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Low libido—What is it? Over the years of meeting women who ask about low sexual desire, I work hard to understand my patient’s personal and medical history, screening for potential causes for low sexual desire. It has been reported by women of all ages, but with a trend towards those approaching or in menopause.  What are reasons I hear?   “I don’t have any feeling there anymore.”  “I do it to please my husband because he wants it.” “I get through it even if it is painful.” “I don’t really think about it or care about it.” “It hurts.”  There clearly has been an unmet need in this area of women’s health.  Female sexual dysfunction of which low desire is the most common symptom affects almost 50% of American women and the prevalence is unknown worldwide. We have learned that satisfying sex confers many benefits including improved cardiovascular and mental function, longevity, improved self-esteem and simply happiness or the joie de vivre.  Even more importantly, as humans are we not all susceptible to pleasure-seeking activities? So why are so many women suffering silence?

In 2015 and in 2019, a perceived breakthrough in female sexual wellness occurred with FDA approvals for two medications to address low sexual desire termed HSDD which is thought to be caused by a problem in core female biology with age.  Is it declining hormone levels (low testosterone, low estrogen), evolution or neurochemical imbalances in your brain? Are these the culprits?  Are these FDA approved medications the answer?  Is hormone replacement the answer? What role do cultural contributors play in this fallout of an overwhelming number of women with low female sexual desire? What role does relationship disparity in terms of power, status, autonomy play in sexual entitlement or lack thereof and sexual desire?

Women describe consent as wives or girlfriends and a grit or a false pretense to bear the duty of sex.  Some go on to describe an “out of body” nature of sex, likening it to a critique of their best and worst bodily angles, their performance, hoping for things to end soon and to smile the entire time even if it hurts and thankful when it is over. The aim to please is almost ubiquitous with all women.  Can sexual desire exist absent of sexual fulfillment?

Underlying every scenario of bearing sex for the purposes of being a good partner, the relationship between mind and body is pronounced.  How in sync are our genitals and mind?  Women who suffer from HSDD (low sexual desire) report a lack of conformity of mind and body, termed sexual discordance.   If you are worrying about what your partner is thinking, how large or unsightly your labia are, if the kids are crying, if it feels different or loose to him after childbirth, the stresses of your job, you may be unmoved by any touch to the clitoris or any part of the body.  For my patients, I also find that low desire was intricately tied to many factors including how she feels about herself and her sense of entitlement and ability to be autonomous, and the inclination to give up weighted assumptions about herself. 

In time, women may simply not desire sex due to the history of persistent mediocre sex or quietly unwanted sex they’ve endured.  If women have engaged in activities that aren’t inclusive of their pleasure, I’m skeptical that more activity will harness pleasure and elicit desire. We desire things because we associate them with pleasure. Let’s start with the glaring discordance of an unmet need, unmet recognition and acknowledgment.  Penetrative sex results in true pleasure for only a minority of women, and for some, who associate it with, pain, guilt or chore-like duty, it may incite total aversion.  How can we work towards reinforcement of pleasure for women first and foremost?

Is her pleasure less important or subsumed by her partner? If so, I wonder at how addressing low libido with hormone replacement or a medication could help. When so much informs the sexual encounter, the biology of a pleasure giving organ like the clitoris is numbed.  Treatments to heighten clitoral sensation such as plasma-rich injections, sound therapy, radio frequency at a specified wavelength have been known to shorten the time to orgasm, the frequency and ultimately the rewarding quality and intensity of orgasms.

Menopasual or women transitioning into menopause are the highest population  of women who are known to be affected by low libido, however, this may be a result of the many changes they have undergone from childbirth to aging that affects the delicate tissues along with relationship factors.  At our center,  we emphasize support of women’s concerns for bodily changes in  order to foster inner confidence, the sense of feeling beautiful and ultimately sexy to engage in any activity she may desire in the future.

Feeling sexy is first and foremost and feeling sexy in the eyes of one’s partner is second.

Labiaplasty is a surgery I commonly perform to address the cosmetic concerns and stretching or drooping by women after delivery of her children or commonly with aging.  A surgery can support her in comfort in daily activity but also to feel confident and positive in the way she looks at herself and what she sees when her partner views her.  I see this miraculous boost after every labiaplasty!

Above and beyond are vaginal rejuvenating surgeries or in office treatments to help the health of tissues and restoring both the appearance and function in these areas.  Blood flow is a key component as well as tissue elasticity and sensation.  Vaginoplasty and noninvasive energy treatments like radio frequency have been innovative technologies in this area of women’s health to improve arousal and sexual responsiveness.   Hormone replacement and neurochemical agents in the form of injective medications like Vylessi or daily oral medications like Addyi can support women in their journey to increasing libido for the purposes of sustained sexual encounters notwithstanding that feeling sexy cannot be overemphasized as the first step towards meaningful and rewarding sex.   

Our center supports women in their voiced concerns of genital appearance and diminished function through her natural life span and life events.  Urinary or fecal incontinence, lack of sensation and sexual pain are all areas which we address to support the sexual wellness of our patients.  These can have an impact on your sexual function.  Our center focuses on comprehensive assessment and treatment of all areas that may contribute to sexual wellness including bladder, bowel and pelvic floor functions.