Low Libido? Natural Solutions

“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.

Testosterone: Satisfying Sex Once More per Month

Here's a summary of another study on testosterone in women, this time in women not on estrogen or estrogen plus progesterone. Duration longer than in previous studies: 52 weeks. On average, women on testosterone reported satisfying sex once more per month. Main question is: Is the unknown long-term risk of testosterone worth the benefit to your sex life? Many of my patients would say that contented sex, even if it only happens once more per month above baseline, is worth it. --SG

Testosterone Improves Sexual Function in Women Not Taking Estrogen
Posted 01/16/2009

Robert A. Wild, MD, PhD, MPH
Author Information

Summary

Davis SR, Moreau M, Kroll R, et al, for the APHRODITE Study Team. Testosterone for low libido in postmenopausal women not taking estrogen. N Engl J Med 2008;359:2005-2017.

Therapy with a testosterone patch placed on the abdomen and delivering 300 µg daily provides some benefit to postmenopausal women with hypoactive sexual desire disorder (HSDD) who are not using estrogen therapy (ET) or estrogen plus progestin therapy (EPT), according to this randomized, double-blind, placebo-controlled study. The Phase III Research Study of Female Sexual Dysfunction of Women on Testosterone without Estrogen was initiated to determine the efficacy and safety of the testosterone patch in postmenopausal women not receiving estrogen who are suffering from HSDD and included women from 65 centers in the United States, Canada, Australia, the United Kingdom, and Sweden. The trial was conducted for 52 weeks and included 814 healthy postmenopausal women (aged 20-70 y) who were randomly assigned to receive a patch delivering either 150 µg or 300 µg testosterone per day or placebo. Participants were seen at baseline and at weeks 6, 12, 24, 36, and 52.

Efficacy was measured through women's responses on a weekly sexual activity log for 24 weeks and their scores on a Profile of Female Sexual Function and a Personal Distress Scale that were completed at baseline and at weeks 12 and 24. Adverse events were assessed at each visit through week 52. Some women continued treatment for a second year to provide additional safety data. The primary endpoint was a change through week 24 in frequency of satisfying sexual episodes over 4 weeks.

Baseline scores for frequency of satisfying sexual events, sexual desire, and distress were similar among groups. By week 24, the increase in 4-week frequency of satisfying events was significantly greater in the group with the 300 µg/day patch, with an increase of 2.1 episodes versus 0.7 episodes for placebo; P < 0.001. There was an increase in satisfying episodes of 1.2 in 4 weeks for the group receiving 150 µg testosterone. Both groups receiving testosterone had significantly increased scores for sexual desire and decreased scores for distress by week 24. The overall incidence of adverse events among groups was similar, with incidence of androgenic events highest in the 300-µg group, mainly increased hair growth. Breast cancer occurred in three women in the testosterone groups by week 52 and in an additional woman receiving hormone in the extension phase.

Commentary by Robert A. Wild, Md, Phd, Mph

Prior clinical trials (typically lasting 3-6 mo) with exogenous testosterone have been well conducted. The majority of trials show modest overall improvement in desire, sexual responsiveness, and frequency of orgasm as well as the number of satisfying sexual episodes (an endpoint required by the Food and Drug Administration [FDA] as evidence of efficacy). The short duration of these trials has worried those concerned about potential for serious adverse effects. Studies have been restricted to postmenopausal women taking ET or EPT.

Here, Davis et al assess testosterone therapy in postmenopausal women presumably estrogen deficient for up to 2 years. Efficacy was shown in women who had natural menopause but not in those with surgically induced menopause (probably because of a lack of statistical power). It is reasonable to ask whether the absolute increase of satisfying sexual episodes of 2.1 per month (1.4 more events per month than in the placebo group) was of value. The article does not indicate whether the women were asked if this was meaningful for them. Baseline data suggest it probably was. The mean number of such episodes almost doubled for the high-dose group (84% vs. 28% for placebo).

All groups had reaction at the application site (49.5%-52.8%, which is high) and various androgenic events (acne, alopecia, and voice deepening in less than 8% of each group). A little more than half in each group completed 52 weeks. Reasons for dropping out are well illustrated. Increased unwanted hair growth was significantly more common with 300 µg of testosterone per day (19.9% vs. 10.5% in the placebo group). Of greater concern are the four cases of breast cancer in the groups receiving testosterone, including one case detected 3 months after the extension period ended, versus zero in the placebo group. This could simply be due to chance, yet it is potentially worrisome and cannot be ignored. Findings suggest the need for caution until we understand more about testosterone's possible link with breast cancer and until we are better able to predict which patients are more likely to have negative effects.

Transdermal testosterone is available in Europe for use in surgically postmenopausal women who have persistent symptoms of HSDD despite adequate nonconjugated ET. However, the FDA in the United States is concerned about potential adverse effects over the long term. Breast cancer risk and potential detrimental lipoprotein physiology with unknown cardiovascular disease risk, as well as androgenic side effects (well documented here), have been the major challenges. The reported lipid profiling in this study is reassuring yet not definitive. Small, dense lipoprotein particle concentrations are a better predictor of events but were not measured. The pharmaceutical industry sponsored and analyzed this multisite study.

Because of a lack of FDA-approved testosterone patches in the United States for women, compounding pharmacy preparations for transdermal testosterone are often prescribed. If this route is chosen, full disclosure of off-label use and documentation of the known and unknown risks is strongly recommended. With the breast cancer concern and the need for studies with large numbers of women enrolled to answer this concern, it is likely that the FDA will continue to be very conservative regarding this issue.

From the NAMS First to Know e-newsletter released December 23, 2008

For more, please visit http://www.menopause.org/news.aspx

Libido: Bay Area Boosts

Libido is one of my favorite topics both as an area of physical, mental and spiritual inquiry and as a scholarly pursuit. Plus it's just fun to rev it up as much as possible especially when in a long-term monogamous relationship.

Now, as an aside, let me reassure my friends who are depleted and gave up caring about libido months or years ago: you can get your game back. My heart and pharmacoepia especially goes out to fellow depleted moms. That reminds me - I need to do a blog post on Depleted Mom Syndrome.

We are blessed in the Bay Area (and in New York and Los Angeles, and tell me if there are more libidinously enriching parts of our fine country) to have many places that offer succor to the libidinally-challenged.

My personal fave haunt is S Factor in San Fran, but also available in other cities. What is "S?" It's a hybrid form of movement that weaves yoga, pilates and connecting to your erotic creature. It's completely hot and a lot of fun. Take an intro class or sign up for a private with my dear friend, Michelle Cordero. Since I have a tendency to overachieve, I have attended 3 intros, devoured Sheila Kelly's book on "S" and practiced every DVD she's put out. My husband and I haven't figured out a way for me to attend a session in San Francisco - at two hours plus the commute time - it just doesn't fit into my schedule. But maybe your schedule? Get the intro schedule right here.

Here is Sheila teaching Oprah how to move.

Did you see the cover of last Sunday's NYT's Style Section with the orgasmic woman on the front page? So great. The article was about the Bay Area's OneTaste Urban Retreat Center, a co-ed gathering space with a focus on pleasing women. Where do I sign up? The founder, Nicole Daedone, is the creatrix of the joint, and at 41, she is tapping into a hugely unmet need among women -- the idea that we access freedom, full embodiment, and full-throttle living through our sexualty. A core of 38 men and women live in the SOMA location, but OneTaste offers workshops, a thriving online community (read: free), and a residential program. Check 'em out right here.

My brain tends to cluster around groupings of three, so here is another favorite resource: famous Bay Area sex coaches Celeste and Danielle. I met these women three years ago over lunch at Cafe Gratitude in Berkeley. They offer sex therapy, workshops and hands-on-in-the-bedroom, down and dirty sex couching (they wear gloves!). I have one patient with low libido who had picture-perfect hormones, and we discussed Celeste and Danielle's workshops. She asked her husband to go to their workshop, "Become an Extraordinary Lover," and that was the only intervention she needed to reconnect deeply and wildly with her man.

Wish it were always so easy....

For the rest of us, libido is a complex and very interdependent mix of the right hormonal balance (the players are estrogen, progesterone, testosterone, DHEA, cortisol among others) plus emotional connectivity, healthy body image, time and commitment. More on that later, in the meantime, enjoy your local resources and share via the comments section other discoveries for raising your libido.