“I’d rather read a book than have sex with my husband,” Daphne sheepishly admitted during her last pap smear. She checked for my reaction. Would I brush off her complaint? Would I empathize? Better yet, could I offer any solutions?
Daphne is a 44-year old healthy woman and her symptoms, low sex drive and a growing aversion to having sex with her partner, is very common among women in long-term relationships. In fact, 40 to 50% of women her age complain of low libido. You may have noticed that Viagra and its newer cousins haven’t solved the sex problem for women. While most cases of low desire are multi-faceted, there are many proven treatments available. What follows is an integrative, evidence-based path for revitalizing libido to a more evolved place and how to live abundantly and restore balance when your libido feels low.
Daphne got married at 32, had her first baby at 33 and another at 35. Since the birth of her second baby, she has quietly avoided sex with her husband. Now they have sex about once per month and it feels like a chore to her, another pull on her overly busy juggle of work and family. The timing Daphne describes, of a dip in sexual interest after four years of partnership, and especially after a birth, is very common among couples. Daphne is distressed about her waning desire and it is negatively impacting her marriage, which is why she sought help. There are physical and psychological reasons for low libido, but usually the cause is a combination of the two. Primary physical causes of low desire include hormone changes, adrenal burn-out and other medical conditions.
Low estrogen during the post-partum period, premenopause (the time from age 35-50+ when you still have periods and/or cyclic ovarian function) and menopause can dramatically affect your mood and sexual interest as well as cause thinning and decreased sensation to your vulva, clitoris and vagina. Blunted sensation is due to regression of the nerve and blood supply to the genitals as a result of lower estrogen levels. Daphne felt like her clitoris “went numb” after having her last child and stimulation that usually brought her to climax no longer worked. Fortunately, there are simple and often effective remedies for this such as application of bioidentical estrogen cream.
Generally, between the age of 35 and 50, progesterone declines. Estrogen, although it can fluctuate wildly, overall maintains a near-normal level. This imbalance often leads to estrogen dominance, heralded by bloating, mood swings, insomnia, painful breasts, unexplained weight gain, headaches, anxiety, infertility, foggy thinking and weepiness. Often low libido is a byproduct of the lack of restorative sleep and general feelings of being unwell triggered by hormone imbalance. Both low estrogen and testosterone can diminish drive and responsiveness. These are most common in women at menopause or later, or postpartum which is a pseudo-menopausal state in a breastfeeding mom. We are still learning what levels of estrogen and testosterone correlate with a healthy libido for women. Most thought leaders in Sexual Medicine agree that replacement with levels to the upper half of the normal range is the goal. However, synthetic versions of estrogen and testosterone carry significant risks including the recently reported doubling of breast cancer chances in the Nurses Health Study. It is very important to be thoroughly educated regarding these risks, be monitored for them, and to be prescribed the safest and smallest amounts, tailored for you by an experienced medical physician. For instance, all women on testosterone should get liver function tests and a lipid panel every 3 to 6 months to monitor for harm to the liver and heart, which is why I prefer to prescribe bio-identical hormones when possible as they are often more effective and may have less negative side effects.
Another major component of healthy libido is stress management. Who wants sex when it feels like you’re constantly under assault by a crazed schedule, 2 kids and the mortgage crisis? Stress causes cortisol levels to rise above normal, and cortisol then can occupy the progesterone receptor, the lock in a cell into which progesterone fits, and block the action of this important hormone. Many women then experience an imbalance between their estrogen and progesterone. Subtle changes in progesterone action can cause low libido. Often a small amount of progesterone can improve desire along with working to minimize the impact of stress. In addition to progesterone receptor effects, stress causes disharmony between the sympathetic and parasympathetic nervous systems. The sympathetic nervous system triggers our “fight or flight” response, which increases heart rate, blood pressure and breath.
The parasympathetic system controls two crucial functions: digestion and sexual function. Most people who are chronically stressed have an imbalance of the sympathetic and parasympathetic systems, meaning that they are chronically stressed by deadlines, demands, children, work, and poor support systems, and find that their digestion is sluggish and they have no energy for sex. Women also report feeling debilitating fatigue, depleted life force, unstable blood sugar including hypoglycemia, intolerance to exercise, low blood pressure, dry skin, hair loss and sometimes brown spots on their face. This is also known as adrenal fatigue or burned-out adrenals, a popular diagnosis in the alternative medicine community but not recognized by conventional medicine. There are simple tests to assess for whether you have adrenal fatigue, and many supplements available.
Please take care to be diagnosed and treated accurately. I recommend an evidence-based approach to adrenal dysregulation with vitamins, minerals, healthy nutrition with adequate protein and whole grains, rest and stress reduction, and, when needed, supplementation with pharmaceutical-grade cortisol at low doses. Other important physical causes include side effects from medications such as anti-depressants and blood pressure lowering pills. At Gottfried Center for Integrative Medicine, we offer proven protocols for improving low libido while on these agents as well as “Integrative Medicine” approaches to tapering off of antidepressants successfully.
Besides physical causes, there are various psychological and social contributions to low desire. Primary psychological issues include relationship stress, untreated or partially-treated anxiety, depression, chronic stress and a history of abuse. While some of these can be managed by a primary care physician or integrative medicine physician, sometimes psychotherapy and/or sex therapy is advised. Body image, your partner’s age, health and self-care, and your emotional intimacy with your partner all impact your sexual feelings. Most women also don’t realize that male sexual feelings start with drive, then move to arousal, and from arousal and sexual connection, they feel intimacy. Women must feel a sense of intimacy first, then arousal, and then desire. This is subtle gender difference yet fully understanding how this difference plays out in your partnership can be profound.
Practical sex coach tips. While I do not want to discount the importance of treating the previously mentioned multi-factorial causes of low libido, sometimes we also need to bring levity to the bedroom. These are some tried-and-true tips I’ve gathered from seasoned sex therapists combined with my 20 years in practice, counseling women about their libidos.
1. Try something new every third time you have sex. We are living longer in monogamy than ever before, and if we expect our sexual connection to remain vibrant, inject creativity and thoughtfulness. Check out S Factor or OneTaste for ideas!
2. Get the TV out of your bedroom! Consider your bedroom sacred space and for enhancing your parasympathetic nervous system. Bedrooms are for sleep and love making only.
3. Have sex weekly. Studies have shown that you must have sex at least 3 times per month to notice a benefit. It also prevents the need for couple’s therapy in my experience!
Daphne had low progesterone and estrogen dominance. With use of bioidentical hormones, she got her levels back into balance. She attended my class, Sex 101, and learned about emotional intimacy and its role in her receptivity to making love. Additionally, she found ways to manage her volume of stress and her reaction to it. Daphne happily reports that her energy and sex drive have returned, not to pre-children levels but to a mutually satisfying place for her and her husband. She now reports that her marriage feels strong and passionate again. If you felt a strong sexual connection with your partner in your early days of romantic sex, you can reclaim that connection again. Sexual love is mysterious and not easily controlled, yet if suppressed or ignored, it can drain your life force. Often sexual disharmony is an indicator of deeper imbalances. These imbalances once understood and addressed can lead to the restoration of optimal health, energy and libido.
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