Scroll Top

Lower Libido (HSDD)

Lower libido around 40 is common and can be tied to hormonal changes, but many other factors are involved as well.

What do we mean by libido?

Libido is biopsychosocial, meaning there are biological, psychological, and social factors involved. We use the word libido because that is the commonly used term but lower libido in perimenopause often includes both sexual functioning and libido.
  • Sexual functioning includes the ability to orgasm and the amount of lubrication.
  • Libido has more to do with desire, drive, and interest.
Hypoactive Sexual Desire Disorder (HSDD)

The medical term for lower libido is Hypoactive Sexual Desire Disorder (HSDD). For those interested in a deeper dive, this Expert Consensus Panel Review from the International Society for the Study of Women’s Sexual Health (ISSWSH) is very thorough.

Read More

3 things to know about lower libido during perimenopause

  • The medical term for libido is Hypoactive Sexual Desire Disorder (HSDD). It has two components: 1. You have no interest in sexual activities and 2. it bothers you. If it doesn’t bother you, not a problem!

  • Libido is about the desire, drive, and interest. But physical changes can lead to less interest: pain with penetration, less lubrication, and diminished ability to reach orgasm.

  • There are relationship factors, feeling less connection to a partner, self-esteem factors, body image, self-confidence, and self-worth that can play a role too.

When you were once very sexual and enjoyed intercourse and suddenly that changes, it’s quite a loss. It’s very hard now to associate pleasure with intercourse, as it has become painful despite the lubricants. Be creative and buy a vibrator!
WLB Community Member

WLB 2020 SURVEY RESULTS

These data represent the % of respondents reporting each symptom on the Women Living Better Survey. LRS stands for the late reproductive stage and MT for the Menopause Transition. These are two stages on the path to menopause (the final menstrual period).

Less interest in sexual activities

Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%

More interest in sexual activities

Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%

Pain with vaginal sex

Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%

More difficulty experiencing orgasm

Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%

More trouble feeling aroused

Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%

Less vaginal lubrication

Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%

Libido and the brain-behavior connection

Increasingly, recent research about sexual well-being is focusing on the brain-behavior connection. In her book Come as You Are, Emily Nagoski explores the important but little-known factor of “arousal nonconcordance.” Nagoski disagrees with the common hypothesis that hormones and monogamy are the causes of low libido. Rather, she believes that desire (her preferred term for libido) can be changed by changing one’s context.

Soon off the press (on Jan 30, 2024) is Emily Nagoski’s latest book, Come Together: The Science (And Art!) of Creating Lasting Sexual Connections.

More about it at the WLB blog here.

 

Disclosure: This section contains affiliate links and we receive a small commission for any purchase you make from them.

The number one reason couples seek sex therapy is for desire differential: One person wants to have sex more than the other person does. In heterosexual couples, despite stereotypes, it’s actually just as likely to be the man as the woman who has low desire, just to do away with that stereotype right now.

Emily Nagoski, “How to Have Better Sex”

Lower libido in perimenopause

Hormonal contributors to low libido

In one longitudinal study of 286 women, higher urinary estrogen and testosterone were associated with higher levels of sexual desire. Those with higher FSH levels reported significantly lower sexual desire.

Another longitudinal study that looked at various hormones found only lower levels of DHEAS were associated with dysfunction.

In late reproductive stage women (still getting a monthly period but noticing subtle changes to cycle length or flow), decreased libido was associated with higher fluctuations in testosterone.

Remedies to help with lower libido

NON-MEDICAL

Mindfulness for libido

A group mindfulness intervention tailored to midlife women with low desire was found to be effective. The control group got basic menopause education. A high percentage of Women in the mindfulness group (73%) were very or extremely satisfied and were more likely to recommend the intervention to another person with low libido as compared with those in the education group. While there were no significant changes in sexual function in either group, those in the mindfulness group had significant improvements in sexual distress.

Solo sex (a.k.a masturbation)

We continue to see more and more from many sources about the health benefits of masturbation — from increasing endorphins to maintaining blood flow to keeping vaginal tissues healthy.

Cognitive Behavioral Therapy

In a trial with 106 women, CBT led to improvement in these outcomes; desire and interest, foreplay, excitation and tuning, comfort, and orgasm and satisfaction.
MEDICAL

Flibanserin to treat decreased sexual desire (with some major side effects)

Flibanserin (Addyi ®) is an FDA-approved drug used to treat decreased sexual desire in some women, but it has a considerable side effects profile, which includes sedation, dry mouth, fatigue, and insomnia and it’s contraindicated (you shouldn’t take it with) alcohol or if you have any liver impairment.

Testosterone is not FDA approved for HSDD but is often used off-label

The International Society for the Study of Women’s Sexual Health (ISWSH) supports its use (2021). The Menopause Society does not.

The Global Consensus Position Statement on the Use of Testosterone Therapy for Women endorses the use of testosterone for the treatment of HSDD in postmenopausal women (2019).

Bremelanotide

Bremelanotide is an injection to treat hypoactive sexual desire disorder (HSDD). It is only for use in premenopausal women and not women after menopause. Brand name: Vyleesi®.
FEATURED RESOURCES
Women may not often feel spontaneous desire, especially if they are in long-term relationships, but initiate sex out of a wish for intimacy or to express love for their partner and begin feeling aroused and trigger desire after sexual contact has begun. Initial desire is desirable, if you like, but not mandatory. Women are more likely to spontaneously feel the urge to have sex if they are in a new relationship, or perhaps at a certain point in their menstrual cycle.

Rosemary Basson, M.D.

Learnings from in-depth research & longitudinal studies*

A study of 31,581 female respondents in the US, ages 18+ years, looked at 2 outcomes: sexual problems (any, desire, arousal, and orgasm) and sexually related personal distress (based on the Female Sexual Distress Scale)

  • 43.1% reported any sexual problems
  • 22.2% sexually related personal distress.
  • Reporting both was most common in those 45-64 years (14.8%)
LONGITUDINAL STUDIES

The Penn Ovarian Aging Study (POAS) documented an increase in sexual dysfunction along the path to menopause.

  • Post-menopausal women were 2.3 times as likely to have sexual dysfunction than premenopausal women.
  • Contributing factors to an increase in sexual dysfunction were: children under 18 at home, absence of a sexual partner, and anxiety.
  • In 326 women with still monthly periods but subtle changes to cycle length, amount of flow or days of flow (LRS) 27% reported decreased libido.
  • This was associated with fluctuations in testosterone, depression, vaginal dryness, and children living at home.

The Seattle Midlife Women’s Health Study (SMWHS) defined sexual desire as interest in sexual expression.  They studied 286 women and found:

  • An overall decrease in sexual desire was associated with age, particularly just before and after the final menstrual period (menopause).
  • In perimenopausal women, a decrease in sexual desire was associated with hot flashes, fatigue, depressed mood, anxiety, difficulty getting to sleep, early morning awakening, and awakening during the night.
  • Surprisingly they found no effect of vaginal dryness on sexual desire.
  • History of sexual abuse did not have a significant effect.
  • Better perceived health and lower perceived stress were associated with higher levels of sexual desire.
  • More exercise and more alcohol intake were associated with higher levels of sexual desire.
  • Having a partner was associated with lower sexual desire.

*A longitudinal study involves the same participants over many years so you can see how things change over time.

BOOK RECOMMENDATIONS

Disclosure: This section contains affiliate links and we receive a small commission for any purchase you make from them.

REFERENCES

  1. Holly N. Thomas, MD, MSa,*, Genevieve S. Neal-Perry, MD, PhDb, Rachel Hess, MD, MSc. Female Sexual Function at Midlife and Beyond. Obstet Gynecol Clin North Am. 2018 Dec;45(4):709-722. doi: 10.1016/j.ogc.2018.07.013. Epub 2018 Oct 25.
  2. Thomas HN, Brotto LA, de Abril Cameron F, Yabes J, Thurston RC. A virtual, group-based mindfulness intervention for midlife and older women with low libido lowers sexual distress in a randomized controlled pilot study. J Sex Med. 2023 Jul 31;20(8):1060-1068. doi: 10.1093/jsxmed/qdad081. PMID: 37353906; PMCID: PMC10390320.
  3. Goldstein I, Kim NN, Clayton AH, DeRogatis LR, Giraldi A, Parish SJ, Pfaus J, Simon JA, Kingsberg SA, Meston C, Stahl SM, Wallen K, Worsley R. Hypoactive Sexual Desire Disorder: International Society for the Study of Women’s Sexual Health (ISSWSH) Expert Consensus Panel Review. Mayo Clin Proc. 2017 Jan;92(1):114-128. doi: 10.1016/j.mayocp.2016.09.018. Epub 2016 Dec 1. PMID: 27916394.
  4. Woods NF, Mitchell ES, Smith-Di Julio K. Sexual desire during the menopausal transition and early postmenopause: observations from the Seattle Midlife Women’s Health Study. J Womens Health (Larchmt). 2010 Feb;19(2):209-18. doi: 10.1089/jwh.2009.1388. PMID: 20109116; PMCID: PMC2834444.)Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol. 2008 Nov;112(5):970-8. doi: 10.1097/AOG.0b013e3181898cdb. PMID: 18978095.)
  5. Gracia CR, Freeman EW, Sammel MD, Lin H, Mogul M. Hormones and sexuality during transition to menopause. Obstet Gynecol. 2007 Apr;109(4):831-40. doi: 10.1097/01.AOG.0000258781.15142.0d. PMID: 17400843.
  6. Freeman EW, Sammel MD, Lin H, Gracia CR, Pien GW, Nelson DB, Sheng L. Symptoms associated with menopausal transition and reproductive hormones in midlife women. Obstet Gynecol. 2007 Aug;110(2 Pt 1):230-40. doi: 10.1097/01.AOG.0000270153.59102.40. PMID: 17666595.
  7. Davis SR, Baber R, Panay N, et al. Global consensus position statement on the use of testosterone therapy for women. J Clin Endocrinol Metab 2019;104:4660–4666.
  8. Parish SJ, Simon JA, Davis SR, et al. International society for the study of women’s sexual health clinical practice guideline for the use of systemic testosterone for hypoactive sexual desire disorder in women. J Womens Health 2021;30:474–491.
  9. Lerner T, Bagnoli VR, de Pereyra EAG, et al. Cognitive-behavioral group therapy for women with hypoactive sexual desire: A pilot randomized study. Clinics (Sao Paulo). 2022;77:100054. Published 2022 Jul 26. doi:10.1016/j.clinsp.2022.100054