Dr Amanda Deeks PhD
Psychologist, Jean Hailes Foundation, Melbourne
Many women present to their doctor reporting vaginal dryness and pain with intercourse around the time of the menopause transition. We know that urogenital symptoms, vaginal atrophy and dryness can be linked to the endocrine changes of menopause. It is enough for some women to say "I wouldn't care if I ever had sex again!" When vaginal dryness and dyspareunia are the key presenting sexual problems of the menopausal woman then treatment involving Hormone Therapy is very effective.
What if it is more than this? What if the presenting problem also involves issues of desire - "Doctor I just don't seem to have the same drive or motivation for sex anymore"? What do we do then? Then we need to open up the can of worms that is sexual LIBIDO!
What is libido really?
Libido is a complex aspect of human sexual function. The word 'libido' is often used inappropriately when referring to sexual function. For example libido is often used when referring to arousal. Sexual arousal is actually a 'state' which involves the excitation of physiological responses such as the swelling of the labia and vaginal lubrication for example. Some women may present saying they are having problems with their libido when they are actually talking about arousal problems. Research into sexual function has also added to the confusion. While some researchers will talk about female libido they may only be recording coital frequency which is not a true measure of female desire (it could be the male partner's measure of sexual interest).
Libido is sexual desire or the drive to participate in sexual activity. Thoughts about sex, sexual fantasies, interest, and actually seeking sexual activity contribute to libido. Libido is actually quite subjective in that it is often hard to define a person's motivation or the strength of this motivation to participate in sexual activity. Consequently if a woman presents saying she is having problems with her libido it is important to clarify exactly what she means by this. If a woman presents saying her libido is low because she can't get lubricated in the same way she did before menopause then her problem may be related to arousal and not desire. The following review will help separate out the many influences on libido and provide possible areas of investigation in the woman who presents with low libido.
What influences libido?
The influences on libido are multifactorial and research supports that a biopsychosocial approach be factored into any assessment and treatment of the woman who presents with issues of lowered sexual desire. Physiological changes such as health status, previous sexual history, personality, emotional wellbeing, body image, attitude to ageing, midlife issues and social role are also influential. Factors such as the presence and interest of a partner and sociocultural expectations may also impact on desire.
Physiological / Biological Influences on Libido and their Secondary Effects
The endocrine changes of menopause, health status and disease may impact directly on desire, but there are also secondary effects to consider. For example the pain associated with a dry atrophic vagina may set up a negative reinforcement pattern for some women. The association of sex with pain may linger long after treatment has addressed the physical discomfort. The symptoms of hot flushes and night sweats may impact on sleep which in turn may make a woman fatigued, lethargic and feeling less like sex than when there was a newborn baby in the house! Diagnosis of an illness or disease or pharmacological treatments used may also have secondary effects on libido. For example a diagnosis of diabetes or breast cancer may impact on psychological functioning to the extent that a woman does not have any interest in participating in sexual activity because of the stress associated with the diagnosis and issues of negative self image.
Psychosocial Factors and Libido
Psychological Functioning: Anxiety & Depression
Anxiety and depression have each been associated with decreased frequency of sexual intercourse and a reduction in sexual desire. Interestingly, depression has been found to be more significantly associated with low sexual interest than age and vaginal symptomatology. Symptoms of anxiety such as palpitations, rapid breathing, increased sweating, and depressive symptoms such as fatigue, decreased motivation and negative thoughts may all negatively impact on sexual desire. Pharmacological therapy commonly used to treat depression and anxiety are known to impact negatively on libido and this should be factored into the treatment of low libido at any stage of a woman's sexual life.
Past Experience, Present Stressors and Libido
Pre-existing thoughts and behaviours related to sexual interest may influence libido in the menopause transition. Interestingly one of the best predictors for sexual activity post-menopause is a woman's frequency and satisfaction in the preceding years. Often women have experienced a negative attitude or problems with sexual function prior to menopause but have not had a reason to discuss this or have been too embarrassed. Past traumas that may be of a sexual nature such as sexual abuse and rape often seem to present for the first time in women during the menopausal transition, and this may be impacting on libido also. The current context and environment of a woman's life as well as her current level of stress exposure may impact on desire. For some women, the physical changes to the vagina as a result of menopause means they can ask for help for the first time for many sexual issues.
Body Image and Libido
Body image has been linked to self esteem and the willingness of women to participate in sexual activity, regardless of age and menopausal status. However, some women report that menopause often makes them feel their body is out of their control. Increased abdominal fat, drier skin, reduced muscle tone, hot flushes and fear of incontinence make some women self conscious of their bodies particularly during sex. Conversely some menopausal women decide that they have spent enough of their life worrying about their body and actually find sex more enjoyable; they are not so self conscious and get their self esteem from other areas of their life not just their body image.
Partners and Libido
Whether a woman is in a relationship, the quality and sexual history of the relationship, the health and sexual function of the partner are all important considerations in a woman who presents with low libido. Many researchers have found that partners, lack of emotional intimacy, and a negative relationship environment accounted more for reduced sexual desire than menopausal status. Often it is the male partner who is the initiator of sexual activity and with mid-life and aging, his role as initiator may decrease. Many men experience sexual dysfunctions as they age such as erectile problems and this may impact on female libido. It is vital that both partners communicate and seek help if they are experiencing any type of sexual dysfunction. Sometimes the male partner thinks he is doing something wrong when he can not get his partner aroused in the same way she may have been before menopause. Whether this is an arousal or libido issue, communication is essential.
Mid-life Issues, Aging, Social Role and Libido
Women who experience menopause usually are in middle age making it hard to separate the effect of these two factors on libido (low libido in women with an early menopause requires specialist help and counseling). It is important that the impact of age related factors such as heart disease for example are taken into consideration when discussing sexual desire problems. Age itself is an important determinant of sexual frequency and interest.
At midlife there are often a lot of other changes occurring such as partner's retiring, children becoming teenagers or more independent, parent's dying or requiring care. Some women are negatively influenced by children leaving the nest, however, there is now a trend for children to return home, negatively impacting on sexual motivation also.
Menopause often marks the beginning of a new life stage which for some is very positive while other women resist change and have a negative attitude to aging. This negative attitude can have a greater impact on desire than menopausal status. Many women reassess the roles they have in their life at this time such as that of partner, friend, worker and mother. If women are facing increased stress because they are unsure of what they want from their future life, or they are questioning their purpose in life, this may impact on desire.
Sociocultural Factors, Menopause, and Libido
Different cultures place different interpretations on the importance of sex in our lives making some women less inhibited post menopause while other women feel uncomfortable discussing sexual matters in public. For example researchers have found that Japanese women felt that gynecological problems were private matters and it was not appropriate to discuss these issues in public to anyone.
The attitudes of society to sexual behaviours at a particular time in history may influence how women respond with their own sexual behaviour. Women who became menopausal in the decades prior to the 1970s for instance, have not had the sexual freedom offered to them by contraception that subsequent women have. While there is more discussion about sex in the media and the community and it is generally more accepted that older people still have sex, further communication on this issue is still needed.
A thorough appreciation of each individual woman and her life circumstances will benefit the understanding and treatment of low libido at menopause. It is important that the interactive effect of physical and psychosocial factors are all taken into consideration in any assessment of low libido.
It is helpful to understand and assess:
* Psychological function including depression and anxiety
* Past experiences and attitude to sex
* Body image and self-esteem
* Relationship satisfaction, function and health of the partner
* Attitude to menopause and aging
* Age and stage of children and parents
* Role and purpose in life
* Social and cultural background
After a detailed understanding of the sexual background and possible influencing factors both pharmacological and psychological therapies may be appropriate for issues related to low libido. Psychological therapies may include Cognitive Behavioral Therapy (particularly for depression, anxiety, and fear of sex issues) as well as 'talk therapy' centered on relationship counseling, past traumas, issues of grief and loss and future roles. Sexual function and libido is an important part of life, love and relationships and if a woman experiences any sexual problem she should feel encouraged to seek help rather than just put up with it or say "I wouldn't care if I ever had sex again."
Bancroft J. Human Sexuality and its Problems. Edinburgh: Churchill Livingstone, 1998.
Deeks A. Sexual Desire: Menopause and its psychological impact. Australian Family Physician, 2002; 31(5): 433-439.
Deeks AA & McCabe MP. Sexual function and the menopausal woman: The importance
of age and partner's sexual functioning. The Journal of Sex Research, 2001; 38(3): 219-225.
Dennerstein L, Lehert P, Burger H, & Dudley E. Factors affecting sexual functioning of women in the mid-life years. Climacteric, 1999; 2: 254-262.
Segraves RT & Segraves KB. Human sexuality and aging. Journal of Sex Education and Therapy 1995; 21(2): 88-102.
Content updated August 2008