In a society ravenous for sex, Brenda McHugh, a 40-ish, married mother of two and pediatrician in New Jersey has simply lost her appetite. Once, Brenda eagerly indulged in "great sex" with her husband.
Gradually, McHugh lost interest in sex. Even if she were in the presence of a smorgasbord of alluring men, McHugh feels she would not have the urge to merge. "Sexual desire does not seem to be a part of my nature anymore," she says.
McHugh is not alone. According to the findings of a NIH-sponsored survey published in the Journal of the American Medical Association (Feb. 10, 1999) 43 percent of women report recognizable sexual dysfunction. Problems range from not being able to have orgasms to having no sexual desire at all.
In fact, 35 percent of the estimated 40 to 50 million women who have sexual dysfunction have no or low sexual desire — what the experts call hypoactive sex drive, or HSD for short. By definition, women with HSD lack sexual fantasies, suddenly find sex uninteresting, and rarely masturbate. "They feel neutered — nothing turns them on," says Susan Kellogg-Spadt, director of sexual medicine at the Pelvic Floor Institute, Graduate Hospital in Philadelphia.
While women with HSD may not feel deprived without sex, a defining feature is that lack of libido causes distress. "I worry about losing my husband and am sad to be missing out on this natural — and pleasurable — part of living," says McHugh.
The devastating effect on women's self-esteem and a couple's relationship is compounded by the fact that ours is a hyper-sexualized society, says Kellogg-Spadt. "The media would have us believe that women are in sexual ecstasy simply by opening a bottle of herbal shampoo."
Libido Can Be Reclaimed
The good news is that libido can be restored, although it may take more than a Viagra-like aphrodisiac. With men, HSD is usually related to an erection problem. But a woman's lack of sexual desire is often more complex, and directly intertwined with many aspects of her life.
"Female sexual dysfunction is like a pie made up of relationship conflicts, emotional issues, past traumas, hormonal imbalances and physical responses such as pain, arousal, or orgasm problems," says Laura Berman, Ph.D, co-director of the Center for Women's Urology and Sexual Medicine at UCLA Medical Center and co-author of For Women: A Revolutionary Guide to Overcoming Sexual Dysfunction and Reclaiming Your Sex Life. "A problem in one area impacts on the other," she says.
Emerging research is revealing that libido is neither all in your head nor all in your body, says Dr. Berman. "Reclaiming desire takes a mind-body approach customized to each woman's symptoms. There is no magic cure and no one set solution."
Uncovering the Sex Squelchers
You have to investigate a bit. Start by asking yourself what symptoms you have related to fantasies, arousal, vaginal dryness, genital sensation, and orgasm. When did the libido problems begin? Were these problems sudden or gradual? What else was going on in your life when your interest in sex took a nosedive?
Here are the leading libido killers:
- Post-childbirth and breastfeeding. Desire can wane for a number of reasons, says Kellogg-Spadt. After childbirth, a woman is exhausted and sleep-deprived. What's more, pelvic nerves and muscles may have been damaged during delivery, which lowers genital sensitivity. Moreover, breastfeeding lowers levels of estradial — the hormone responsible for keeping the urogenital tract lubricated and supple. This can make penetration painful. Breastfeeding also raises the prolactin hormone, which suppresses sexual desire and lowers testosterone — the hormone in both genders that stokes desire. If you are breastfeeding for one year, not having sex can become a way of life.
- The onset of menopause. The output of estradial is reduced with natural or surgical menopause (removal of ovaries, via hysterectomy) To compound matters, testosterone production drops by up to half. This may trigger a sudden dip in sex drive, loss of pubic hair, diminished sensitivity in the clitoris and nipples and a weakened ability to climax.
- Antidepressants and other drugs. Low libido — and impaired orgasm — is a notorious side effect of selective serotonin reuptake inhibitors,(SSRIs), most notably Prozac or Paxil, two of the most commonly prescribed drugs to treat depression. Other culprits include birth control pills, blood-pressure lowering drugs, and in some cases, estrogen replacement.
- Stress. Juggling job/childcare, marital problems, a death in the family, change of location — all can overload the adrenal hormones, deplete energy, jump start an over-secretion of prolactin and may lead to depression — a major contributor to HSD. Underlying disorders. Desire can diminish if you have a thyroid deficiency, or a joint, nerve or blood flow disorder, or from pain-causing urogenital problems such as fibroids, endometriosis, yeast and bladder infections, vulvodynia or inflammation.
- Couple problems. A sex shutdown in women often stems from power struggles, resentment over unequal distribution of household chores, feelings of inattention, or anger about past injustices, according to Kellogg-Spadt. "Anger is often a leading — if not the leading — sex suppressor," she says. In Brenda's case, control was an issue. "I sexually pursued my husband before marriage, but when I had to share the sexual control, my desire disappeared," she notes.
- Other issues. Feeling bad about gaining weight or having small breasts can kill lust. "The bombardment of sexual images has raised the bar on what it means to be sexy. The message is we must have a perfect body and very frequent intercourse. It's especially hard to live up to these standards as you age," says Kellogg-Spadt.
Remedies that Restore the Spark
Depending on your symptoms or function of your desire disorder, you may need one or several of the following options:
- Adjust your meds. Working with your doctor, you may need to switch to a higher estrogen birth control pill or use a barrier contraceptive. Gradually lower your SSRI dose or try Wellbutrin (bupropion) which boosts the production of dopamine, a chemical messenger linked to sexual desire. In one study comparing the effects of SSRIs, Wellbutrin-treated patients reported a significant increase in libido, arousal and orgasm; patients on other SSRIs had a decrease. Even non-depressed women may benefit from Wellbutrin, recent studies show. There's more good news. "Preliminary evidence shows that Viagra — the highly touted remedy for flagging erections — may help override the side effects of SSRIs in women when used before sex," says Dr. Berman.
- Restore vaginal lubrication. Depending on the severity of vaginal dryness, there are a range of options available to restore vaginal moisture, plump up thinning tissues and make penetration more comfortable. For severe dryness, prescription estrogen regimens provide effective relief. Choices include creams, suppositories (such as the recently FDA-approved Vagifem), or the diaphragm-like E-string vaginal ring. For mild dryness, try over-the-counter vaginal moisturizers such as Replens (designed to be applied regularly) or Lubrin (applied just prior to sexual intercourse.). Herbs — in liquid or pill form — purported to help relieve mild vaginal dryness include black cohosh or dong quoi.
- Try a dose of testosterone. Dubbed the "hormone of desire," testosterone replacement in women has become the focus of intense study. While no preparations are as yet FDA-approved, a spate of studies show that in women nearing or beyond menopause, the administration of oral or topical testosterone may help switch on sexual urges and re-sensitize the genitals. Testosterone may also boost energy and well-being and override the libido-lowering effects of SSRIs.
If you choose to experiment with taking testosterone, it's important to note that "we don't have long-term randomized clinical studies and there have been no conclusive studies on testosterone in younger women," notes Sharon Youcha, M.D., general gynecologist at Lankenau Hospital in Wynnewood, Pa. and clinical faculty member at Thomas Jefferson College of Medicine in Philadelphia. Because testosterone has the potential to change HDL (high density lipoprotein — the "good" cholesterol) and LDL (low-density lipoprotein — the "bad" cholesterol), your cholesterol levels should be monitored carefully.
Women at risk for heart or liver disease may not be good candidates for testosterone. Women at risk for breast cancer should avoid testosterone since a percentage of this hormone converts to estrogen, believed to fuel certain breast cancers. Start with a low-dose regimen.
Patches, Creams, and Troches
Testosterone can be prescribed in pill, patches, creams, suppositories and lozenges (also called troches) in compounded or synthetic forms. Non-pill preparations that bypass the liver may be the best place to start. A six-week trial is generally recommended. Here are two options:
- Under-the-tongue troches. "Testosterone lozenges can be used intermittently as as a kind of jump-start for libido," says Dr. Youcha. "You could, for example, take a lozenge after dinner in preparation for sex that night," suggests Dr. Youcha. A recommended starting dose is 0.2 milligrams (for methyltestosterone) or 0.5 milligrams for compounded testosterone.
- Topical cream. An array of creams and gels that can be rubbed directly on the vulva can be prescribed. "Methyltestosterone does not get converted to estrogen so these preparations may be theoretically safer," according to Dr. Youcha. Preparations range from 1 percent to 2 percent. If you have the right dosage for your body, the effects of the creams can kick in as early as a half-hour later.
Testosterone replacement need not be long-term. "Once the sex behavior has shifted, you can stop testosterone and see how sex goes without hormones," Dr.Youcha says.
Work on it as a couple. When a woman turns off sexually, her mate may feel undesired. He may withdraw, causing the woman to shut down further. "Couples need to find ways to reconnect both verbally and non-verbally outside the bedroom," says Karen Brash McGreer, marital and sex therapist in Cherry Hill, N.J. She counsels couples to do things that help to build intimacy:
- Take a walk after dinner or have coffee on Saturday morning (no kids).
- Tell your partner what you need to feel aroused — that may be words, cuddling or other signs of affection.
- Talk about the redistribution of the workload. A skilled therapist can help you resolve deeper conflicts and to "bring it up, talk it out, let it go." You can then advance to techniques that focus on stimulating sensations without actually having sex. For example, deepening eye contact and breathing together helps build trust.
- Take steps to resexualize yourself. You are responsible for your own pleasure, "but you have to work at it," says Kellogg-Spadt. For 20 minutes, three times a week, get your brain off the cub scouts, soccer club and grocery lists and do some fantasy work. For many women, reading erotica is an effective trigger. Treat yourself to sensual pleasures — dance lessons, a pedicure or even a massage. Lastly, engage in exercise such as yoga that involves squats, lunges and lifting. This helps blood flow in the pelvis and clitoris. Yoga also helps open your body to sensations and can boost your body image.
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