A few years back I was chatting with a patient after her exam, and she started to ask me, “What’s the most common question you get from patients over 40—?” She never finished her sentence. I replied, “What happened to my sex drive?!” Every day, year in and year out, at least one of my peri- or postmenopausal patients asks me that question. Usually she thinks she's the only one experiencing this condition.
Unfortunately, it’s a very common complaint: Between one-half and three-quarters of women age 45 to 58 report a significant drop in sex drive.
And that’s just the ones who are brave enough to talk about it. While it’s no picnic for anyone, libido loss can be particularly distressing for women in long-term relationships who have enjoyed a good sex life and have now lost interest, much to their — and their partner’s — chagrin and surprise.
What to Do About Loss of Libido?
There are two main causes for libido flameout (after you’ve ruled out psychological ones, such as depression, stress or a change in relationship status): One has to do with estrogen, and the other, testosterone.
Loss of estrogen can affect your mood, but this in itself will not necessarily depress your libido, though the physiological side effects can make vaginal sex so painful as to render it virtually impossible or at least undesirable. When estrogen loses its decades-long influence after menopause, the vagina narrows, and the skin in the genital area gets thinner and less moist and loses its elasticity, leading to the No. 1 complaint of women in this age range: Sex hurts.
Along with the loss of estrogen, women stop secreting testosterone from their ovaries, thus diminishing their ability to become aroused and sometimes affecting their ability to reach orgasm. While some women barely notice these changes, for others they’re life-altering.
A 53-year-old patient who had her last period 18 months ago still wants to have vaginal sex with her longtime partner, but it’s too painful. On exam, I found the skin in the vaginal region was very thin and pale and showed a lack of elasticity. As I often will in this situation, I prescribed a local estrogen, the most effective remedy.
(MORE: Sex and the Midlife Woman)
Vaginal estrogens are not the same as hormone replacement (HRT), which has been associated with a slight rise in risk for breast cancer, strokes and heart disease. (I routinely prescribe conventional HRT to only the 5 to 10 percent of my patients who experience severe menopausal symptoms — but this is a different issue than libido.) Local vaginal estrogens, on the other hand, are safe and easy to use and have been on the market for more than 30 years. After just a few weeks of using it, the patient reported that sex had become more comfortable and that she was feeling much better about herself.
Local estrogen comes in three different forms: a cream that needs to be applied every few days; tiny pills that are inserted vaginally every few days; and a ring that releases a very low level of estrogen and can be left inside the vagina for three months at a time. The ring’s main drawback is that it may be difficult for the patient to insert or remove it. (While some have no problem doing it at home, others prefer to have the physician do it.)
Because of her thin skin, Rita still needs to use a lubricant, like KY Silk or Astroglide, when she has intercourse. For women who are reluctant to use hormones or have conditions for which hormones are contraindicated, such as a history of breast cancer or atypical changes in the breast, I recommend Zestra, a botanical blend of evening primrose oil, angelica and borage seed oil, as well as coleus forskohlii, ascorbyl palmitate and di-alphatocopherol. This cream is used topically before intercourse, and its effects last about 40 minutes. Like a topical Viagra, it is purported to increase blood flow to the vaginal tissues and improve conduction in the nervous system, thus improving arousal, comfort and sexual pleasure.
And Then There's Testosterone
“I never understood why mother would drag me shopping all the time when I was a teenager,” a 56-year-old patient told me recently. “It wasn't really about shopping — it was to get out of the house. As soon as we were out of earshot, she’d turn to me and say, ‘He’s driving me crazy, wanting to have sex again’ — the he, of course, referring to my father. I would just laugh at her and ascribe these outbursts to having a crazy, old-fashioned mom.
Now I know what she meant. My father was still interested in having normal relations with his wife, but she had lost interet.” The patient went on to share that her own husband was worried that she didn’t love him anymore because she had such a hard time getting excited about having sex with him. “We’ve always had a great sex life together, but now I would rather sleep than have sex with him,” she said flatly. “I just don’t care anymore.”
I heard a similar story from a single woman in her early 50s. Recently she had gone out to dinner with a man who, she said, might have been the most attractive guy she had ever dated, yet she found it hard to get excited at the prospect of any sort of sexual behavior with him. “Ten years ago, this would have been the man of my dreams,” she says.
Unfortunately for these patients, there’s not much we can do to treat the condition we call hypo-desire, the likely result of low levels of testosterone. I gave them some suggestions on how to make their sex lives more enjoyable — more foreplay, taking the pressure off having only vaginal intercourse, trying "toys" — but once you lose interest, it’s difficult to bring it back.
Not surprisingly, the pharmaceutical industry is trying to. It rakes in billions a year from erectile-dysfunction drugs and is keenly aware that there is a huge market for any drug that could restore a women’s libido with testosterone. A few years ago Procter & Gamble came out with a testosterone patch, but after four women in the initial trial developed breast cancer, the Food and Drug Administration pulled it from the market, urging further study.
While the patch’s effect on sex drive was promising (about 50 percent showed improvement), the reality is that we don’t know the long-term effects of putting millions of postmenopausal women on testosterone. It is not the type of drug you can put on before you go out for a date: you would have to use it daily. In the meantime, some of my patients have reported some good results with a nutritional supplement called ArginMax, an over-the-counter product made from gingko, ginseng, damiana, vitamins, calcium, iron, selenium and zinc. Taken daily, it claims to boost libido. There are some small studies out, but it is too early to know how efficient or safe this remedy will prove to be.
While I never strongly encourage its use, I do mention it to clients who prefer natural to pharmaceutical products. (Note that ArginMax is contraindicated in women with diabetes or asthma, or taking anticoagulants, antihypertensives or hypoglycemics.)
The good news for women suffering from a loss of libido is that you can become aroused, even if you do not start out that way. So in addition to prescribing hormones and recommending supplements like Zestra and ArginMax, I counsel women to be patient if it takes them longer to get in the mood, and to be open to new things like vibrators or dildos, the visual stimulation of magazines or movies, or trying new positions or techniques in the bedroom. And always use a lubricant!
Sex may never again be like it was in your 20s, but it can be great in different ways. Many postmenopausal women who have adopted these strategies tell me that sex has become more satisfying than when they were younger because they are no longer worried about getting pregnant and are more comfortable with who they are at this stage of life. Give yourself a little more time — and remind your partner to try a little more tenderness (both physically and emotionally).