It can be unnerving when your sex drive isn’t behaving like you want or expect it to. For women, personal concerns about low libido can be compounded by fun things like accusations of frigidity. What’s more, female sexual desire is a complicated issue rooted in both the brain and the body, and we’re still figuring out how it works.
Libido struggles are also common: At least 4 in 10 premenopausal women report some measure of sexual dysfunction. “At some point in life, every woman will struggle with libido issues,” says Alexandra Katehakis, clinical director of the Center for Healthy Sex in Los Angeles. “It’s totally normal.”
We spoke to experts on both the psychological and physiological ends of the sex-medicine spectrum. If you have a vagina, here’s what to know about getting care for getting it on.
A laundry list of interrelated factors can undergird libido problems. Here are some common culprits:
Lifestyle factors: Daily routines can play a significant role in arousal. Various good-for-you habits appear to protect against sexual dysfunction, whereas sleep problems, unhealthy diet and physical inactivity have been linked to low libido. Among other things, poor lifestyle habits often lead to increased levels of fatigue and stress, which are known enemies of sexual desire.
Illness: Many medical conditions and procedures can curb your desire for sex, says Katehakis, who points to the link between diminished sex drive and pelvic pain disorders such as dyspareunia, vulvodynia and vaginismus. While these conditions aren’t likely to affect sex drive on their own, they can make sexual activity painful. As a result, someone might associate sex with physical discomfort, thereby creating a negative feedback loop that depressess desire. Breast surgeries and genital operations, whether elective or medically necessary, can also affect sexual function and body image, which are both elements in the desire equation.
Nonsexual medical conditions can have an impact too. Fatigue from a cold or the flu can make it hard to get in the mood for as long as you’re sick. The same is true of longer-term or chronic medical conditions, such as multiple sclerosis, fibromyalgia, lupus and certain autoimmune disorders. Medications for these conditions can also cause fatigue, potentially amplifying any libido effects.
Those are only a few of the medical conditions that could be relevant to a listless sex drive. Arthritis, cancer, diabetes and high blood pressure are also on the list — and it goes on for a while. Could is a key word, though, because health problems can interact with desire in different ways for different women.
Mental health: Both mood disorders and the medications that treat them can interfere with sexual desire. Sudden loss of libido is a warning sign of depression in women. Selective serotonin reuptake inhibitors (SSRIs), such as Lexapro, are the most frequently prescribed type of drug for anxiety and depression, and a lowered sex drive is one of their most commonly cited side effects. It’s possible that long-term SSRI use leads to persistent changes in brain chemistry related to sexual desire, says Sharon Parish, a physician who specializes in sexual medicine and a professor of medicine in clinical psychiatry at Weill Cornell Medicine in New York.
Psychological trauma from physical or sexual abuse, or other emotionally difficult experiences, can also influence sex drive. Poor or distorted body image and feelings of physical undesirability have been associated with sexual disinterest as well. One Brazilian study on women with polycystic ovary syndrome, or PCOS, found that the disorder contributed to “body image dysfunction” in some of the women surveyed. In turn, these PCOS-related body image distortions were found to amplify the symptoms of depression and sexual dysfunction already associated with the disorder.
Hormones: Menopause comes with hormonal shifts known to diminish libido. Common symptoms like vaginal pain and dryness can be addressed with hormone replacement therapy and/or laser surgeries. Pregnancy and breastfeeding also bring about hormonal changes that can temporarily dampen sex drive, as can hormonal birth control and thyroid imbalances.
When “not in the mood” warrants help
While we all deserve to have satisfying sex lives, every woman has her own relationship with sex and desire, and her own barometer for what’s “normal.” Symptoms of low sex drive, according to the Mayo Clinic, include losing interest in any type of sexual activity, including masturbation; never or rarely having sexual fantasies or thoughts; and feeling worried about your lack of interest. The Mayo Clinic emphasizes that the worry in and of itself is reason enough to seek care.
Katehakis recommends that any woman dealing with low libido seek out professional advice “as soon as it’s a problem for her, her partner and their sex life.” But given how complicated libido problems can be, women who feel they need professional help might not know who to turn to. No matter what the precise libido concern is, Katehakis says, it’s a good idea to see a gynecologist. Some patients opt to use Eastern medicine instead, she says, and there’s some evidence to suggest that techniques like yoga, mindfulness and acupuncture can enhance sexual function. But it still makes sense to start with an MD, who will be able to identify or rule out underlying medical causes and refer patients to specialists. If painful sex is part of the problem, for example, they might send you to a pelvic floor specialist.
If all the parts work, without pain, a gynecologist might keep hunting for other explanations for libido loss, such as stress or depression, or send you to a sexual medicine specialist instead. A doctor might also recommend behavioral treatments like relationship counseling or sex therapy.
In some cases, libido struggles are diagnosed as hypoactive sexual desire disorder. HSDD, estimated to affect about 10 percent of adult women, is defined by libido loss that can’t be explained by other medical issues, drug side effects or modifiable lifestyle factors. For an HSDD diagnosis, low desire also needs to be both distressing and persistent across all partners and types of sexual activity.
“If one partner wants more sex than the other,” says Parish, “that’s not HSDD, it’s a relationship problem.”
Together, the patient and doctor can consider different treatment options for HSDD. Behavioral approaches include mindfulness meditation, cognitive behavioral therapy to raise desire, and sex therapy. There are also two medications: Addyi (aka Flibanserin) has been on the market since 2016. Vyleesi (aka Bremelanotide), which secured FDA approval in June, is available to patients as of this month.
They’ve both been branded as empowering to female sexuality and hailed as “female Viagra.” They’ve also faced similar blowback, with critics calling comparisons to Viagra misleading for both drugs. The little blue pill is a well-understood mechanical fix. It’s obvious when it does what it’s supposed to, and the body can respond without involvement from the mind. Addyi and Vyleesi attempt to target the fuzzy neurological, psychological and physiological underpinnings of female desire, and their efficacy is subjective. In other words: different problems, different solutions.
While Addyi and Vyleesi treat the same problem, they do it differently. Addyi is a daily drug, taken before bed, that targets neurochemicals. “It’s seeking to moderate brain chemistry and promote pathways of desire,” says Parish, “kind of like when we treat depression, but [Addyi] has different effects on the brain.”
Vyleesi, on the other hand, is injected into the thigh or abdomen at least 45 minutes before sexual activity, and lasts up to 12 hours. It’s thought to activate melanocortin receptors in the brain, which help regulate a variety of biological functions, including skin pigmentation, appetite and sexual arousal. But there are still questions to answer about how Vyleesi works. In fact, according to the FDA, “the mechanism by which [Vyleesi] improves sexual desire and related distress is unknown.”
“The biggest difference, potentially, between the two drugs and their use will have to do with whether someone wants an on-demand therapy or daily medication,” Parish says. “[Addyi] is about being interested in wanting to have sex, having the desire and motivation to plan and seek out sexual experiences. It creates a state change. With Vyleesi, you may or may not at the beginning of using it have sexual desire; it’s more about knowing you’re going to be turned on, and able to get into it, when you have sex. But positive experiences may also create an overall improvement in more generalized desire.”
Some critics of these drugs also say that medicating female desire sends the message that something’s wrong with a woman if she doesn’t want to have sex. Parish, however, feels that people are often too quick to dismiss the idea of using medication to treat low desire in women.
“It may make clinical sense to prescribe a medication,” Parish says, “especially if modifiable factors have been addressed, and lifestyle interventions have been dealt with, and there’s still a persistent problem that’s not responding to psychosocial interventions. Because it might be that there is sort of an etched-in pattern in the brain that could be rewired.”
Under certain circumstances, Parish says, doctors might even prescribe these drugs off-label to patients who don’t meet the HSDD criteria: “For someone who’s being treated for depression, and one of the side-effects of the antidepressant is a change in libido — if she’s doing well on the medication, sometimes we also treat those people because you can give Addyi to someone who has antidepressant-induced sexual dysfunction. So it depends whether the condition is remediable or not.”
How to talk to an expert
Sexual intimacy is a touchy subject for virtually everyone, especially women and members of marginalized gender groups. If talking about your sex life feels uncomfortable, that’s totally okay. Go ahead and blush — just try to be clear, firm and specific, Katehakis says: “Women have to advocate for themselves and track their own bodies.” That means monitoring menstrual cycles, career and personal stressors, conflicts with partners, and any changes in environment, lifestyle or medical status. “Any routine that has changed is worth looking at,” she says.
What’s most important is that patients be open and honest about their symptoms and histories, and understand that their healthcare providers are there to help and not to judge. Providers need to be able to assess the full picture of a patient’s symptoms and concerns in order to determine the best course of treatment. Sure, it’ll be awkward — but it’s also something a lot of women go through. And, as with any first time, you’ll be way happier once you get it out of the way.