Q: I feel like my desire and enjoyment of sex have dropped off quite a bit. Is this normal, or do I have some kind of medical problem?
Talking about sex and possible sexual dysfunction shouldn’t just be a conversation about anatomy or sexual mechanics. It should always be a conversation that looks at all aspects of sex, pleasure and desire. Sexual motivation is complex; it relates to a woman’s relationship to herself and her own body, the relationship she has with her partner both emotionally and physically, her own history, and then, yes, anatomy and sexual mechanics.
We also need to keep in mind that a problem for one person might not be a problem for someone else. The most important thing to ask yourself is, are you happy with whatever your level of sexual function is? If your answer is yes, you can stop reading here!
A common concern in the family doctor’s office is “I’m here to talk about my lack of libido because my partner feels that I don’t want to have sex frequently enough.” If one partner desires sex every 10 days, and the other every three days, neither of those is normal or abnormal. But it is a mismatch – so the conversation shifts to one about finding common ground around intimacy, in a relationship where you both want to make each other happy while staying true to yourselves. This is of course not a conversation about dysfunction at all.
For women who do have concerns about their sexual function, we then need to take a closer look to understand whether the core issue relates to desire, arousal, orgasmic dysfunction, or pain (or a combination of these). As a first step it is important to rule out factors such medical conditions and medications that can affect sexual response. For example, some anti-depressants can negatively affect sexual response with 30 to 70 per cent of patients reporting some degree of dysfunction. Sometimes oral contraceptives are tied to low desire, in which case a trial off the pill to another contraceptive method may be a good idea. Common medical problems like diabetes can also affect sexual function across the gender spectrum. More broadly, when a woman’s partner experiences dysfunction that will also affect her experience of sex, so thinking about both partners is another important factor to consider.
When women experience major life changes such as having a baby or being under stress at work or at home, their desire to engage in sexual intimacy may be affected for a combination of physical and mental reasons. Menopause in particular is a common time for concern: roughly 68 to 86.5 per cent of women experience changes in sexual function at this stage of life.
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Low or decreased desire is the most common sexual health concern among women across age groups. It is essential to look at what’s happening in your body, your life and any medical conditions to understand the underlying factors that could be affecting you and how to best address them. Depending on the underlying reason, mindfulness or cognitive behaviour therapy are often part of the approach. Problems of arousal, which in the perimenopause and post-menopause are often linked to vaginal dryness, can be helped with medications.
And then there’s pain and orgasmic dysfunction. Pain during sex can be linked to multiple factors including inadequate lubrication and a history of sexual trauma. Often it’s helpful to understand whether a woman is able to successfully climax when she masturbates in order to differentiate between different kinds of orgasmic dysfunction. A complete medical history and physical exam should be performed. Pelvic physiotherapy, as well as forms of cognitive behaviour therapy can help, depending on the source of the pain. For orgasmic dysfunction, psychological factors are particularly important to consider and treatment options can range from yoga to sex therapy.
For all these issues, hormone testing is not usually helpful, but some forms of hormone treatment can have a role, especially after menopause. For example, local estrogen can be very helpful for some women. However, there’s the idea out there that progesterone, estrogen and testosterone supplements will magically awaken desire. That’s just not true, there is no cure all treatment. Desire is a very complicated thing.
It sometimes seems to me that Viagra and its cousin medications for male sexual dysfunction have made the conversations that we have with men about sexual dysfunction overly simplistic, because so often these treatments work no matter what the combination of causes of dysfunction might be. There’s no such pill for women. And just as the problem is often multi-faceted, so is the solution.
Danielle Martin is a family physician and vice-president, medical affairs and health system solutions, at Women’s College Hospital in Toronto.