Management of Low Libido (Female)
The first step in the management of low libido is to determine whether the woman truly has low libido or simply a different appetite than her partner. If she is interested at least every couple of weeks, then the problem is one of appetite differences and the partner may need to be brought in for a discussion. It makes no more sense to say in that case that she has a low libido problem than it would be to say that the partner’s libido is “too high”.
The second step is to rule out medical causes. These include hypo-or hyper-thyroidism, hyperprolactinemia, testosterone deficiency in menopausal women (recent research suggests that some pre-menopausal women may also suffer from testosterone deficiency, but this is not common in spite of what popular talk-shows suggest), depression, and fatigue from medical causes.
The most common reasons for low libido in women are tension-fatigue states and relationship difficulties. Women ARE different from men: men use sex to relax, while most women need to be relaxed in order to have sex. Men can have an argument with their partner and still feel like having sex afterwards; many women need time before they want to be close again. If the patient says that the relationship is fine, ask her how she and her partner work out disagreements; if they don’t, resentment may be expressed in the bedroom. Ask her also if she knows what she likes sexually and if she is comfortable expressing her preferences to her partner. Some women assume that their partners should know what turns them; these women need to be encouraged to take responsibility for their own sexual pleasure.
Ask the woman to describe a typical day. If she doesn’t stop from the moment she rises until she drops into bed exhausted at night, sex is probably just one more thing on her todo list. Explain that she may need to plan for sex. Many people resist this idea, feeling that sex should be spontaneous. Unfortunately, in today’s hectic world, if we don’t plan for something, we often don’t get around to it. The sexual component of a relationship is important enough that it deserves the same attention and care that we devote to other aspects of our lives.
If everything in the patient’s life and relationship is such that there are no obstacles to libido, there may be underlying intra- or inter-personal issues. These include unresolved family of origin issues, a history of sexual trauma, body image, sexual self-image, sex education or lack of, religious influences, and the partner’s sexual issues. Some family physicians do counselling and are comfortable dealing with these issues; others, and the vast majority of gynecologists, would rather refer. It is helpful to have a list of people one can refer to. In many cases, discussion of the Circular or Intimacy-based model for women (SOGC Journal May 2000) and trying to identify with the patient “where the break in the cycle is” is very helpful.