Low sex drive? You may be suffering from Hypoactive Sexual Desire Disorder
Low Sex Drive

Let’s talk about sex, baby.

In my clinical practice, I often hear a common concern from my female patients “I feel like my sex drive is low”. This difficult admission can accompany feelings of guilt, shame, and a feeling of being “broken”. Many of these same women are busy professionals with loving, caring partners and in overall good health. They are in their 20s, 30s, 40s, and 50s. They used to enjoy an exciting and dynamic sex life with their partner and they don’t understand what happened. This may leave their partners feeling rejected and leading to conflict in the relationship or may have stemmed from interpersonal dynamics between the couple, yet to be addressed. Sometimes the couple becomes apathetic, giving up on their once satisfying sex life. Other times there is truly nothing wrong with the relationship and ultimately there may be an underlying physical component to the loss of interest in sex. Lastly, and probably most common, is the assumption that this is ‘just the way it is’ post-kids, multiple years married, stressful jobs etc. There is a lot to say on this last one, but for now, just know not all is lost. There are options to get you through beyond a wine-text subscription (amazing deals though, right?!).

In any case, the acquired loss of sex drive is almost always multifactorial. This is different than individuals who may have always had a low sex drive and have never had the interest or desire in engaging in robust sexual activity. For the purposes of today’s article, I am going to focus on the acquired loss of desire in sexual behaviors, presuming a previously satisfying sex life.

Defining Hypoactive Sexual Desire Disorder

In psychiatry, there is a manual called the DSM-V, which is a large aggregate of diagnoses and conditions that contain criteria for someone to be “diagnosed” with a specific condition. The purpose behind this manual, which has been around for many decades, is to help clinicians identify who fits into what category so the best treatment may be decided accordingly. One of the categories of conditions is called Female Sexual Disorders (FSD). One of the conditions under the FSD designation is called Hypoactive Sexual Desire Disorder (HSDD).

HSDD is defined in the DSM-V manual as follows:

“A lack or loss of motivation to participate in sexual activity and decreased spontaneous desire or responsiveness to erotic cues or stimulation that is accompanied by personal distress and is not due to another medical condition or medication side effect.”

It is important to point out that the criteria include ‘personal distress’ as part of the definition. If a woman is finding a loss of sexual desire not to be negatively impacting her quality of life this does not mean there is pathology but simply a difference in how she chooses to live her life. This distinction is critical as culturally we are taught, as females, that we should want sex with our partners whenever the conditions are right, but if we don’t “respond” to our partner’s initiation, we are malfunctioning in some way. Let’s throw this idea out the window. If you don’t want sex and are FINE with not wanting sex, more power to you. Your body, your choice. I do advocate for communicating with your partner about your needs in a respectful dialogue so that everyone is on the same page.

So, you’re still here so you’re likely experiencing personal distress due to loss of sexual desire in your relationship or relationship(s)? Well, you’re not alone. According to the PRESIDE study published in 2008, a survey of 31,581 US women found 37.7% of them reported concerns in sexual desire. Of this group, 24% of these women were pre-menopausal and ages 20 through 49. This data disassembled the classic assumption that female sexual desire only wanes after menopause. Surgical menopause continues to be one of the leading explanations for loss of sexual desire in younger women and can often be attributed to complications from surgical nerve damage and/or early-onset into menopause. The study also elucidated the additional emotional stress that was added on women who had a current partner who felt they were unable to respond to their initiation for sex. This perceived disappointment was associated with depression, anxiety, and heightened pain scores. This is likely due to some of these psychosocial and emotional components that go along with stories we tell ourselves about not being as sexual as we once were and the meaning we give those interpretations.

Ruling out the basics

Remember, the criteria for HSDD, specifies that it is not due to another medical health condition. In the PRESIDE study, it was found that women who reported depression, fatigue, back pain, memory problems, diabetes, and osteoarthritis were more likely to report loss of sexual desire. This is where it gets a little bit sticky. It seems obvious that if a woman is depressed or tired or has back pain that of course, she’s not going to be in the mood all the time to want to have sex. Yet, some women who do report depression, fatigue, back pain, etc do not report an associated loss of libido or sexual desire thus making it challenging to place a cause and effect on those conditions but merely an association between them. There is a common saying in medicine ‘association does not equal causation. As an example, a patient comes to my office and reports she is having back pain. She says every time her backaches she does not want to have sex with her partner, this is a clear association of back pain with loss of sexual desire. The obvious treatment plan would be to treat her back pain first as opposed to presuming a hormonal, neurochemical, or psychological reason for her loss of libido. The same is true for other conditions like low thyroid, high anxiety, fatigue, and so on. Ensuring the patient is in a good physical state makes it easier to tease out the underlying causes of her diminished desire.

In my clinical practice, in addition to a lengthy subjective intake, I order a set of comprehensive labs at the onset of most patient visits to assess where opportunities may be to optimize health prior to prescribing hormones, performing procedures, or even recommending most supplements. This allows me to better understand where the low-hanging fruit may be before we use advanced techniques that may or may not be necessary.

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

Specialty Testing:

  • Digestive Analysis
  • Stress hormones
  • Salivary Sex Hormones over 28 days (premenopausal women)

 

What about hormones?

There are several key players in the hormonal milieu that can contribute to whether one has an associated decline in sexual desire (Kingsberg et al., 2020).

Dopamine: Most famous for being the brain’s “pleasure-seeking” neurotransmitter, it is now seen as the critical component of libido and stimulating desire. Inadequate dopamine levels are associated with depression, irritability, loss of concentration, and anhedonia.

Testosterone and Estrogen: The two most famous libido-enhancing hormones that are discussed are testosterone and estradiol. These two engage at the central nervous system (brain and spinal cord) and peripheral nervous system (tissues, organs) level to promote and enhance arousal and desire. They are also important to facilitate blood flow and support vaginal lubrication to the tissue.

Nitric oxide: This chemical compound helps to support erectile tissue in both sexes by bringing more blood flow to the area, supports vaginal lubrication, and drives the arousal response.

Norepinephrine: This short-acting neurochemical Is important for sexual motivation and is most heightened during arousal and orgasm

Serotonin: A critical ‘feel good” neurotransmitter. Unfortunately, it also restricts our sexual stimulatory signaling systems and can lead to a sexual desired disorder secondary to medication side effects. This is most notable when given antidepressant medication commonly used to elevate serotonin levels.

How do you ‘get’ HSDD?

Let’s use the example discussed by Emily Nagoski, PhD in her book Come As You Are of a dual control model. We have the accelerator, and we have the brakes. In the case of the brakes, we have two: a handbrake and a footbrake. If our accelerator is not active enough and our foot is too firmly on the brake, we are unlikely to be able to become sexually aroused or achieve orgasm. This simplified analogy interprets the complex web of neurochemical and hormonal signaling that involves the excitatory side of our brain and our inhibitory side thus the accelerator and the brakes. An additional oversimplification example, if we just look at dopamine and serotonin, if someone has too much serotonin and not enough dopamine, they will constantly have their foot on the brakes. However, humans are complex and there is more to it than just a couple of hormones (Nagoski E. 2015).

It is also important to think about our sexual ‘seeking system’, borrowing from the work of Nan Wise, Ph.D. Our seeking system it’s most activated when we are in balance with other components of our core needs as humans. If our brain states are predominated by rage or anxiety, there will be inhibitory signals that do not allow for arousing thoughts to be translated into a physical response of an erection (yes, women get erections!). Dr. Wise discusses this concept extensively, in her book Why Good Sex Matters. She explains the importance of why we must work towards calming and balancing these other components of our brain in order to activate our sexual seeking system (Wise, NE. 2020).

Both authors and highly acclaimed experts in the field of sexual neuroscience elucidate the concept that excitation and inhibition must be in balance for desire and arousal to occur.

As an aside, please note that I said desire and not a reproduction. Perhaps it doesn’t need to be said that desire and enjoyment of sexual activity is not a requirement for procreation to occur, at least in women. Therefore, sexual satisfaction as a requirement for the propagation of the species has evolved biologically different than it did for males, who typically ejaculate with orgasm. This biological detail, within the confines of a patriarchal society, has led to very little research around therapeutics for female sexual disorders. Fortunately, we are starting to see some momentum gain traction in the last 10 years.

Fact: It wasn’t until 2011 (only 10 years ago?!?) that a study was published mapping the locations of the brain linked to the clitoris, vagina, cervix, and nipple (Wise, NE. 2020). The male counterparts had been studied in the 1950s and medical students, physicians, and neuroscientists had been using that model ever since. Sigh, I digress…

So how do you know if you have HSDD?

The standardized questionnaire aptly named “Decreased Sexual Desire Screener” is a questionnaire that can be used to help identify hypoactive sexual desire disorder. Please keep in mind this should always be done as part of a medical office visit in which your personal physician can also ask specific questions that may identify additional causes for low libido such as medication side effects and other physical manifestations (Kingsburg et al., 2020).

  1. In the past, was your level of sexual desire or interest good and satisfying to you? YES/NO
  2. Has there been a decrease in your level of sexual desire or interest? YES/NO
  3. Are you bothered by your decreased level of sexual desire or interest?
  4. Would you like your level of sexual desire or interest to increase? YES/NO
  5. Please circle all the factors that you feel may be contributing to your current decrease in sexual desire or interest:
  6. A surgery, depression, injuries, or other medical condition.
  7. Pharmaceutical medications, illicit drugs, or alcohol you are currently using
  8. Pregnancy, recent childbirth, menopausal symptoms
  9. Other sexual issues you may be having (pelvic pain, decreased arousal, or orgasm)
  10. Your partner’s sexual problems
  11. Dissatisfaction with your relationship or partner
  12. Stress or fatigue

Answers to the questionnaire:

Responses to Q1-Q4 – ALL YES

Response to Q5 = NO

= Generalized, Acquired HSDD

Response to ANY Q1-Q4 – NO (to any of them)

= NO HSDD

Responses to Q1-Q4 – ALL YES

Response to ANY part of Q5 – YES

= Possible HSDD, other primary conditions may exist

No matter what you scored, knowledge is power. Therapeutics exist for the treatment of HSDD and I’m thrilled that there are more coming out each year. Let’s dive into the therapeutics in part II of this blog series.

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

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