HSDD Part II: The role of neurohormones and neurotransmitters

Hypoactive sexual desire disorder has many different etiologies including physiologic and social contributors. Often the combination of the two make for a perfect storm. This makes the discussion around treatment less direct and definitely NOT a one-size-fits-all. Fortunately, the last decade has brought on more research dollars and emphasis on the importance of female pleasure in relation to health and therapeutic treatments are progressing. However, it’s slow and still a very small piece of the research pie, as no one is going to call 9-1-1 if they don’t have an orgasm. Unless they happen to have a thing for the local paramedic… Ok, bad joke.

An area where research and pharmaceutical development has focused on in the last decade, and for good reason, is the system of the brain called the dopaminergic systemic that drives sexual desire. This paired with sex hormones like testosterone, estrogen amongst other neurohormones like oxytocin, and the inhibitory neurotransmitter serotonin leaves a lot of room for us to explore.

Lifestyle stuff

First off people…I hope it goes without saying that sleep, stress management, movement, and nutrition should be strongly advocated here. But sometimes it’s chicken or the egg… meaning if we don’t feel sexy, sometimes our motivation for self-care is lower. SOO prioritize getting rest, drink those green smoothies (Hey @thegreensmoothiegirl), and go for a head-clearing walk or jump on your peloton (love you @Allymisslove). Oh, and then meditate. All in a day’s work right? Remember our potent little mitochondria are critical for love and lust so take care of them with some lifestyle foundations.

Cephalic Phase (Brain phase)

Think sexy thoughts. Sounds BASIC. I know. What do you absolutely LOVE about your body? Where do you like to be caressed? What is your spot? Not sure? That’s step 1. Learn your body, love your curves. Masturbate with your fantasies in mind. Think about what you want to do to your partner and vice versa. Learn about yourself without inhibition, then you will be closer to letting your partner explore that world with you.

Not able to go there yet due to discomfort with your body? Ah-ha! We’ve found an area of opportunity for you. Cultivating self-love, acceptance of your feminine form, and rocking her world is where you will begin. Finding a great sex therapist can be especially helpful here in identifying where your subconscious or unconscious roadblocks may be.

Presuming you’ve been able to seduce yourself, at least a little, create a routine of private time. If you’re into erotica, sexy music, or visual stimulation it’s fine to bring that into the mix. Ok, Justin Timberlake, we are Bringing Sexy Back, and this time without the auto-tune. Unless you’re into that.

Blah, blah, blah

Bored with the info above? Feel like the reason you even decided to read this article is that you know all of this and were hoping there was finally a simple solution that will make it all better? Well, you might be right, but as I said earlier, there is not a one-size-fits-all. Women are like complex electrical wiring and you flip one switch it shuts down all the rest. Having all wires connected to the right circuits is challenging all the time, but we can optimize using a Functional Medicine approach. Reminder on what you might want to ask your doctor about for lab testing:

Labs may include:

· Vit D

· Thyroid Panel

· Blood sugar markers (beyond just blood glucose)

· Methylation markers

· Omega 3 fatty acid levels

· Blood count of red and white blood cells

· Liver, Kidney, and Electrolytes

· Inflammation markers

· Sex Hormones (depending on contraceptive status)

· B12/folate levels

· Iron studies

· RBC magnesium

Specialty Testing

· Digestive Analysis

· Stress hormones

· Salivary Sex Hormones over 28 days (premenopausal women)

· Comprehensive Nutrient Testing


Some women can be a little moody at times (ahem, me? NEVER). The difference between moody and outright depressed comes down to frequency, severity, and whether there is an underlying reason for the low mood (loss of job, relationship issue, transitional period of life etc). Women who display signs of low mood and/or anxiety may be prescribed anti-depressant medications, many with an unwanted side-effect of lowering libido. Unfortunately, this is the action of the serotonin that is being RAISED in your brain by the drug, which also has an inhibitory effect on dopamine, which is a direct stimulant of desire (Croft, HA 2017). Chronic cannabis use (endocannabinoids) can also have this effect of inhibition. This is why the treatment of sexual dysfunction secondary to anti-depressant therapy is to give a second anti-depressant prescription called Bupropion (generic). Might not make a lot of sense to many but depression can be NO JOKE and sometimes anti-depressants are needed. In my practice, I prescribe these medications when medically appropriate, and ultimately most patients use them while working on their foundations of health and doing therapy. The goal is not using them forever but typically to help dig out of a little ditch that sometimes we need support getting out of. Alas, I digress… The bottom line, meds that increase serotonin may contribute to HSDD and there are options to help reduce this unwanted effect.

Dopamine, Adrenaline, and Mile high club

Dopamine is the starring neurotransmitter that neuroscience has identified as the most critical for creating pleasure-seeking behavior. It is what increases in dramatic amounts in the brain when someone abuses cocaine and other amphetamines. It is stimulated by our natural amphetamine PEA (more about that in a separate article) and is highest among new lovers. It works synergistically with testosterone to drive sexual initiation and receptivity. Closely associated with adrenaline, more specifically norepinephrine, dopamine stimulates desire and subjective excitement and norepinephrine enhance that situational stimulus, hellooo Mile High Club. Add a little testosterone into the mix and you have a well-primed individual with high sexual energy, presuming their inhibitory stimuli don’t override.

There are now a few ways to increase dopamine exogenously (outside the body), beyond amphetamine medications or illicit drugs, which I do not encourage for obvious reasons.

Natural Agents to Raise Dopamine and Adrenaline:

– Tyrosine: An amino acid important for the production of dopamine. Rapidly absorbed through oral consumption. Can be useful for alertness, ADHD, and thyroid disorders.

– Phenylalanine: Amino Acid is a precursor for our lust hormone, PEA. Mild to moderately helpful in my experience with patients, especially if the person tests LOW on an amino acid nutritional test for phenylalanine.

– Yohimbe: Raises adrenaline, thus stimulating sexual arousal. Can cause anxiety, raise blood pressure, and hyper-alertness (Brunetti et al., 2020).

– Mucuna pruriens: Raises dopamine, helps with depression, and possibly infertility in men (Lieu, et al. 2010).

Pharmaceutical Agents to Raise Dopamine

– Bupropion medication: An atypical antidepressant with dopamine stimulating effects. Can raise mood while improving sexual desire. Can be over-stimulating for some individuals. Very well-studied. Also helpful for food addictive behaviors and smoking cessation. Can raise blood pressure.

– Buspirone medication. An anti-anxiety agent that can help calm down those overstimulating signals meanwhile raising dopamine, norepinephrine, free serotonin (Croft, HA., 2017).

– Bremelanotide: An injectable medication that is administered up to 2x. Activates a system known as melanocortins which have a stimulatory effect on dopamine. Effective for stimulating sexual desire as needed but common side effects include nausea and flushing. Works well as an as-needed agent. Can last up to twenty-four hours for sexual arousal (Pfaus JG et al., 2021). Best to plan a weekend here ladies… DO NOT USE IN CARDIOVASCULAR DISEASE. Max # of doses in 1 month period is 8 doses.

– Flibanserin: Fully unknown mechanism but believed to have effects on reducing serotonin inhibition and raising dopamine, leading to more sexual desire. The research was mixed. Lots of drug interactions, including alcohol. Despite this being the first drug on the market approved for HSDD, I do not Rx it due to the lack of impressive evidence and side-effect profile.

– Apomorphine: A drug agent, currently available compounded, that was historically used to raise dopamine in patients with Parkinson’s disease. A neurodegenerative disorder is classified by degeneration of the neural tissue that produces dopamine. Research in women has demonstrated the safety and efficacy of dosing apomorphine daily sublingual for enhanced sexual desire via raising dopamine-related pathways (Caruso, et al., 2004).

Feel like your head is spinning? A little, maybe? Well good. Part of PSB is intended to share, educate, and understand how we, as empowered women, can take charge of our minds and bodies. Sometimes we may want to reach for a dopamine stimulating agent because, frankly, they can be a lot of fun.

In our third part of HSDD we will dive into the hormonal approaches (testosterone and beyond) for the management of this complex but common disorder.

Writer: Michelle Leary
Writer: Michelle Leary
December 9, 2021

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