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Navigating Low Libido at Any Age
By Dr. Daiana Castleman, Naturopathic Doctor and Menopause Society Certified Practitioner (MSCP)
In my practice, low libido is one of the top three concerns I see among patients. While it’s common to attribute this solely to hormonal changes, hormones are just one piece of the puzzle. Low libido often has multiple causes.
Let’s start off by defining low libido. The term “low libido” is often used to describe low sexual desire. It’s important to distinguish between sexual desire and sexual arousal, as they are different concepts and understanding which one we are referring to is important.
Sexual desire refers to your interest or longing for sexual activity – it’s the “I want to engage in sexual intimacy.” Sexual desire can ebb and flow depending on many different factors, and we will touch on some of these.
There are 2 types of sexual desire:
- Spontaneous desire is the type of desire typically portrayed in movies and social media, when sexual interest arises suddenly and without any specific external trigger. This type of desire is more common in the early stages of a relationship or in situations where novelty and excitement are high. If most of our knowledge comes from these places, it can be common to believe that spontaneous desire is the only kind there is.
- Responsive desire, on the other hand, occurs when sexual interest develops in response to sexual stimuli. What this means is that someone may decide to engage in sexual activity before they feel the desire to, and then their desire emerges as a result of this process. This is a very common desire type experienced by many people.
The same person can experience both types of desire at different times and under varying circumstances. For example, you might feel spontaneous desire at the start of a relationship when everything feels new and exciting. However, it is completely normal to experience responsive desire in a long-term, monogamous relationship. Many women worry that something is wrong with them if they don’t experience spontaneous desire while their partner does, but I assure you, there is absolutely nothing wrong.
Sexual arousal is the physical and emotional response to sexual stimuli. It involves changes in your body, like increased blood flow to the genital area, which prepares you for sexual activity. Understanding which of these components is occurring for you is important to delineate in order to seek appropriate solutions.
Now that we’ve clarified the definitions, let’s look at the factors that can contribute to low sexual desire.
Causes
The biopsychosocial model is a comprehensive approach that considers biological, psychological, social, and interpersonal factors that may contribute to reduced sexual desire. Let’s briefly discuss each of these.
Biological Causes
Medication Use
Many medications can negatively affect female sexual function. Some of these include:
- Psychological/neurological:
- Selective serotonin reuptake inhibitors (SSRI) (ex. Benzodiazepines (ex. Xanax, Ativan, Valium)
- Lithium
- Antipsychotics
- Phenytoin
- Hormonal
- Oral contraceptives
- Anti-androgens
- Tamoxifen
- Aromatase inhibitors (Letrozole, Anastrozole, Exemestane)
- Ketoconazole
- Cardiovascular
- Spironolactone
- Digoxin
- Methyldopa
- Beta blockers
- Clonidine
- Pain
- Opioids
- Tricyclic antidepressants
- Indomethacin
Source: Krakowsky Y, Grober, 2018.
Medical Conditions
Several medical conditions have been shown to impact female sexual function. Some of these include:
- Cardiovascular disease
- Diabetes mellitus
- Hypothyroidism
- Generalized anxiety disorder
- Pelvic cancers
- Urinary incontinence
- Genitourinary syndrome of menopause
- Gynecologic surgery
Loss of sexual function is a major cause of anxiety for women scheduled for hysterectomy. The effects of hysterectomy on quality of life and sexual functioning does differ from person to person. There are 3 types of hysterectomy: partial (where the cervix is left intact), complete (where the cervix is removed) and radical (for cancer, where the lymph nodes and supporting structures are also removed). For complete and radical hysterectomies, orgasms can change after surgery, as there can be injury to the nerves surrounding structures such as the cervix. If the cervix is spared during the surgery, it can preserve the nerves in the region that pass into the vagina. On the other hand, some women see improvements in sexual function post surgery. For women with moderate to severe clinical symptoms of fibroids, complete or partial hysterectomy has been shown to result in improved sexual function.
Psychological Factors
The World Health Organization (WHO) estimates that almost one third (27%) of women aged 15-49 years who have been in a relationship report that they have been subjected to some form of physical and/or sexual violence by their intimate partner. Painful memories can be associated with intimacy for many and can lead to avoidance behaviour which translates to low sexual desire. Please seek the appropriate support and care with a qualified therapist if this is the case for you. Depression, anxiety, alcohol and/or substance abuse are other psychological factors that can play a role in low libido.
Sociocultural Factors
There are many factors at play here. Here are some questions to help guide you to see if this could be a playing factor for you:
- Do you compare your sexual experiences to those portrayed in movies, TV shows, or social media?
- How do your cultural or religious beliefs impact your views on sex and sexuality?
- Were there any specific messages or attitudes about sex that you took on from your family or community?
- Do you feel that your upbringing has affected your current views on libido?
Interpersonal Factors
The quality and satisfaction of your relationship plays an important role in your libido. Here are some questions to reflect on:
- How do your partner’s cultural or societal beliefs about sexual intimacy align or differ from yours?
- Are there any relationship dynamics that might be affecting your sexual desire? ie: Communication issues?
- Do you feel supported, safe, and understood by your partner when discussing sexual concerns?
Now that we’ve discussed some common causes, let’s talk about treatment options.
Treatment
Exercise
Research has been shown to correlate with increased sexual satisfaction. Exercise helps to boost mood, and it has a positive impact on body image. Research shows that women who exercise regularly tend to have lower levels of body dissatisfaction compared to those who exercise less frequently.
Exercise helps you to feel strong and discover what your body is capable of.
Alcohol
Research has shown a close link between alcohol consumption and sexual function. Alcohol can affect sexual function in several ways. As a depressant, it impairs sensory input and reduces sensitivity to touch, leading to lower libido and less arousal. It can also reduce blood flow to the genital area and delay orgasm. However, studies vary widely in defining what constitutes moderate to severe drinking, with some not specifying quantity at all. In my practice, I use the Canadian alcohol guidelines to advise my patients, which can be found here.
Supplements
Supplements are often marketed to women for low libido, but there isn’t one that consistently supports sexual function for all women. Some studies suggest that ashwagandha can help improve arousal, lubrication, and increase sexual encounters by reducing stress.
Additionally, many of my patients report low energy as a barrier to sexual intimacy. If this is something you are experiencing, it’s important to check for common nutrient deficiencies like iron, Vitamin B12, and Vitamin D on blood work, and supplement appropriately if needed.
Mindfulness
We multitask all day long, and therefore, it is no surprise that it becomes hard to turn our brains off to be fully present to our sexual experiences. When we are consistently on the go, thinking about the next thing on our to-do list, that constant distraction is a significant contributor to both reduced desire and arousal. Mindful intimacy is about being able to let thoughts go even when they do come up. To explore strategies for becoming more mindful, I highly recommend the work of Dr. Lori Brotto.
Strategies to help maintain intimacy and connection during menopause
Menopause is a time of hormonal changes and many women can experience low sexual desire during this time. However, this does NOT mean that your sex life is over (despite what you may hear). With the proper support in place, you can still experience a thriving sex life!
- Making sure your partner is in the know of the changes that are happening around the menopause transition is extremely important. You could send them a podcast episode that explains the changes women experience during this time and have a conversation about it afterwards together.
- In order to continue experiencing pleasurable sexual intimacy, make sure to support your vulvovaginal tissue. Many women report not wanting to engage in intercourse because it is now painful – this is not your new norm. Dr. Kara Dionisio wrote an excellent blog post on Genitourinary Syndrome of Menopause (GSM) that can be found here.
- There is still a lot of stigma around things like using lubricants during sexual activity. Using a lubricant even though you never used to does NOT mean something is wrong with your relationship. The amount of natural lubrication your body produces is not an indication of how “turned on” you are. Lubricants are recommended with every sexual encounter, and for people of all ages. They make sexual activity more pleasurable and feel better. A lubricant is NOT a moisturizer. Treating GSM symptoms with non-hormonal or hormone options is still important, as a lubricant does not treat GSM.
Testosterone therapy
Testosterone therapy is gaining a lot of media attention at the moment. The good news is that we have a lot of research to support the role of testosterone in sexual function. We know that androgen levels decline with age and drop abruptly after bilateral oophorectomy (surgery to remove both of your ovaries and fallopian tubes.) While the exact mechanisms of action of testosterone on sexual desire is not completely understood, women who meet the criteria for hypoactive sexual desire disorder (HSDD) can consider testosterone therapy (this is considered off-label use). Testosterone has been shown to improve the frequency of satisfying sexual events, arousal, orgasm frequency, pleasure, responsiveness, and self-image.
HSDD is a medical condition characterized by “decreased or absent spontaneous or responsive sexual desire (i.e., sexual thoughts or fantasies) associated with negative emotional states and personal distress” (Goldstein et al., 2017). HSDD affects approximately 10% of adult women. In order to be diagnosed with HSDD, your clinician will first rule out other potential causes of low sexual desire, such as relationship concerns, vaginal dryness/pain with intercourse, medication use, medical conditions, among others. The diagnosis of HSDD does not require complete loss of sexual desire but rather a change for at least 3 months from what it was previously. Personal distress is a prerequisite for the diagnosis of HSDD, and the distress can manifest in different ways, such as frustration, grief, incompetence, loss, sadness, low self-esteem, or worry.
There are 2 FDA-Approved medications for HSDD, which are Addyi (Flibanserin) and Vyleesi (Bremelanotide). Addyi is currently only Health-Canada approved for premenopausal women as the safety and efficacy of Addyi have not been established in patients over 55 years of age. Talk to your healthcare provider if either of these medications are right for you.
Note: Testosterone can be used with combination menopause hormone therapy (estrogen and progesterone). However, it is advised transdermal testosterone not be used with tibolone, as tibolone itself has androgenic impacts.
Can testosterone be used in perimenopause?
First, it is important to address any perimenopause symptoms you may be experiencing, such as insomnia, low energy, irritability, vulvovaginal dryness, hot flashes/night sweats, among others. Improving these symptoms will often have a positive impact on low sexual desire. Many of my patients report feeling too irritable and exhausted to even think about sexual intimacy so this could very well be the ideal place to start.
I hope this information was helpful and will facilitate informed discussions with your healthcare provider. I’ve included a list of books below that are a fantastic place to start to further your knowledge. So much of this has to do with the education we never received around female sexual function.
Recommended Reading
- Becoming Cliterate by Dr. Laurie Mintz
- You Are Not Broken by Dr. Kelly Casperson
- Come Together: The Science (and Art!) of Creating Lasting Sexual Connections by Emily Nagoski
- Better Sex Through Mindfulness: How Women Can Cultivate Desire by Dr. Lori Brotto
Join a vibrant community of midlife women learning + growing together here.
Dr. Daiana Castleman, ND MSCP sees patients one-on-one both in-person and virtually in Ontario. Learn more about her low libido masterclass that she ran in March 2024 titled “Reigniting Intimacy: Solutions for Navigating Low Libido.”
DISCLAIMER: This content is provided for informational purposes only and is not intended as medical advice or as a substitute for the medical advice provided by a doctor or other qualified medical professional.
References:
Goldstein, I., Kim, N. N., Clayton, A. H., DeRogatis, L. R., Giraldi, A., Parish, S. J., … & Worsley, R. (2017, January). Hypoactive sexual desire disorder: International Society for the Study of Women’s Sexual Health (ISSWSH) expert consensus panel review. In Mayo clinic proceedings (Vol. 92, No. 1, pp. 114-128). Elsevier.
Kingsberg, S. A., & Althof, S. E. (2018). Psychological management of hypoactive sexual desire disorder. In I. Goldstein, A. H. Clayton, A. T. Goldstein, N. N. Kim, & S. A. Kingsberg (Eds.), Textbook of female sexual function and dysfunction: Diagnosis and treatment (pp. 53–57). John Wiley & Sons.
Krakowsky Y, Grober ED. A practical guide to female sexual dysfunction: An evidence-based review for physicians in Canada. Can Urol Assoc J. 2018 Jun;12(6):211-216. doi: 10.5489/cuaj.4907. Epub 2018 Feb 23. PMID: 29485038; PMCID: PMC5994984.
Parish, S. J., Simon, J. A., Davis, S. R., Giraldi, A., Goldstein, I., Goldstein, S. W., … & Vignozzi, L. (2021). International Society for the Study of Women’s Sexual Health clinical practice guideline for the use of systemic testosterone for hypoactive sexual desire disorder in women. The journal of sexual medicine, 18(5), 849-867.
Parish, S. J., & Kling, J. M. (2023). Testosterone use for hypoactive sexual desire disorder in postmenopausal women. Menopause, 30(7), 781-783.
Pauls, R. N. (2010). Impact of gynecological surgery on female sexual function. International journal of impotence research, 22(2), 105-114.
Salari, N., Hasheminezhad, R., Almasi, A. et al. The risk of sexual dysfunction associated with alcohol consumption in women: a systematic review and meta-analysis. BMC Women’s Health 23, 213 (2023). https://doi.org/10.1186/s12905-023-02400-5
Stanton AM, Handy AB, Meston CM. The Effects of Exercise on Sexual Function in Women. Sex Med Rev. 2018 Oct;6(4):548-557. doi: 10.1016/j.sxmr.2018.02.004. Epub 2018 Mar 30. PMID: 29606554.
Thomas HN, Thurston RC. A biopsychosocial approach to women’s sexual function and dysfunction at midlife: A narrative review. Maturitas. 2016 May;87:49-60. doi: 10.1016/j.maturitas.2016.02.009. Epub 2016 Feb 21. PMID: 27013288; PMCID: PMC4808247.
Violence against women Prevalence Estimates, 2018. Global, regional and national prevalence estimates for intimate partner violence against women and global and regional prevalence estimates for non-partner sexual violence against women. WHO: Geneva, 2021
