What can you do about a low libido in women?

Sex drive in women - whether it is low, high or normal (clue: there is no normal) - can be a taboo subject.

Yet, the majority of women either have a low libido, or think they do. This can be an issue at any age of a woman's sexually active life, but libido is particularly tricky during midlife when a woman nears the end of her reproductive stage with menopause.

There could be one single reason for a woman's depleted sex drive, but it is more likely numerous reasons, which could range from pain during sex, residual trauma from sexual assault, hormonal changes, the invasiveness of fertility treatments, fatigue, medication side effects, a blunted orgasm due to a weakened pelvic floor muscle, and the list goes on.

"When I talk about libido it is just understanding the complexity because it's not a straightforward symptom in that it is so multifactorial," Dr Diana Ford, a GP in Tauranga who has a special interest and training in women's health, says.

A woman coming to a doctor with a low libido might not have an issue. A bombardment of over-sexualised media can create the illusion that something is wrong.

"It's all thrown at us every day, isn't it? Everything we look at, everything we pick up, every movie, every celebrity photograph, everything is telling us that we all must be sexual all the time," Dr Megan Ogilvie, an Auckland-based endocrinologist (a doctor who specialises in hormones) says.

"There is no normal. What's normal is what people are happy with, but the problem comes with one partner is in a different space to the other partner and that can cause conflict."

Reports of a "female Viagra" are overblown. While two new medications - Flibanserin and Bremelanotide - have been approved in the United States to lift libido in premenopausal women, it is not yet approved for use in New Zealand. However, it is possible to get the drugs in New Zealand through a special prescription.

"It's pretty expensive and I haven't had anybody who has actually taken that up," Ogilvie says.

Flibanserin would cost a New Zealand woman more than $500 a month, but Ogilvie predicts that price will come down.

Thankfully there's a lot available for women in New Zealand who want to lift their libido. Here's how different medical and psychological professionals can help you want more sex:

GP

Your local family doctor is never a bad first port of call. However, female patients might feel more comfortable chatting with either a female doctor or one like Ford, who also has an interest in women's health.

To determine the sources of low libido, Ford will first divide her patients into pre-menopausal and those who are perimenopausal, the prequel to menopause when a woman's hormones start significant changes.

Symptoms of perimenopause and menopause that could impact libido include vaginal dryness causing pain during sex, hot flashes that can leave women hot and sweaty (not in a good way), depression, and exhaustion from a lack of sleep.

Menopausal hormone therapy (previously called Hormone replacement therapy or HRT) can be safe and beneficial for many women, despite earlier concerns that it can cause breast cancer.

While there are still risks, the benefits to a woman's quality of life outweigh those risks.

MHT comes through patches, creams or tablets and typically replaces the oestrogen the body is no longer producing, helping with those libido-zapping symptoms of menopause. Testosterone medication might also be needed.

If a GP won't talk about libido or consider MHT for a patient "that would be a red flag to me and then obviously go find somebody that does deal with that more often", Ford says.

Another option is to go to an endocrinologist like Ogilvie who specialises in hormones.

In women of all ages, GPs should take a holistic approach to libido. Are there skin conditions around the vagina? How is the relationship with the patient's sexual partner? Is there trauma from previous sexual assault? Stress levels? Nutrition deficiencies?

Low libido could also be the side effect of medication, especially for diabetes, heart disease and depression, Ford says.

Pelvic health physiotherapist

Pelvic health physiotherapists are specialists who deal with all the muscles of the pelvic region, which can have a massive impact on pain during sex and even the climax of an orgasm.

"Every time you have sex and it's painful, then you just don't want to go there," Liz Childs, a pelvic health physiotherapist in Wellington, says.

Pain could come from many sources, including unresolved birth injuries or pelvic floor muscles that are too tight. Ideally, the cause is determined through an internal vaginal exam by the therapist.

"We see a lot of young women who can't have penetrative sex because their muscles are too tight," Childs says.

A weak pelvic floor can also be an issue. That can lead to urinary and faecal incontinence, impacting a woman's psychological drive for sex.

Pelvic floor muscle training with a pelvic health physical therapist can strengthen the pelvic floor, increasing the blood flow to the clitoris and the response of muscles, Childs says. This will lead to a greater orgasm and heightened sex drive in the future.

Sex therapist

Our psychological approach to sex is a "really big jigsaw puzzle," Auckland-based sex therapist Jo Robertson says.

Our past experiences, the sex education we received, the models of sexual partnerships we look to, and our relationship with our sexual partner will impact our desire for sex.

"People think about it as your desire to have sex, but it is much more than sex. 'Do I want to give my body to that person?'" Robertson says.

Respect, a strong relationship and actually liking your partner need to happen before couples should work on sex.

A great way to work on your sex drive is to stop having penetrative and oral sex, and go back to "old school dating", Robertson says. This could mean kissing, having showers together and holding hands.

"The body responds really well to a slow burn so I want them to build that over time."

Women, especially those with children, might have lost contact with their sexual selves, according to Robertson.

Self-touch, which isn't necessarily masturbation, can reconnect a woman to her body, as can snapping a few sexy photos, even if they are quickly deleted.

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