The female sexual response is complex; many factors—physical, mental, and interpersonal—are involved. So when a woman experiences loss of libido, arousal problems, painful intercourse, or inability to have an orgasm (a cluster of conditions controversially labeled “female sexual dysfunction”), it’s difficult to pinpoint the exact cause, let alone find a “cure.” Certain medical conditions (diabetes, hypertension, thyroid disease, and gynecological problems, for example), as well as hormonal changes, may underlie some sexual problems, many of which tend to increase with age.
For diminishing libido, everyday matters may be to blame—like an overextended work or family schedule and the stress and fatigue that come with it. Many women are in long-term relationships as they age, and may no longer find as much excitement in sexual activity with their spouse or partner. Or other factors may be involved, such as depression, anxiety, a poor body image, physical ailments, sexual inhibitions, or the lack of a partner. Loss of desire and physical intimacy between partners may also reflect unresolved conflicts about nonsexual problems. Some drugs, including antidepressants and birth control pills, can dampen desire.
Sexual desire and response vary from woman to woman and over a lifetime. Some women may be bothered by a low sex drive; others may not be concerned. Many women tend to value the emotional side of sex more than the physical aspect, but for others, physical satisfaction is as important as the romance. Assuming that you have ruled out underlying illness, whether to get help for a sexual problem is a personal decision.
Turning to testosterone
Testosterone is not just a man’s hormone. Secreted in small amounts by the ovaries and the adrenal gland and made from other hormones, testosterone plays a role in female sexuality, too. It stimulates desire, boosts vaginal lubrication and genital sensitivity, and may also affect the enzyme that makes nitric oxide, a compound that helps dilate blood vessels in the genitals. Several studies, including a review by the Cochrane Collaboration, have shown that testosterone (both in pills and patches) increases desire, orgasm, frequency of sexual activity, and other measures of sexual functioning in postmenopausal women.
Testosterone is sometimes prescribed “off-label” in the U.S. for sexual dysfunction in women, meaning that it is not approved for that purpose. (There is currently no testosterone product approved for women in the U.S.) But before you consider it, keep in mind that the testosterone connection is not so clear-cut. Although testosterone production drops with age, not all studies show a relationship between low levels and low libido. A study in JAMA of more than 1,000 women found no relationship between sexual function and testosterone level.
Also, most research has included women who have had their ovaries removed (surgical menopause). Evidence that testosterone helps women who go through menopause naturally is more limited. And little is known about its effects in premenopausal women and women not also taking estrogen. Furthermore, no one knows what a “normal” range of testosterone is for women—and, therefore, what a proper dose would be. Depending on the form and dose, side effects may include excess body or facial hair, acne, deepening of the voice, psychological changes, liver damage, and a lowering of HDL (“good”) cholesterol.
A ‘Viagra for Women’
The Food and Drug Administration (FDA) in 2015 approved flibanserin (Addyi), the first drug to treat low sexual desire in women before menopause, formally known as hypoactive sexual desire disorder. Flibanserin is actually an antidepressant that failed to help depression in clinical trials, but was noted to have improved sexual health outcomes. It’s not uncommon for a drug to be developed for one purpose, then approved for another. Sildenafil (Viagra) was originally developed to lower blood pressure, but failed those trials. The benefit of both of these drugs was discovered by accident. However, flibanserin has now been studied for its effects on sexual health for nearly a decade.
Researchers think that flibanserin restores some of the chemical imbalances that affect sexual desire disorders. Most people have heard of antidepressants known as selective serotonin reuptake inhibitors, like fluoxetine (Prozac). SSRIs can have negative sexual side effects, such as reduced libido. This suggests that serotonin plays an important role in sexual desire and excitation. Flibanserin affects serotonin but in a different way than SSRIs. It stimulates one type of receptor while blocking another, and it also increases dopamine in the body. Dopamine is known to have positive effects on sexual health.
Flibanserin has both benefits and drawbacks. While many people think that desire is more psychosocial than biological, there are clear biological processes that affect sexual desire and function. Flibanserin was shown to have a modest improvement over placebo in increasing desire. Women taking the drug had up to two more satisfying sexual events (SSEs) each month, compared to the placebo’s increase of one more SSE a month.
Controversy around flibanserin’s approval has centered around whether one more sexually satisfying event each month is enough of a benefit. For many women, this is a significant increase and should not be discounted, given how important sex can be in a relationship. Overall desire scores also increased in the most recent trials, which is very important to many women.
The drawbacks of flibanserin include adverse effects such as dizziness and drowsiness, which can affect 10 to 15 percent of women taking the medication (about the same rate as in the widely prescribed SSRI antidepressants). Another concern is that long-term data on other potential risks, including cancer, aren’t available—though it should be pointed out that Viagra was approved with only six months of safety data. Most studies on flibanserin have one to two years of safety data.
What to do
If you are experiencing a decline in sexual drive or sexual response, here are steps to consider:
• Get a complete physical examination; treat any underlying medical conditions. Though it may be difficult to talk to your doctor about sexual problems, he or she can be a valuable resource or can refer you to other professionals.
• Ask your doctor if any medications or dietary supplements you are taking may be interfering with sexual function. These may include drugs for hypertension, diabetes, cancer, depression, and anxiety.
• If you smoke, quit. Smoking contributes to erectile dysfunction in men and also may negatively affect sexual functioning in women.
• If you decide on testosterone therapy after menopause, the North American Menopause Society recommends using the lowest dose possible for the shortest time, taking it together with estrogen, and using patches, creams, or gels rather than pills. Custom-compounded prescription products vary greatly in quality and dose, however; we recommend against using them. Women with breast or uterine cancer or heart or liver disease should not take testosterone. Healthy women on testosterone should have their liver enzyme levels monitored.
• Do not take sexual enhancement supplements. Sold in drug and health-food stores and on the Internet and containing various herbs, vitamins, and other nutritional ingredients, none of these supplements are proven effective or safe. They can also interact with other drugs and be dangerous for people with certain health conditions.
• If vaginal dryness is a concern, over-the-counter lubricants (such as Replens, Astroglide, Vagisil, and K-Y Jelly) provide relief with no known side effects. During menopause, prescription estrogen creams, tablets, and rings for vaginal use (such as Estrace, Estring, and Vagifem) also may help, but their long-term safety is untested.
• Kegel exercises help with vaginal tone and may make for more pleasurable sex. They involve repeatedly tightening and releasing the pelvic floor muscles, which are the muscles that also support the bladder and close the urinary sphincter.
• If the problem is largely psychological or related to your relationship, individual or couples therapy may help. Sex therapy also may be recommended. To find a therapist who specializes in sexual problems, contact the Society for Sex Therapy and Researchor the American Association of Sexuality Educators, Counselors, and Therapists.