing problems that don’t have anything to do with sex, e.g. financial issues
- changes to the physical appearance of your partner, e.g. excessive weight gain, poor hygiene
If your relationship is unhappy and/or the sex you are having is disappointing, your willingness to engage in sex will be reduced. If you and your partner are not satisfied with your sex life, you can seek professional counselling. Speak to your general practitioner for more information.
What can you do?
Don’t be concerned about when or how often others have sex; there is no ‘normal’ when it comes to the frequency of sex. What’s important is whether you and your partner are happy with your level of sexual activity. If your libido level worries you or is very different from your partner’s and causes you distress, there are a number of things you can do to improve the
situation. Finding a solution to the problem involves determining what factors are reducing your libido and then trying to remove or reduce these factors as much as you can.
The most important thing to remember is that just because one person has a lower level of libido than the other in a relationship doesn’t necessarily mean there is something wrong with them. It is when the difference in libido is causing problems that you may need to seek help to manage the issue.
Some things to consider in managing your libido
The following are a variety of simple tips and things you can do to maintain, increase or improve your libido:
- maintain a healthy lifestyle by being physically active, eating a healthy diet, reducing your alcohol intake and taking time out to relax regularly
- if you are overweight, losing weight may help you feel better about your body and improve your level of desire
- try to find ways to manage your stress levels; this may improve your mental, physical and sexual wellbeing
- if you are busy, don’t wait for sex to happen spontaneously; allocate time for sex in your schedule
- find or create a physical environment that will be conducive to sensuality and intimacy
- you are more likely to want sex with your partner if there is plenty of goodwill in your relationship; women who are fulfilled by their relationship are more likely to feel sexually generous towards their partner
- ensure that your partner knows what makes you feel loved and wooed and encourage them to do these things and do the same for them in return; ask your partner to provide a regular supply of desire enhancers, e.g. affection, communication and conversation, quality time together, romance
- sharing the domestic responsibilities at home may increase goodwill between partners and this may in turn contribute to maintaining a healthy relationship. Reassess what chores/cleaning are really necessary; not everything has to be spotless all the time. Ask your partner to do their share of the chores
- if you have low desire but still enjoy sex with your partner don’t wait to feel lust before you have sex, as many women only feel sexual desire after they become sexually aroused. Rather than waiting to have ‘desire-driven’ sex fuelled by lust, engage in ‘decision-driven’ sex, where you make a conscious choice to have sex and enjoy it
- when desire is low you can choose to have sex for a range of good reasons, e.g. for affection and intimacy, to please your partner, because you enjoy the sex or because regular sex is good for your relationship
- work with your partner together as a team to deal with libido issues. If there is desire discrepancy try to find a compromise by negotiating with your partner to find a solution agreeable to both of you
- when desire is low you might be more willing to have sex if you don’t feel under pressure to become aroused during sex or you may prefer to give your partner manual or oral stimulation rather than have intercourse
- rather than automatically saying no to sex when the opportunity arises, ask yourself ‘why not?’ and if no good reason presents itself, go ahead and give it a try
- optimise the quality of sex you are having with your partner; the better the sex, the more likely you are to want it
- get to know your sexual anatomy (genitals) and learn how it works and what gives you pleasure
- don’t focus on getting turned on, rather focus on what is sexy and feels good to you
- try communicating with your partner what works best for you during sex, they may not know what you like
Note: You should never feel that you have to have sex with someone that you are not attracted to or don’t like or have sex that doesn’t please you.
With greater awareness, knowledge and discussion about sexual health issues, more women are seeking advice for low libido from health practitioners. You may want to seek advice, with your partner if appropriate, from your general practitioner if your libido is causing problems in your relationship. Some of the following management options may be appropriate:
- treatment for any underlying illness or medical condition
- hormone therapy
- antidepressants (certain antidepressants may be suitable, others can reduce libido)
- stress management
Where can I get more information?
www.betterhealth.vic.gov.au – Better Health Channel 1800 126 637
‘Where Did My Libido Go?’ by Dr Rosie King available at www.jeanhailes.org.au
Good loving, Great sex
By Dr Rosie King
The Sex Starved Marriage
By Michelle Weiner Davis
Where Did My Libido Go?
By Dr Rosie King
HRT improves libido –Prof John Studd.
HRT certainly improves libido if estrogens are used to cure vaginal dryness and painful intercourse. Even without these characteristic symptoms, estrogens can improve sexual desire. However, if necessary, the addition of testosterone has a more dramatic effect upon libido, frequency of intercourse and intensity of orgasm. Testosterone patches licensed in women after hysterectomy and testosterone gels in the appropriate dose are often and should be used ‘off license’ with full consent and explanation.
Women must be aware that testosterone is not only a male hormone but it is an essential female hormone present in women in about 10 times the blood levels as estrogen. It is an essential hormone, important for energy, mood and sexuality.
Libido and the Menopause,
The traditional view that libido decreases after the menopause is mostly true but the reasons are complex. It may be simply the result of ageing or the result of oestrogen deficiency. It may be the response to a less sexually active partner as there are studies that indicate that if post-menopausal women have a sexually enthusiastic partner or partners then her libido is maintained for many years after the menopause.
It is also difficult to understand what libido really is. Coming from the Latin route, “lib-, libet” – to want or to desire – it was not originally a verb related to sex but certainly the contemporary meaning is clearly sexual. But even libido or sex drive relating to women or men has other non-sexual connotations in that it is related to general health, to self-confidence, to energy, and generally how a person feels towards her/his environment and body. It is easy to increase the libido by hormonal therapy and apart from the obvious increase in sexual events, such as fantasies, both intercourse, masturbation and orgasms, there is also the knock-on effect that women are happier and have more energy and give out an aura of being sexually confident. Women speak of the extra advantages that attend an improvement in the libido, particularly their enthusiasm for life, self-confidence at work, and a greater feeling of friendship with their partner.
Libido is a strange mixture of Head, Heart and Hormones and as gynaecologists we can only really influence the hormonal part of this triad. Psychologists and psychiatrists may think they can alter other aspects but the results are less reliable and treatment much more time-consuming. In spite of this the bulk of the literature concerning the treatment of libido loss does not come from gynaecologists nor is it related to hormonal based therapy.
Women after the menopause often have problems of flushes, night sweats, feeling wet and unattractive during the night. They have insomnia and the loss of libido often takes the form of a total rejection of even being touched by their partner. This is very hard for them to understand if they remain very fond of this person and with whom they have lived happily for 30 years. There may also be vaginal dryness due to the atrophy of oestrogen deficiency linked to dry intercourse and painful intercourse. These are often the physical causes of loss of libido.
It is often claimed that women have a loss of libido after hysterectomy but this should not occur even if the ovaries are removed if proper HRT is given. This is contrary to the message given in every women’s journal in articles about hysterectomy which always indicate that the operation causes depression, loss of sexuality, marital disharmony and so on when the reality is that every single randomised scientific trial has shown that hysterectomy with appropriate HRT is associated with less anxiety, less depression, better sexuality and better general health scores. It is very odd that journalists continue to produce this fashionable but increasingly dishonest message about hysterectomy. Ovarian deficiency following oophorectomy will, of course, produce the predictable menopausal symptoms and the loss of ovarian androgens will produce the Female Androgen Deficiency Syndrome (FADS) of loss of libido, loss of energy, depression, loss of concentration, and even headaches. This occurs frequently after hysterectomy without the adequate and appropriate hormone replacement therapy but it is unknown how often it occurs in normal, middle-aged women who have not had a hysterectomy or oophorectomy. It is probably quite common but is ignored by most doctors who prescribe HRT and virtually all psychologists and psychiatrists who are not familiar with the use of hormones.
With the usual menopausal woman it is easy to treat hot flushes and sweats and its resultant insomnia by oestrogens and also to treat the atrophic vaginitis which causes painful intercourse by local or systemic oestrogens. This is a clear domino effect removing the most familiar and characteristic symptoms of prolonged oestrogen deficiency. Most people with these clear symptoms of the menopause would be helped by oestrogens alone.
However, there remains a group without vaginal dryness and without vasomotor symptoms who have this incomprehensible loss of libido. They may also be helped by oestrogen but the most effective treatment is by the addition of testosterone which, although available by many routes – tablets, injections, creams, and gels, is only licensed for use in women as a hormone implant. This is best given with oestrogen and the usual dose is oestradiol 50 mgs and testosterone 100 mgs and this should be repeated every six months. The improvement in libido occurs within a week and lasts for about five months at which time the implant should be repeated. In patients who have had a hysterectomy, this treatment is all that is required. Women with a uterus will need to have cyclical progestogen such as Provera 5 mgs for the first ten days of each calendar month to produce a regular bleed or they can have progestogen in the uterus as a Mirena intra-uterine system which will protect the endometrium and also suppress the periods.
Loss of libido is a common, distressing but treatable condition in the menopausal woman. For women who have no objection to hormones, oestrogen with or without testosterone, should be – in my view – the first-line treatment.
Testosterone for perimenopausal and postmenopausal women
There is good evidence that adding testosterone to hormone therapy (HT) has a beneficial effect on sexual function in postmenopausal women. However, the combined therapy is associated with a higher incidence of hair growth and acne and a reduction in high-density lipoprotein (HDL) cholesterol. These adverse events may vary with different doses and routes of administration of testosterone. Adding testosterone to HT did not increase the number of women who stopped HT therapy.
The question of whether adding testosterone therapy to conventional postmenopausal hormone therapy (HT) is effective or safe is unresolved. Therefore, we aimed to determine the efficacy and safety of testosterone therapy for postmenopausal women using HT.
To determine the benefits and risks of testosterone therapy for postmenopausal women taking HT.
We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched 21 July, November 2008), The Cochrane Library (2008, Issue 3), MEDLINE (1966 to July 2008), EMBASE (1980 to July 2008), Biological Abstracts (1969 to 2008), PsycINFO (1972 to July 2008), CINAHL (1982 to July 2008), and reference lists of articles. We also contacted pharmaceutical companies and researchers in the field.
Studies included randomised comparisons of testosterone plus HT versus HT alone in peri or postmenopausal women.
Two review authors independently assessed the quality of the trials and extracted data. For dichotomous outcomes, a Peto odds ratio (OR) and its 95% confidence interval (CI) were calculated. For continuous outcomes, non-skewed data from valid scales were synthesized using a weighted mean difference or standardized mean difference. If statistical heterogeneity was found, a random-effects model was used and reasons for the heterogeneity were explored and discussed.
Thirty-five trials with a total of 4768 participants were included in the review. The median study duration was six months (range 1.5 to 24 months). Most of the trials were of adequate quality with regard to randomisation and concealment of allocation sequence. The major methodological limitations were attrition bias and lack of a washout period in the crossover studies. The pooled estimate suggested that the addition of testosterone to HT regimens improved sexual function scores and number of satisfying sexual episodes for postmenopausal women. Significant adverse effects were decreased high-density lipoprotein (HDL) cholesterol levels and an increased incidence of hair growth and acne. The discontinuation rate was not significantly greater with the addition of testosterone therapy (OR 0.99, 95% CI 0.83 to 1.19).
There is good evidence that adding testosterone to HT has a beneficial effect on sexual function in post-menopausal women. However, the combined therapy is associated with a higher incidence of hair growth and acne and a reduction in HDL cholesterol. These adverse events may differ by the different doses and route of testosterone administration. There is insufficient evidence to determine the effect of testosterone in long term use.