Dr. Holly Thacker, MD, FACP is the director of the Cleveland Clinic Center for Specialized Women’s Health, one of the world’s foremost clinics for women. She has authored two outstanding books on menopause and hormones and is a recipient of the “Lila Wallis Women’s Health Award” in recognition of her lifetime achievement in the field. She’s also a straight talker and a totally FOF woman.
Is low sex drive a cause for concern, or a natural part of aging? FOF investigates.
But what’s behind this lacking libido? Is it menopause? Is it a physical problem that requires medical treatment? Or is it just a natural part of aging? Here, Dr. Thacker explains how to suss out the origin of your sexual dilemmas.
Is loss of libido an inevitable part of aging?
For most women, some loss of sex drive with aging is inevitable. The purpose of a sex drive is to reproduce, so if a woman is past reproductive age, she’s not going to have the constant sexual thoughts that she might have had when she was younger--and that her male partner may have.
What’s the connection between menopause and libido?
Loss of estrogen following menopause can lead to changes in a woman’s sexual functioning. Menopausal women may notice that they are not as easily aroused, and may be less sensitive to touching and stroking, which can result in decreased interest in sex.
Further, the emotional changes that often accompany menopause--including anxiety and depression--can add to a woman’s loss of interest in sex and/or inability to become aroused. In addition, lower levels of estrogen can cause the vagina to be thin, pale, and dry. The lower one-third of the vagina can shrink, leading to painful sexual intercourse.
Is this something women should learn to accept, or can these problems be fixed?
There are many options for women and ways to improve sexual function, and some problems, such as vaginal pain and dryness, are absolutely medical issues. Figuring out the causes of the problem are key to know how and if it should be treated.
How do you treat vaginal pain and dryness associated with loss of estrogen?
Vaginal atrophy happens to at least 80 percent of women after menopause if they’re not on hormone therapy. The vagina gets thin and delicate and goes into a pre-pubertal state. Obviously, sexual activity can become painful if not impossible. That’s very easily treated. We have estrogen creams, tablets, and even a small estrogen ring called the Estring. For women who can’t or won’t take vaginal estrogen because they have a history of uterine cancer or blood clots, we mix up compounded vaginal DHEA in a little suppository that’s put in the vagina. All of these improve sensation, lubrication and sexual function.
Are these creams something you use just before you want to have sex?
No, they’re used as maintenance to keep the tissue healthy. Estrogen cream is not a lubricant. Whether or not you’re actually having intercourse, we still want you to have a healthy vagina so you don’t end up with other infections.
Speaking of lubricants . . . can those help as well?
Vaginal dryness during sex is a common complaint among menopausal women. You can use water-soluble lubricants such as Astroglide® or K-Y Jelly®, and that can help a lot. There is also an over-the-counter “feminine arousal fluid” called Zestra that’s available without a prescription. A small, randomized trial showed that when women applied Zestra to the genitals--versus some other over-the-counter oil--they had better sensation and slightly better ability to climax.
What is the active ingredient in Zestra? Is it an estrogen product?
No. It’s a botanical oil that contains Evening Primrose Oil, thought to improve blood flow.
When should you consider menopausal hormone therapy to treat sexual dysfunction?
If you have good sexual function before menopause and then it deteriorates suddenly after menopause, or if you have other serious menopausal symptoms such as hot flashes, bone loss, etc. But you have to make sure it’s not just a partner issue. The vast majority of women who come to be complaining about sexual dysfunction . . . a lot of times they’re not attracted to their partner or they have other relationship issues. That will not be fixed by hormones or medication.
What if you’ve been attracted to your partner, but then you lose your libido from menopause and you think, ‘I’m just not attracted to this man any more.” How do you know what’s your partner and what’s biological?
Well, that’s not so much that case usually...most patients are able to identify if they’re attracted or neutral or repulsed by another person. Often a woman is sexually functional, she just has less of a sex drive than her partner. For example, she may have spontaneous sexual drive twice a month, and her partner has the drive twice a week or even twice a day. So she may be having sex more than once a week--to appease her partner--and therefore never feeling her spontaneous drive. It’s sort of like, if you ate a little before every meal, you’d never feel very hungry for the meal itself!
So to some extent, your sense of your libido has to do with your expectation of what it should be.
Exactly, a lot of women come in complaining of low sex drive, but when you get into their history they have a good relationship, they’re able to climax some of the time, they don’t have pain with sex, and it’s enjoyable--they just don’t have the same drive to be as active as they were when they were younger. That’s not a disease or a problem, that’s just the natural state.
Do you think some women come to you wanting permission to not care about sex anymore?
Some want permission to feel that there’s not something wrong with them, especially if they’re getting their information from the media--movies, TV--which tells them they should constantly want to be having sex. Some women never feel that way or they can identify wanting that only in their 20s or 30s. Once women understand that their sex drive isn’t meant to be what it was in their 20s and 30s, they feel better about how they’re feeling.
So what do you do if you’re not particularly motivated to have sex, but your partner is?
One question I always ask women is, ‘Once you get involved in sex, do you enjoy it? And they say, ‘yeah,’ and i say, ‘Well, it’s like exercise.’ Most people aren’t addicted to exercise--they have to force themselves to do it. But once they start exercising, they enjoy it and feel good and they think ‘Why don’t i do this more often?!.’
I’ve read that men also experience loss of sexual drive and ability with age. But, they have Viagra! Is there a similar pill for women?
Doctors are studying whether a combination of estrogen and testosterone may be helpful in creating sex drive in women; however, there aren’t currently any drugs available in America to treat sexual problems in women.
Why is that? Viagra has been around forever...
Women’s sexual function is a lot more complicated to evaluate and study than male sexual dysfunction. I also think we have a very paternalistic FDA. For example, in Europe and Canada, the testosterone patch is approved for low sexual desire and female sexual dysfunction, and in America it’s not, and I think that’s a shame.
So there’s no way to get testosterone in the US?
We are forced to use compounded testosterone for women who have low testosterone or have had their ovaries removed. There are some ongoing studies with a testosterone gel, but it has not reached the market. The company that was developing a pill for low sexual desire in pre-menopausal women have unfortunately stopped studying the drug--Flibanserin--based on the feedback they have received from the FDA.
What happens if a woman uses Viagra?
Even though we don’t have a female Viagra, we will use off-label Viagra in certain circumstances, for example women who are on anti-depressant drugs, who are interested in sex but have difficulty climaxing. In those cases, sometimes the use of Viagra does allow them to climax. Or sometimes we change their antidepressant medication to something call Wellbutrin or Bupropion which can help them climax more easily. Sexual dysfunction and loss of libido can be a side effect of some medications, so it’s important to visit your doctor with a complete list of medicines you’re taking.
Even if you can’t medically increase your libido, are there non-prescription ways to get in the mood?
The most important thing is to educate yourself about your physical anatomy. A lot of women just don’t understand their bodies--they don’t understand what their erogenous zone is. For some women it’s the clitoris and for some women it’s the g-spot, which is the interior lower one third of the vaginal wall, and some women just need to be educated and given permission to explore their bodies.
That can be easier said than done. How do you get a woman who’s over fifty to suddenly start exploring her sexual self?
I might send her to a sex therapist who can give her very specific exercises or help her work out a communication issue with her partner. For women who can not climax, there is one very specific, FDA approved device called the EROS which is a vibrator that also pulls more blood into the clitoris.
For other women it’s using erotic materials such as books and videos. It can be helpful to try physically stimulating activity that does not include intercourse, such as sensual massage or even exercise.
While overall libido may decrease, many women understand their bodies and are more comfortable with themselves and actually are more orgasmic after the childbearing phase.
NOTE: Want to learn more about this topic? Dr. Thacker recommends two “excellent” resources: