Libido: Expect Ups and Downs

“Dr. McNally told me to leave my husband.”

While reviewing the notes in a patient’s chart, I was startled to see that she had said this to another provider. Noooooo, I did not say that! 

Allow me to explain.

My patient had complained that her libido wasn’t what it used to be, so I asked how long she had been with her partner.  It’s a fact that one of the best aphrodisiacs is novelty–a new relationship or a new setting.  If a couple has been together for more than a few years, I explain that it’s normal to not be as sexually eager as they were in the beginning.

Defining what’s normal and what’s cause for concern is part of my job, but what she heard was “you need a new lover.” Oops. I had clearly failed to communicate my point. No wonder she didn’t schedule a follow-up.

Low libido is one of the most common reasons women see their gynecologists–over 30% of women surveyed by the National Health and Social Life Survey in 1999 felt they had low libido. When a woman schedules an appointment for this, it might be cloaked in other terms like “hormone problems” or my favorite catch-all phrase, “something wrong down there.” So is there something wrong down there? That is the first question that needs to be answered.

If you are not able to achieve orgasm, no matter what you try, then something may be wrong down there, and a history and physical exam–especially neurological exam–is important. However for the vast majority of women with sexual problems, it is the desire that is the issue, not the actual functioning, and this is more up there than down there, and there is even a medical diagnosis to describe this: Hypoactive Sexual Desire Disorder (HSDD).

HSDD has strict diagnostic criteria. A woman must have the following for at least 6 months: a lack or diminished desire for sex, either spontaneous or reactive (we will discuss the difference later), and difficulty maintaining interest, resulting in either personal or interpersonal distress. This last point is very important. If you or your partner are not upset about this lack of interest, then it is not a problem! Like with so many other relationship issues, what matters is congruence.

There is also, since 2015, an FDA-approved medication to treat HSDD: Flibanserin.

The decision by the FDA to approve this was highly controversial. Depending on who you read and how you interpreted it, it was either a Godsend to women or Big Pharma dictating how women should feel about their sexuality. Some women’s groups felt that it was about time that women’s sexual function was taken as seriously as men’s. I mean, Viagra has been on the market since 1998! Other women’s groups felt that this was driven by men wanting their women to be sexier and more willing.

How do I feel about this medication? I still don’t know, but here are some facts about Flibanserin, also known as Addyi:

  • Only certain practitioners, who are certified by Risk Evaluation and Mitigation Strategy (REMS) program are allowed to prescribe this.
  • Since psychiatric disorders such as depression and anxiety can cause HSDD, these need to be treated first. I should add that many anti-depressants as well as birth control pills decrease libido, so it may be that you need to change medications instead of adding one.
  • It can interact with other medications metabolized by the liver, including birth control, hypertension meds, anti-depressants and some antibiotics.
  • There is a black box warning not to drink alcohol while on they medication, although studies that showed adverse events had women drinking pretty hefty doses.
  • It can take up to 8 weeks of nightly use to notice an effect, and that effect is a few extra “satisfying events” per month, nothing mind-blowing.
  • It is approved for premenopausal women, but it is being used off-label for post-menopausal women as well.

Ok, Q&A time. Here are some common questions I get about libido:

“What about testosterone?”

I was taught in my residency that the amount of testosterone needed to improve sexual function would result in a full beard and a heart attack from all the cholesterol that it released. Like many of my contemporaries, it takes me a while to change my mind but I am beginning to see value in testing testosterone levels and supplementing if low.

Other possible therapies that have shown promise: Sensate Focus Exercises, Cognitive Behavioral Therapy, Mindfulness Meditation. Sure seems easier to take a pill. I get it.

“How can I improve orgasms?”

Kegels exercises can help a lot, the same ones that women use to stop from peeing on themselves. There is also the use-it-or-lose-it school of thought. More sex begets more orgasms, and works the muscles that are intrinsic to orgasm. Work these muscles, and they get stronger. Simple but true.

“What is a normal sex-drive?”

The honest truth is there is no normal. I have women who tell me they have a good sex life, having sex once a month. Others are frustrated because they only have sex 4 times a week. I tell them that seems pretty frequent to me, and they respond that they feel bad because the desire is there only half the time. Which leads to my next point . . .

“I enjoy sex… so why is so difficult for me to get in the mood?”

I went to lecture recently by a renowned sexpert. She told a room of (mainly) female gynecologists that sex can be like exercise. You really don’t want to do it, but once you get started, you’re glad you went to the gym. (Substitute bed or kitchen table or whatever.) She emphasized that it is okay to not always want it, as long as you’re glad you did it. It’s okay to sometimes view it as a chore. Don’t beat yourself up for thinking that way.

One last thing…

Women and men are different.

Very un-PC but there, I said it. Part of my spiel to reassure women that they are “normal” is explaining that men are better at compartmentalizing their desire and function. For women, if their kids are in trouble at school, or the house is a mess, or they feel fat, or all of the above, it is no-go. For men, their worlds can be falling apart. Maybe it is literally Armageddon, but they still want to go at it. I know this advice mainly applies to hetero couples, but I suspect that some women in same-sex relationships are better at ignoring Armegeddon than their female partners. It’s not fair, but it is how it is.

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