Providers routinely call ZRT for support in addressing low libido for their patients during the menopausal transition.
Busy lifestyles, everyday stress, not enough or poor quality sleep and many other factors can all contribute to putting sex at the bottom of the to-do list, well after laundry, scrubbing the floor, and taking the dog to the vet.
Low libido is a multidimensional issue that can have a little bit of everything infused into its mosaic. It's not uncommon that the symptom of low libido is accompanied by fatigue, sleep disturbances, mood swings, and perhaps even mild depression. Helping patients with waning libido is attainable, and one just needs to know where to look. There are a number of factors that appear to be intimately linked to libido that can be divided into three broad categories – endocrine, lifestyle, and physical.
Endocrine Factors
What Happens to Libido When Hormones Fall Out Of Balance
As women approach perimenopause and transition into menopause, declining levels of estrogen, progesterone, DHEA and testosterone may have a negative effect on libido. Not always intuitive, but adrenal, thyroid, and growth hormones can contribute to sexual dysfunction as well.
Estrogen dominance – in perimenopause, the delicate balance between estrogen and progesterone is disrupted by fewer and fewer ovulatory cycles – progesterone plummets and estradiol levels fluctuate erratically. When estradiol levels are high, symptoms of estrogen dominance arise, such as water retention, breast tenderness, bloating, and irritability. When estradiol levels plummet, hot flashes, night sweats and vaginal dryness typically emerge. In the context of these endocrine changes without the body’s natural balance between estradiol and progesterone, low libido can commonly be experienced by many patients. Natural progesterone therapy can help restore the balance and bring relief to those women who suffer from unopposed estrogen [1].
Adrenal dysfunction – with increasing age, the levels of DHEA decrease steadily, but the amount of cortisol either remains constant or actually increases, giving rise to an essentially skewed DHEA/cortisol ratio. The unbalanced relationship between DHEA and cortisol can make some patients experience low androgen symptoms – fatigue, foggy thinking, decreased stamina, and low libido. On the flip side, when the body doesn’t make enough cortisol, as is the case with hypothalamic-pituitary-adrenal (HPA) axis dysfunction, extreme fatigue, low blood pressure, and low blood sugar can make the patient feel perpetually drained. Not surprisingly, lack of desire also surfaces prominently in cases of HPA axis dysfunction.
DHEA replacement therapy appears to be an effective strategy to balance out the cortisol and additionally address low libido along with a number of other accompanying symptoms. Adrenal adaptogens (e.g., Rhodiola, Ashwagandha) can work with the body to balance the HPA axis and promote a return to normal physiologic function [2]. Moreover, because the adrenal glands synthesize progesterone, adrenal health becomes an important focus in combating estrogen dominance in peri- and post-menopause. In other words, by supporting adrenal health, we support progesterone balance.
Hypothyroidism, characterized by low or low-normal T4 and T3 levels along with high TSH, affects the entire body with profound mental and physical symptoms. It is not uncommon for patients with an underactive thyroid to discover that they have a decrease in sexual interest [3]. Selenium and iodine can help support the conversion of the thyroid hormone (T4) into its active form (T3), improve hypothyroid symptoms and generally contribute to a sense of wellbeing [4].
Metabolic syndrome – metabolic disturbances associated with a myriad of endocrine changes in perimenopause may predispose some patients to developing metabolic syndrome. Women with metabolic syndrome report having lower sexual drive – symptoms specifically related to having higher triglyceride levels [5]. Abnormalities in the lipid profile, fasting insulin, hemoglobin A1c and IGF-1 levels can provide useful insight into the basic cardiometabolic status for a given patient and track progress after intervention.
Physical Factors
How to Approach Dyspareunia
Ovarian production of estradiol, the master hormone of female reproductive maturity, begins to decline during perimenopause. With decreasing estrogen, vaginal dryness and atrophy can occur. Even if desire remains, pain during intercourse can be especially unappealing. Thankfully, there are a number of hormonal and non-hormonal approaches to treating the physical aspect of low libido.
Estrogen therapy helps alleviate some of the somatic symptoms associated with the perimenopausal transition. Specifically, low-dose estradiol cream applied vaginally, estrogen receptor modulators (e.g., Osphena), or vaginal creams or suppositories containing estriol or DHEA can be an effective therapeutic approach to help prevent or treat vaginal dryness, vulvodynia, and atrophy.
Testosterone – not just for men – plays a prominent role in the physiology of both sexes. In women, testosterone specifically plays a key role in the physical aspect of libido. As the levels of testosterone decline with age, topical androgen therapy can help maintain physical sensation by improving blood flow to the target organs. Systemic testosterone can also improve mental aspects of libido as well. Low testosterone is a particular concern for women who have undergone surgical menopause, in whom androgen replacement is often necessary.
A non-hormonal approach works for those patients who can't take hormones or present only with vaginal dryness. Hyaluronic acid suppositories with cocoa butter or vaginal application of vitamin E can work wonders. For patients with suspected pelvic organ prolapse, a non-hormonal approach in the form of pelvic floor therapy and/or tonic herbs to strengthen the muscles in the pelvic floor may be very effective too.
Lifestyle Factors
Focus on Supporting a Healthy Brain
Addressing brain health when discussing libido issues becomes especially important for patients in perimenopause and menopause. |
The female brain is one of the most powerful erogenous zones. Addressing brain health when discussing libido issues becomes especially important for patients in perimenopause and menopause. When considering lifestyle factors for a healthy brain, consider in particular those that increase blood flow and include them in everyday life, while at the same time reducing or eliminating the ones that decrease blood flow and deprive the brain of vital nutrients. After all, as Dr. Daniel Amen says, "Whatever is good for your brain is good for your genitals [6]."
Avoid smoking, nicotine, and excessive alcohol, as they constrict blood flow and reduce the overall health of the vascular system.
Exercise – strengthens the heart, floods the body with endorphins, increases serotonin levels, tones the body, and facilitates blood flow to all tissues.
Good fats – omega 3 fatty acids are essential to the integrity and function of cell membranes. Cholesterol (yes, cholesterol!) is needed to make adequate levels of sex hormones [7].
Hydration – drinking enough water throughout the day helps keep tissues hydrated, including those below the belt. Plus a dehydrated brain (which is 80% water!) makes it difficult to think, yet alone feel amorous.
Nutrition – healthy foods supply the body with adequate vitamins and minerals – B vitamins, magnesium, zinc, and iron are necessary for neurotransmitter synthesis in the brain and periphery. Dopamine, for example, the brain’s so-called "pleasure center" requires both iron and vitamin B6 for its production.
Sleep – an adequate amount of good-quality sleep is essential for a healthy libido [8].
Supplements – Asian ginseng (Panax ginseng), the Peruvian herb Maca (Lepidium meyenii), and Ginkgo (Ginkgo biloba) are examples of supplements used in traditional medicine to improve blood flow and sexual function [9].
For some women, particularly those in mid-life whose partner's hormones are similarly declining, the waning of desire may be accepted as a natural consequence of aging, with physical sexuality transitioning into more emotional expressions of intimacy. For others, however, low libido may have a negative impact on the quality of life, emotional satisfaction, and general happiness. For those menopausal women seeking help from their health care providers, hormone balance and lifestyle improvements are key areas to address.
Related Resources
References
[1] Lee JR: What Your Doctor May Not Tell You About Menopause. ed revised edition, New York, Hachette Book Group, 2004.
[2] Head KA, Kelly GS: Nutrients and botanicals for treatment of stress: adrenal fatigue, neurotransmitter imbalance, anxiety, and restless sleep. Altern Med Rev 2009;14:114-140.
[3] Pamela Wartian Smith: What You Must Know About Vitamins, Minerals, Herbs & More. Choosing The Nutrients That Are Right For You. Square One Publishers, 2008.
[4] Kelly Brogan M: A Mind of Your Own. HarperCollins Publishers, 2016.
[5] Trompeter SE, Bettencourt R, Barrett-Connor E: Metabolic Syndrome and Sexual Function in Postmenopausal Women. Am J Med 2016;129:1270-1277.
[6] Amen DG: Magnificent Mind at Any Age. New York, Harmony Books, 2008.
[7] Schmidt MA: Brain-Building Nutrition. ed 3rd, Berkeley, Frog Books, 2007.
[8] Kling JM, Manson JE, Naughton MJ, Temkit M, Sullivan SD, Gower EW, Hale L, Weitlauf JC, Nowakowski S, Crandall CJ: Association of sleep disturbance and sexual function in postmenopausal women. Menopause 2017.
[9] Muskin PR: Complementary and Alternative Medicine and Psychiatry. Washington, DC, American Psychiatric Press, Inc., 2005.
