Natural Health Magazine: Interview on Low Libido

Thrilled to be interviewed in Natural Health, published in the April/May 2011 issue. Most of what I said about hormones and how they modulate libido got cut. My main point that libido is extremely complex (and that 70% of the time there's a hormonal component) but that there are many other factors including relationship connectivity - at least that made it in. Click here to read the article.

My long answer on how to manage adrenal dysregulation got distilled into a cliched soundbite: meditate and exercise. Excuse me? That is so not helpful. There's a much bigger story here, but still, it's a start. We gotta start somewhere.

BTW, does anyone know how to post a PDF on blogger? Haven't figured it out yet, so had to send you to my website, where I do know how to post PDFs.

Resolving Differences in Libido

Yesterday, I taught "Yoga for Restoring Energy & Libido" at Yoga Kula in Berkeley, and realized afterward that we didn't spend the 10-15 min I had prepared on how to resolve differences in desire, and sometimes, when needed, to compensate for both high and low libido when your libido is discordant than your partner's. Most partners have discordant libido, and how your find the middle path together is an essential part of a deepening, mature, mutually toe-curling sexual connection.

I mean "compensation" in the most loving, inclusive way -- such as how a kinesthetic learner would compensate for a class that requires visual learning, such as in Art History. I mean it with no judgment and no shame associated with it.

If you have low libido, I recommend a comprehensive medical exam, ideally with someone who is well-versed in hormones and their role in energy and libido. While causes for low libido such as adrenal dysregulation, fatigue, low testosterone, estrogen dominance, and underactive thyroid are described in previous blogs, as well as their natural solutions, I will focus here on the ways that have been shown to help bridge the divide if you have a partner with a higher or lower desire than yours, at least stronger than yours, and perhaps it's motivating you to do something about it.

For those with low libido:

1. Lean into your strength - Identify and fortify your sexual strengths. Even when desire is relatively low, often other aspects of your sexuality such as technique, variety, talking about sex, sensuality, romance, verbal intimacy or body image are areas where you are interested in putting more energy. For more info on this, and to perform a helpful survey to identify your sexual strengths and your partner's, read Pat Love's book, Hot Monogamy, esp pages 18-39, Mapping Your Sexual Relationship. 
2. Realize the power of receptivity. Recent thought leaders such as Rosemary Basson have recognized that spontaneous drive is common for men, and relatively uncommon for women. In fact, our most recent conceptual model shows that women do not need to have sexual desire or drive to have a satisfying sexual connection with their partner. Further, many women have difficulty distinguishing desire from arousal. Sometimes just a small opening in our receptivity to our partner's bid for sex can mean the difference between a mutually satisfying sexual connection and a connection that causes distress. 
3. Fan the fire when it strikes. Sometimes we have a small glimmer of interest in sex or sensuality, and the more we act on it, fan it, encourage it, the better. A crucial task here is to identify patterns in your life that are associated with greater libido: perhaps Friday or Saturday is a better day for you than during the week, maybe it's after your husband watched the kids while you went to a yoga or meditation workshop. Maybe it's day 9-14 of your menstrual cycle, when testosterone peaks.
   

For those with high libido:

1. Initiate sex out of love and desire, not habit. We often get locked into how sex needs to be, and breaking out of this habit will create more life and vitality in your connection. 
2. Improve technique. New expertise in love-making can go a long way in getting your less libidinous partner interested and receptive to your bid. We can always learn more and try new things. If you live in the Bay Area, attend a workshop at Good Vibes in Berkeley, or Celeste and Danielle's Become An Extraordinary Lover.  
3. Be respectful of your partner's parameters on sex. This requires verbal fluency in talking about sex, and how to optimize your partner's interest and openness to your bid. Ask your partner what some of their preconditions for sex are (kids are in bed and asleep, dishes are done, prefers sex in the mid-day), and do your best to satisfy them. 
4. Don't take your partner's lower libido personally. Many of us are just born with lower libidos - it's a bell-shaped curve. Find the way to negotiate a mutually satisfying plan for sex that honors your needs as well as those of your partners. Your partner's low libido is your issue as a couple - do not make your partner feel inadequate or that there is something wrong. 
5. Broaden your definition of sex. One brilliant sex therapist I love, Ruth Cohn, defines sex as "any erotic activity that is pleasurable, connecting, makes me feel good about me, good about you (my partner) and good about us." You can create your own list of what would now be defined as sexual activity, and it may include watching a romantic movie together while you hold hands and laugh together, or giving each other a massage and delighting in the pleasure of touch without it becoming sexual.

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.

Maca Improves Anxiety, Depression & Lagging Libido

A new study just published in Menopause showed that in a small group of post-menopausal women, a botanical named Maca, also known as Peruvian Ginseng, improved many of the issues our patients at the Gottfried Center complain of, namely anxiety, depression and low libido. Maca was also shown not to affect estrogen or androgen levels. The study was a randomized, controlled clinical trial, the "gold standard" in terms of high quality evidence.

Maca is thought to influence monoamine oxidase levels, one of the targets of prescription anti-depressants. However, as we all know, prescription antidepressants lower libido, whereas maca seems to improve it.

The improvement in libido I think may also be related to effects on the adrenals. This study confirms a previous study showing improved libido in both men and rodents with maca.

We treat both men and women now with symptoms of andropause and menopause, often with bioidentical hormones. In some, it may be more prudent to try proven botanicals first, such as maca.

Birth Control Pills & Breast Cancer?

We have more data now on the ongoing body of work on whether the synthetic hormones in birth control pills cause breast cancer. You'll notice in my other blog a recent study showing an increased risk (http://menopause.zaadz.com/blog/2006/12/the_pill_linked_to_premenopausal_breast_cancer). In the spirit of unbiased opinion -- here is a recent study showing no increased risk, although remember that The Pill is proven to lessen libido.

Do Oral Contraceptives Affect Risk for Death from Breast Cancer?

OC use had neither a beneficial nor a harmful effect on breast cancer mortality.

The relation between oral contraceptive (OC) use and breast cancer risk remains under constant surveillance. To study the effects of OC use on risk for death from breast cancer, investigators analyzed cancer registry data from the Surveillance, Epidemiology, and End Results Program in conjunction with linked data from the population-based, case-control Cancer and Steroid Hormone (CASH) study. Fifteen-year survival was assessed in 4292 women who had been diagnosed with breast cancer and who were interviewed about reproductive contraceptive and disease history, family history, and personal characteristics and behaviors during the CASH study (conducted from 1980 through 1982).

During the 15-year follow-up, 1473 of the women died from breast cancer; 80% survived for 5 years, 70% for 10 years, and 64% for 15 years. Compared with women who had never used OCs, the relative risk for death from breast cancer in ever-users was less than 1.0 (adjusted hazard ratio, 0.94; 95% confidence interval, 0.83–1.06). Neither duration of use nor age at first use affected the risk for death from breast cancer. Adjusted analysis showed that stage of disease at diagnosis did not affect the relation between breast cancer mortality and time since first and last use of OCs. Women who were currently using OCs at diagnosis had a statistically insignificant adjusted HR of 0.90.

Comment: These researchers did not address the association between oral contraceptive use and breast cancer diagnosis but rather the effect of OCs on breast cancer mortality. One limitation of the study is that it did not take into account estrogen- or progesterone-receptor status or the presence of BRCA mutations or HER2/neu _expression. Nonetheless, these results provide reassurance that prior use of OCs is not associated with increased mortality from breast cancer.

— Sandra Ann Carson, MD
Published in Journal Watch Women's Health November 15, 2007

Citation(s):

Wingo PA et al. Oral contraceptives and the risk of death from breast cancer. Obstet Gynecol 2007 Oct; 110:793.

Original article (Subscription may be required)
Medline abstract (Free)