by Patricia Rackowski & Kathleen Gill, Ph.D.
According to the studies of Dr. Barbara Sherwin of Montreal, and others, Testosterone is responsible for libido in Women as well as in men. While this is generally acknowledged, Sexual Desire is more complicated than that.
We like the definition of sexual desire proposed by biologist Winnifred B. Cutler in her book, Love Cycles. 1 She identifies three components of sexual desire: arousal, willingness and libido. Arousal is the physiological response to sexual stimulation during which blood rushes to the pelvic area, the vagina is lubricated, and orgasm becomes possible. Willingness is an attitude. Libido is more elusive because it happens in the brain and throughout the body. Thinking about sex, fantasizing about sex, actively seeking a partner (or planning sexual encounters with a regular partner), even masturbation, are all evidences of libido.
When a woman says that she feels a lack of sexual desire, it’s important to identify which of these aspects of desire is involved.
ArousalA woman’s physical capacity to be aroused requires some minimal level of estrogen. As women become postmenopausal and their estrogen levels decline, many experience a thinning of vaginal tissue, insufficient lubrication, and painful intercourse. Estrogen replacement therapy can restore vaginal tissue, but so can lower doses of estrogen in vaginally applied creams. Non-estrogen therapies for vaginal dryness include progesterone cream, flax seed oil, and herbal remedies such as dong quai, motherwort, and chickweed. 2
Dr. Cutler reports studies that show that postmenopausal women who have sex regularly (at least twice a week), including self-stimulation, have significantly less vaginal atrophy. 3 Not all women suffer from vaginal dryness but all men and women need more time to reach arousal as they get older. As Dr. Cutler points out:
- “ . . .an unaroused woman tends not to lubricate. Forcing intercourse when a woman is not yet lubricated is the sensual equivalent of having sex with a man who does not yet have an erection . . . Although the use of lubricants is widely touted, I’m not so sure they shouldn’t be used only as a last resort. They do solve the abrasiveness, but I wonder if it wouldn’t serve the couple better to . . . take the time her body needs to promote her own arousal. . . .A woman and a man in their midlife years may require five minutes or more of undemanding stroking or petting to get the blood to flow.
. . .The urge to come and go in a heated rush should give way to a slower, moresensuous pace. 4
Once sufficiently aroused, the majority of women are orgasmic. Orgasm is a reflex response, a muscular contraction triggered by rhythmic pressure on the nerves of the clitoris, vagina and cervix. It can be inhibited, however, by emotions, tensions or mental processes. 5
While orgasm is not necessary for satisfying sex, many women who have not been orgasmic can learn to become regularly orgasmic through self-help or sex therapy.
WillingnessAn attitude of willingness towards engaging in sex is subject to many influences, including past sexual experiences of a positive or negative nature, cultural practices and beliefs, physical health, availability of a desireable partner, fear of AIDS or other sexually transmitted disease, repressed anger against the partner, and the ability of the partner to satisfy one’s desires. Some of the issues that come up in midlife to detract from willingness are: fatigue and irritability due to hot flashes and sleep disturbance, negative beliefs about the attractiveness of middle-aged bodies, and lack of privacy with grown children, grandchildren and/or elderly parents in the house.
Sex therapists recommend the same approach to couples of all ages: talk about it. Improved communica-tion between partners can result in greater understanding, joint problem solving, compassion for each other’s weaknesses and more intimacy than ever. Couples who have difficulty communicating might benefit from a therapist’s help.
Interestingly, sex therapists report that the most common problem presented in therapy today is the same for young and old. People don’t have time for sex. Sometimes this is literally true because responsibilities at midlife can be enormous and there is only so much time in the day. For both men and women, as energy and libido lessen with age, sex can easily fall down on the list of priorities. If both partners are satisfied with this, there is no problem.
If, however, we are not happy and feel that we want
to have more sexual activity in our lives, we have to remember that both sex and intimacy require time . . .for relaxation, for feelings to flow, for needs to be felt. Relaxation practices such as meditation, yoga, tai chi, or massage need a place in our schedules, and this can lead to a resetting of priorities as we keep in touch with all of our needs and try to bring our lives back in balance. This is a never-ending process.
Another process that can enhance willingness is to ask ourselves about our conditions for good sex. Remember and visualize some of your best sexual experiences and identify the elements that pleased you the most. Become aware of your own conditions for good sex and communicate these to your partner, not as demands when you’re having sex but at another time. Let your partner in on what you need or like. “I love it when you do the dishes!” works better than expecting your partner to read your mind.
If your partner wishes to have sex and you are at least neutral about it, let your partner begin. You may become aroused after all and enjoy the experience. At midlife, many women say they don’t think about sex often but enjoy it when it happens. Another possibility, although it flies in the face of cultural norms that define sex as intercourse only) is to give pleasure to your partner without receiving stimulation yourself on occasion. It might be fun, even moving, to focus on your partner’s pleasure. At some other time you can be the recipient.
LibidoAt our workshops on sexual desire in menopause, women express a variety of feelings ranging from, “I couldn’t care less about sex right now,” to “I’m so horny, I’m embarrassed”. Most women are just wondering what’s happening in these bodies that they hardly know as their own anymore. They want to know what’s normal at this time of life.
If there’s one thing that most women are unaware of, it’s the fact that testosterone has something to do with libido in women as well as men. Women secrete from 1% to 5% of the testosterone men do, but it has a powerful effect. In women of reproductive age, the ovaries secrete testosterone on a more-or-less regular basis. Thus nature enhances willingness with libido.
But testosterone output becomes irregular, or out of balance with estrogen and progesterone, at menopause. Libido becomes unpredictable, intermittent or--less often--stronger than ever as the other hormones decline in relative influence. Women who have had their ovaries removed, or subjected to chemotherapy and/or radiation, may experience a sudden loss of libido. If they are already several years postmenopausal, they may have already adjusted to new levels of adrenal androgens and estrogens. If they are pre- or peri-menopausal, they may need to combine testosterone with estrogen and progesterone replacement therapy to restore libido.
In her book The Hormone of Desire , Dr. Susan Rako, a Boston area psychiatrist, explores loss of desire at midlife and recounts her own experiences with supplementary testosterone. She advises that most commercial testosterone preparations contain too high a dose for women. She recommends a more physiologic dose that can be prepared at a compounding pharmacist and checked by blood tests. She includes information on the normal testosterone range in women and the various ways of testing for it. 6
Dr. Rako adds to the debate about natural vs. synthetic hormones when she points out that natural testosterone (an exact copy of human testosterone made from soy or wild yam molecules) can be converted back to estrogen in the body, but very little methyltestosterone is converted back. This could be an important point for women who wish to avoid estrogen. Methyltestosterone can be used pharmacologically to relieve hot flashes and vaginal dryness, although only short term use is currently recommended. Long-term use of pharmacologic doses of testosterone may result in unpleasant side effects such as lowering of the voice, enlargement of the clitoris, acne, unwanted hair, and even more serious effects such as liver disease. 7
If you already have normal levels of testosterone (which can be checked by a blood test), there is no reason to take more. Libido can be lacking for other reasons. Certain drugs--especially some antidepressants and blood pressure medications--suppress libido in men and women, as do depression, hypothyroidism, or simple lack of sleep due to hot flashes. Some women report increased
sexual desire while using natural progesterone cream, possibly because it restores a more normal hormone balance to women who have “too much” estrogen. 8
Just as testosterone stirs sexual thoughts, sexual thoughts can stir testosterone. Even after menopause, our ovaries and adrenals make some testosterone. It’s just not on a monthly schedule any more. We can call it up with fantasizing, watching movies or reading books that turn us on, or making a special date, listening to special music. There’s no law that sex has to be totally
spontaneous. A little planning can do wonders for romance . . . as they say, anticipation is half the fun.
Speaking of romance, a new relationship or the re-blooming of an old one can dramatically increase sexual desire. We have heard testimony to this in our workshops. You can read such accounts in the book Women of the 14th Moon . 9 It’s proof that libido is initiated in the mind and heart as much as by hormone production.k Cohosh, Alfalfa, Licorice Root, Motherwort, Rice Bran Oil
Analyzing "The Problem"A gynecologist consulted about lack of sexual desire in a midlife woman may miss the mark entirely by prescribing testosterone for what is really a relationship problem. A dramatic example is a woman we know who, after mentioning lack of desire along with other menopause symptoms, was given testosterone with her hormone therapy. She was living with a man who physically abused her, but this did not come up in the interview with the doctor. A short time after her testosterone treatment began, she began to experience unusual bouts of anger--wanting to hit other passengers on the subway train who were annoying her. Clearly her aggressive feelings were aroused and displaced.
In contrast, another woman told us that, following a hysterectomy at age 42, she lost all desire for sex with her husband. No one had mentioned that this could be a result of hysterectomy even with ovaries retained. After a year of relationship therapy, it finally dawned on her that the problem might have something to do with the hysterectomy. She then began to do research and to look for a doctor who would work with her in a trial of testosterone.
Another woman felt that she had lost her sexual desire at menopause, but it also coincided with the death of her mother. She was wondering if grief were the true cause of her lack of desire. We suggested a short course of therapy to help her figure out what was going on. Sex therapists are particularly oriented towards this type of problem solving therapy, as opposed to long term analysis. Perhaps all she needed was permission to grieve as long as necessary.
Discrepancies in desire between partners can go either way. It is not always women who have less desire. Men often get depressed when they can’t perform as reliably as they used to. Performance anxiety can make their “failures” more frequent and they may not wish to try so often. Both men and women can benefit from adjusting their definition of “success” from “simultaneous orgasms with intercourse” to something more within reach, allowing for many forms of enjoyment besides intercourse and even without orgasm.
Knowledge of physiology and psychology can be of great help in analyzing problems of desire, but we may also need to rethink our philosophy. What is it, after all, that we desire? As we age, our passion may change its focus. We may no longer desire sex. As we contemplate our bodies’ transition from the “luscious” to the “divine” and follow in our hearts the glimmers and glances of true intimacy in a relationship, we may find new ways to love and new objects of desire. Our desire is for connection and we are never too old for that.
ConclusionThus we see that in the case of lack of sexual desire, it is important to locate the part of sexual desire where our problem lies. Then we can begin to address the problem, if it really is a problem, with hormones, with the help of our partners, with doctor, priest or therapist, whatever is most appropriate to our situation.
Sexual desire is a complicated and sometimes elusive feeling at midlife, and we hope that this article sheds some light into its deep mystery. We believe that by continuing to explore that mystery, and by following our passions wherever they lead us, we will continue to find satisfaction in life.
EstriolEstriol is a human estrogen made in large quantities during pregnancy. Estriol is called a “weak”estrogen because it does not strongly stimulate cell proliferation in endometrial tissue. It has an affinity for tissue of the vulva, cervix and vagina. a Estriol cream used vaginally has been shown to improve tissue health in the area without increasing blood serum levels of estrogen. b Thus estriol cream is safer than estradiol cream for women who have had breast cancer. It has also been successful in reducing urinary tract infections in postmenopausal women. b Estriol could be called nature’s own “designer estrogen” because it has some of the beneficial effects of estrogen without strong stimulation of breast or endometrial tissue. Estriol cream is available by prescription from compounding pharmacies. For a free packet of information about estriol, call the Women’s Pharmacy in Madison, WI (1-800-279-5708).
a. Diczfalusy E, “The early history of estriol”, Journal of Steroid Biochemistry 1984, Vol. 20, No. 48, p. 951.
b. Raz R, Stamm W, “A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections”, New Eng J Med 1993, Vol. 329, No. 11, pp753-756.
Physiologic vs. Pharmacologic DoseA physiologic dose of a hormone will bring a woman into the normal range for that hormone. Hormones work best, with no side effects, as a physiologic dose which is neither too little nor too much. A pharmacologic dose is a large dose given for therapeutic reasons, as in fertility treatments or as in a shot of progesterone to induce a menstrual period. With a pharmacologic dose of testosterone, a woman will feel libido restored quickly as she passes through the normal range, but, in a few weeks or months, new symptoms of imbalance will develop with masculinizing effects.
This article is based on the workshop Sexual Desire in Menopause taught by Patricia Rackowski and Kathleen Gill, Ph.D. Pat is a massage therapist and menopause educator. Dr. Gill is a sex therapist in private practice. Pat and Kathy offer workshops on menopause throughout the Boston, MA area. To attend a workshop, see Pat’s Talks & Workshops. If you would like to schedule a workshop for your women’s group at your church, your place of business or your home, e-mail Pat.