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.

Memo to Your Thyroid: Role of Adrenals & Estrogen/Progesterone, etc

Somehow I made it through med school, residency and years of medical practice before I figured out a key epiphany: interdependence of the glandular systems of thyroid, adrenals and sex hormones (estrogen, progesterone, testosterone). Turns out I needed to teach it to myself - it's not in the medical textbooks or even conventional medical discourse. Once I got "it," meaning how all these crazy thryoid, adrenal and sex hormones fit together, much of my thryoid chaos fell away, for myself and more importantly, for my patients.

Here's the memo I never got.

1.   Got estrogen? Got too much estrogen? Estrogen dominance is common with hypothyroidism. Symptoms are: moodiness, cysts (ovarian, breast), weight gain, night sweats/hot flashes, irregular cycles. Too much estrogen raises thyroid-binding globulin, and this in turn can bind your free thyroid hormones, even if they are present in the right amounts. Think see-saw: if estrogen is high, free thyroid hormone is low. And vice-versa.

2.   Conversely, hypothyroidism causes sex-hormone binding globulin (SHBG) to decrease – this raises both free testosterone and estrogen. Note the significant overlap between estrogen dominance and hypothyroid symptoms – there is both redundancy in this system and crossover. Best fix: balance both systems simulataneously or sequentially. Most conventional docs will look at you like you’re nuts if you mention estrogen dominance – find an integrative doc here or test yourself.

3.   Adrenals operating properly? Adrenal function and thyroid function have a relationship also like a see-saw: when one is up, the other is down. Get both systems balanced so the see-saw is even.

4.   More on cortisol: correct amount of cortisol (not too much, not too little) helps the conversion from T4 (inactive thyroid hormone with 4 iodine atoms) to T3 (active form – 3-4 times more potent than T4, 3 iodines). You can check a questionnaire to assess for this, or even better, get it tested right here. Another benefit of balanced adrenal hormones is less thyroid inflammation.

5.   Polycystic ovaries? Another key aspect of interdependence is the dance between PCOS, your adrenals and your thyroid.  While the cause isn’t well-delineated, I believe most of PCOS begins with the stress cascade of overtaxed adrenals and too much cortisol in the fight-flight-collapse response, and leading to insulin resistance (typically defined as fasting insulin > 7), which is toxic to the ovary and makes progesterone levels drop. This leads to irregular cycles and imbalanced hormones (high androgens, high estrogens). One treatment is more progesterone, preferably the natural flavor as Chastetree Vitex, progesterone cream or prometrium. But that’s another blogpost for another day. Key point is that high cortisol when stressed can block your progesterone receptors, keeping the progesterone you make from doing its job. Another cause of high cortisol? HYPOTHYROIDISM! Oy, interdependence is a vicious cycle until you understand it. But know this: women with PCOS are four times more likely to have hypothyroidism due to autoimmune thyroiditis

6.   Speaking of inflamed thyroids, have you been tested for thyroid antibodies? Know your titers? Crucial, my friend. More often than not, your under-active or over-active thyroid is a result of autoimmune thyroiditis. What makes autoimmune thyroiditis worse? You guessed it, adrenal dysregulation and estrogen dominance. Oh, and digestive inflammation.

7.     Iodine, as the differentiator between thyroid hormones, is essential to the right balance of thyroid. I find most of my patients are deficient in the Bay Area of California, but too much can cause problems too. Best plan of action is to perform a iodine challenge test, available through Meridian Valley Labs in Washington among other places.

8.     Nutrition – what does that have to do with hormones? A ton. Just going gluten-free reduces estradiol (the key estrogen of our reproductive years and bioidentical hormone therapy in women 40+) by 30-40%. Big help if you’re estrogen-dominance.

9.     Got goitrogens? I’ve never heard a conventional doc talk to patients about foods (called goitrogens) that lower your thyroid function. Tell me your stories of docs who are sharing this info! Yet, as with most things, the info is easy to find online. Raw foods are lightly goitrogenic (cooking inactivates the goitrogenic compounds). Short version: strawberries, pears, peanuts, pine nuts, cassava (yucca), Brassica veggies such as broccoli, bok choy and brussel sprouts. I know, I know – they help your estrogen metabolism but recall the see-saw analogy.

10.  Polyendocrinopathy? Long word, key concept – refers to more than one endocrine gland malfunctioning at a time. Sometimes the thyroid is the first to manifest (or perhaps more commonly, the only one to be tested and/or recognized by your doc), yet one or more endocrine glands is on the wane. This can cause a more complex array of symptoms that are harder to treat. This is where a root cause analysis and step-wise or multi-system hormone treatments can be helpful.

You maybe wondering with all this complexity and interdependence, which is the chicken and which is the egg? Often we don’t know. That’s where balancing all three systems either simultaneously makes the most sense.

For more info, visit my website and like my Facebook page, all available right here.

Originally posted on the fantastic site for thyroidistas, Dear Thyroid.

More Stress Resilience in 2010

Thought I'd edit and augment a recent entry from my January e-newsletter on creating resilience. Interestingly, there was a post 2 days later at Oprah.com on resilience, so I added it here at the end to help deepen your connection to creating more buoyancy this year.

Proven Ways of Creating More Resilience

While hanging out with a friend on New Year's Day, we discussed our "word of the year" for 2010. She chose "rebirth" -- she has a crazy busy life with kids, and wants to create work that serves her better. Meanwhile I struggled to find a single word that captures all I am yearning for this year. Stability? Yes, but so not sexy. Hard to get traction with that word. Acceptance? Sounds defeated.

Resilience is my 2010 word. Yes, my adrenals are more saggy than my boobs. I'm perimenopausal at the same time as my eldest daughter hits puberty, which is a dangerous combo. Perimenopause is associated with your stress resilience getting cut in half. My thyroid works only halftime. But this is the year that all the previous work settles, integrates, synergizes and collectively my organism develops deep, fulfilling, rejuvenating resilience.

While on vacation, I find it. Last August - the recipe for resilience was intense flow yoga daily 90 min/day followed by eating amazing al fresco, local, organic meals with family and friends in Point Reyes. Buoyant. Last year - it was when my family joined me on a yoga retreat I taught in Mexico. Two weeks ago, it happened when I had a day off from work and got immersed in the flow of an intense, superbly-taught class at the Dailey Method - bliss combined with creative surge... a transcendent experience.

Resilience is the ability to recover readily from adversity, illness, mood swings or the like. Buoyancy. Deep knowing that change and adversity are to be expected, and being OK with that. Rolling with the punches of life.

What helps? Mindfulness, deep abdominal breathing, dancing, eating as if the Buddha (or your fave enlightened being) was coming to dinner, moving your body in a way that thrills you. Mind/Body Medicine as my early mentors at Harvard Medical School called it. Eliciting the relaxation response that Dr. Herb Benson, MD described when I was 7.

When my babysitter announces her car won't start and she's late to pick up my kids, and I have three more patients to see before I can help her, resilience is needed. Plan A is to get anxious, feel overwhelmed, get flooded by cortisol, adrenaline, epinephrine. Plan B is to say, "This is what I can do...." And put my hands on my belly, take a 5-second inhale. Pause. Exhale for 10 seconds. Repeat. Notice my cortisol responding to my breath. Noticing my calming neurotransmitters (GABA, serotonin) rising.

Other approaches are proven to help, but they are less effective. Adaptogens such as rhodiola, ashwagandha, ginseng. B vitamins (see side bar). Amino acids such as 5-HTP. Sam-e but not if you're bipolar or even a little bit bipolar. But supplements don't work as developing your spiritual practice, and you have to be careful constructing the best cocktail for your age, hormonal balance, neurotransmitters, health history.

What practice best supports your resilience? Hiking in nature? Walking on the beach?  A long weekend at a spa? A yoga workshop? Wishing you abundant, nourishing resilience in 2010.

Strong Life Plan - Building Resilience

by Marcus Buckingham via Oprah.com

You will experience setbacks. If you've suffered one recently, you may still be reeling, feeling helpless and hopeless. But a crisis can also bring you face-to-face with what really matters. Crisis can clarify, illuminate and force you to take notice of what you might have otherwise missed. It can show you brilliant qualities of yourself that you may not have discovered otherwise. It is often an opportunity to feel discomfort and work it through into a place of greater comfort or understanding, to help you find your true strength.

1. Know that everything you are feeling is absolutely valid.

2. Give yourself the time to feel your feelings deeply. It helps to have someone sit with you and listen to your experience objectively. Ask her not to tell you that "It's going to be okay." Just ask her to sit with you and be curious about what you're feeling. Sharing your feelings will help to dissipate them.

3. When you are ready to feel something new, focus on the moments in your life that still create positive emotions in you. Talk about these moments. Feel these moments. Write these moments down. Hold on to them tightly. They are the platform from which you can move forward.

4. Make an effort to do one activity each week that will provide an opportunity to create and celebrate strong-moments.

5. Surround yourself with loving, compassionate companions who will support your decisions. Appreciate them.

6. Never let a crisis go to waste. Lock in valuable lessons and insights into your strengths. They will continue to serve you in life. Recall that growth follows your line of questioning, so ask yourself questions like:

"What can I learn from this?

"What is working about this?"

"Where am I feeling strong amid all of this?"

"Where can I use my strengths to help me to overcome this?"

Your questions are generative, meaning you get what you're asking about. So ask questions that create positive emotional outcomes for you.

Winston Churchill said: "When you're going through hell, just keep going." You're taking the right steps. Decide to look at a setback from a place of possibility rather than bleakness. You ARE on your way up—that's the attitude to hang on to. Focus on what's working and the steps that you're taking to reinforce the positive actions that you've already taken. Remember, attention amplifies, so focusing on self-perceived failures or mistakes will result in a spiraling effect. Focus on the emotional outcomes you want and let your attention amplify them.

Adrenal Dysregulation Syndrome

This is a fantastic review of Adrenal Dysregulation (aka "Adrenal Burn Out" or "Adrenal Fatigue" in other circles) by our Portland neighbor and wise doc, Tori Hudson, ND. Stop that coffee, People! Drink yerba mate or green or white tea!

ADRENAL DYSREGULATION SYNDROME and ELEVATED SALIVARY CORTISOL LEVELS

Tori Hudson, N.D.

First things first: A bit about the naming of adrenal fatigue and adrenal failure. Most practitioners of alternative medicine often use the term adrenal fatigue or adrenal failure to name the complex array of symptoms their patient is having, presumably related to dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis. I would assert that the term adrenal failure should be reserved for Addison's disease. What we are looking to name, is not adrenal failure, or even adrenal fatigue necessarily, but a syndrome with several phases and many different manifestations, caused by dysregulation/dysfunction of the HPA axis. As such, I would propose we avoid the terms adrenal failure or adrenal fatigue, and rather use the term adrenal dysregulation syndrome.

Adrenal functions and stress adaptation mechanisms are among the most far reaching network of endocrine, nervous and immune system interactions regulating our life. The HPA glands and their interactions are responsible for the secretion of critical hormones vital to the control of carefully orchestrated production, synthesis and communication of these hormones. In response to stress, the hypothalamus secretes corticotropin-releasing hormone (CRH) that then stimulates the anterior lobe of the pituitary gland to secrete adrenocorticotropic hormone (ACTH). ACTH then reaches the adrenal cortex and cortisol is synthesized and secreted into the bloodstream. This hormone, cortisol, is the major glucocorticoid that acts as both mediator and inhibitor of the stress response. Cortisol is an insulin antagonist and maintains blood glucose levels by inhibiting glucose uptake and oxidation.[i] Its enhancement of catecholamine release leads to improved cardiac function and blood flow. Cortisol also suppresses collagen synthesis, osteoblast activity, hematopoiesis, protein synthesis, immune responses and kidney function.

Under usual circumstances, our stress response, and the acute/alarm phase is temporary. The HPA axis is under negative feedback control from cortisol. Cortisol then is the primary regulator of the HPA axis with negative feedback on ACTH and CRH, exerting its control of both the hypothalamus and the pituitary gland. Under prolonged stress or increasing intensity of the stress, the HPA axis no longer responds to this negative feedback. This prolonged stress response can then cause continuous cortisol synthesis and chronically elevated cortisol levels. In this state of prolonged stress, increased cortisol levels are linked to metabolic syndrome, overweight and obesity, chronic fatigue syndrome, chronic inflammatory states, coronary artery disease, anxiety, insomnia, depression, and more. This is referred to as the resistance phase of the stress adaptation syndrome. If allowed to persist, there is a significant increase in risk of these diseases. This can also lead to the final stage of the stress adaptation syndrome, i.e. exhaustion. This exhaustion phase may manifest as more acute and serious collapse of vital organ systems and functions.

A comprehensive medical and social history will be the primary tool that will help to identify our patients' phase of stress. Physical exams and select laboratory testing will help to determine not only underlying causes of stress, but also help to diagnose current diseases and to evaluate for risk factors for other significant concerns. This in turn will help with prioritizing treatments and strategizing risk reduction with the goal of restoring hypothalamic-pituitary-adrenal balance.

Many, if not most of the manifestations of chronically elevated cortisol, are more common in women. For example, chronic fatigue syndrome (CFS) occurs more frequently in women than in men. Most commonly, the onset is between 20 and 40 years of age. The majority of patients are middle class and in the helping professions such as nurses, doctors and teachers. Overweight, obesity, insomnia, depression, anxiety and metabolic syndrome, all associated with chronically elevated cortisol levels, are also among the health disorders more common in women. In addition, the hormonal influences of premenstrual syndrome, postpartum, perimenopause and menopause add another layer of complexity and interaction unique to women and adrenal regulation.

It is this chronically elevated cortisol state, most easily identified with salivary cortisol testing, that I wish to address in the rest of this article.

The most effective way to manage chronically elevated cortisol levels is to ensure that the adrenal glands are supported with the proper nutrients. Vitamin B6, pantothenic acid, and vitamin C, often become depleted when the demands on adrenal gland cortisol production are continuous. An abnormal adrenal response, whether it is deficient or excessive hormone release, can be in large part addressed with these key nutrients. These nutrients play a critical role in the optimal function of the adrenal gland and in the optimal manufacture of adrenal hormones. Levels of these nutrients can be diminished during times of stress. Urinary excretion of vitamin C is increased during stress. A deficiency of pantothenic acid results in fatigue, headaches, insomnia and more. L-tyrosine and L-theanine support the adrenal glands by combating fatigue and anxiety related to stress. In addition, the cortisol feedback control mechanism is dependent on adequate amounts of calcium, magnesium, potassium, manganese and zinc.

Ashwaganda (Withania somnifera), also known as Indian ginseng, has been in historical use in the Ayurvedic medical system for over 3,000 years. Ashwagandha has been shown to reduce corticosterone, a glucocorticoid hormone structurally similar to cortisol., An array of clinical trials and laboratory research also support the use of ashwaganda in enhancing mood, reducing anxiety and increasing energy. , , 10 ,

Magnolia (Magnolia officinalis), also known as Holly Bay and White Laurel, has been historically used for weight loss, obesity, anxiety, stress, depression and inflammation. A randomized, parallel, placebo controlled study in overweight premenopausal women resulted in a decrease in transitory anxiety, although salivary cortisol levels were not significantly reduced. Through some of its reported antidepressant and anxiolytic effects, magnolia can improve mood, increase relaxation, induce a restful sleep and enhance stress reduction.

A proprietary blend of two plant extracts, one from Magnolia officinalis and the other from Phellodendron amurense has shown promise in lowering cortisol. In initial evaluations, by the research and development company behind this proprietary product, they found that eight out of 10 stressed individuals felt more relaxed, seven out of 10 enjoyed more restful sleep, and nine out of 10 said it was gentle on the stomach.

In a study conducted at the Living Longer clinic, in Cincinnati, Ohio by Dr. LaValle, (unpublished), the same proprietary blend was shown clinically to normalize the hormone levels associated with stress-induced obesity. It was demonstrated that this combination lowered cortisol levels by 37 per cent and increased DHEA by 227 per cent.

Phosphatidylserine (PS), also known as lecithin phosphatidylserine, is a fat-soluble phospholipid that is the most abundant phospholipids in the human brain. PS is a component of the mitochondrial membrane where it serves as a reservoir for other phospholipids. It is vital in neuronal membrane functions, signal transduction, cell-to-cell communication, cell growth regulation and secretory vesicle release. We obtain most of our PS from dietary sources, although we do synthesize PS as well. PS is known to blunt the rise in cortisol and ACTH following strenuous training, and significantly reduce both ACTH and cortisol levels after exposure to physical stress. Phosphatidylserine also has been shown to improve mood.

Combinations of the above mentioned ingredients can be used together and in multiple ingredient formulations as part of a whole system approach to correcting adrenal dysregulation with elevated cortisol levels. In a recent unpublished study of another proprietary formula, study subjects took a product containing ashwagandha, phosphatidylserine, magnolia and L-theanine. The nutritional/botanical supplement consistently decreased salivary cortisol levels in relation to baseline levels. In addition, participants reported increased relaxation, improved sleep, deeper sleep, and reduced stress levels.

Numerous other adaptogens may be considered in cases of adrenal dysregulation. Traditional herbal definitions of an adaptogen states that an adaptogen is an agent that produces a nonspecific response to counter physical, chemical or biological stressors, thus allowing the body to "adapt" to the stressful circumstance. This normalizing influence on physiology is irrespective of hyperfunction or hypofunction of an organ or organ system. Western botanical researchers look at the effect of adaptogens on regulating the hypothalamic-pituitary-adrenal axis and use them to regulate the neuroendocrine and immune systems. Adaptogenic herbs support the entire neuroendocrine system, in particular the adrenal function and the stress response, which results in a modulating and regulating effect on the use of cortisol. Adaptogens known for their anti-stress qualities and stabilizing effect on the HPA axis include American ginseng, ashwagandha, Asian ginseng, astragalus, cordyceps, reishi, eleutherococcus, holy basil, rhodiola, schisandra, and licorice. Again, combination/multi-ingredient formulations are common in a whole system approach to restoring adrenal regulation.

Reducing cortisol levels and restoring adrenal regulation can be a very effective management approach to addressing stress management, chronic fatigue, sleep disturbances and anxiety, while also reducing the long term risks associated with elevated cortisol levels.
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1 Porth C. Pathophysiology: Concepts of Altered Health Status. 7th ed. Philadelphia, PA; Lippincott: 2004:542-567.
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4 Barliner S. An introduction to amino acids. Adv Nurse Pract 2006;14:47-8,82.
5 Nutall F, Gannon M. The metabolic response to a high-protein, low-carbohydrates diet in men with type 2 diabetes. Metabolism 2006;55:243-251.
6 Begum V, Sadique J. Effect of Withania somnifera on glycosaminoglycan synthesis in carrageniin-induced air pouch granuloma. Biochem Med Metab Biol. 1987;38:272-277.
7 Sudhir S, Budhiraja R, Migiani G, et al. Pharmacological Studies on Leaves of Withania somnifera Planta Med 1986;52:61-63.
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9 Kumar A, Kalonia H. Protective effect of Withania somnifer Dunal on the behavioral and biochemical alterations in sleep-disturbed mice (and over water suspended method). Indian J Exp Tiol. 2007;45:524-528.
10 Rasool M, Varalakshmi P. Protective effect of Withania somnifera root powder in relation to lipid peroxidation, antioxidant status, glycoproteins and bone collagen on adjuvant-induced arthritis in rats.
11 Sankar S, Manivasagam T, Krishnamurti A, Ramanathan M. The neuroprotective effect of Withania somnifera root extract in MPTP-intoxicated mice: An analysis of behavioral and biochemical variables.
12 Kalman D, Feldman S, Feldman, et al. Effect of a proprietary Magnolia and Phellodendron extract on stress levels in healthy women: a pilot, double-blind, placebo-controlled clinical trial. Nutrition Journal 2008;7:11:1-6.
13 Kuribara H, Stavinoha W, Maruyama Y. Behavioural pharmacological characteristics of honokiol, an anxiolytic agent present in extracts of Magnolia bark, evaluated by an elevat3ed plus-maze test in mice. J Pharm Pharmacol 1998;50:819-826.
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15 Slater S, Kelly M, Yeager M, et al. Polyunsaturation in cell membranes and lipid bi-layers and its effects on membrane proteins. Lipids 1996;31 Suppl: S189-92
16 Hellhammer J. Effects of soy lecithin phosphatidic acid and phosphatidylserine complex (PAS) on the endocrine and psychological responses to mental stress. Stress 2004;7(2):119-126.
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18 Author not listed. An open label pilot study of the safety and effectiveness of a cortisol-reducing combination in healthy adults. 2006. Unpublished.

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.