The answers to the following FAQ’s are generalized for the population-at-large and meant to help educate readers. Please be aware, however, that individualized therapy may dictate different approaches for specific patients that can differ from what is written here. That is why it must be emphasized that consulting with Dr. Altman, or any other expert in the areas of menopause, hormonal therapy or sexual dysfunction, is the only way to receive the appropriate individualized care that each and every patient deserves.
Female Sexual Problems
Why is my sex drive down?
Answer: This answer will be different for each individual patient, but there are many reasons that sex drive can be diminished or absent: some of those reasons are hormonal, some are relationship-based, some are due to antidepressant therapy or birth control pills, some have to do with stress at work or within the family, and some are a combination of these reasons, but it’s not all due to hormones!!! It takes an in-depth consultation to determine each individual woman’s reasons or situation. In the end, there are many things that we can do about decreased/absent sex drive, but each patient is different, and the solutions are different. Most importantly, this takes time and patience, as well as an expert clinician who specializes in this area.
Does a woman’s sex drive change as she ages?
Answer: Some women find their sex drive diminished as they age, and others actually find it increased or unchanged. Everyone is different. Many women find their drive is “different” as opposed to increased or decreased. The “spontaneous” sex drive can change and become more “responsive”. This means that instead of wanting to tear his clothes off and have sex, she may need to first be stimulated sexually by her partner before the drive occurs; hence the term, “responsive”. It turns out that this is another variation of normal. This can be very reassuring to a woman who is questioning a change in her sexual drive.
I seem to have my sex drive, but I’m not responding vaginally and clitorally like I used to be?
Answer: This is called an arousal disorder, if it is distressing to the patient. Arousal problems mean that you still want to have sex but for some reason you are not responding in the genital area. Sometimes that lack of response comes from the brain, sometimes from the inability to “vaso-congest” or collect a lot of blood in the genital tissues including the clitoris and the vagina, so that you don’t notice arousal, lubrication, or labial and clitoral swelling. This can be a complicated problem, but therapies exist that can improve responsiveness.
What is the most common sexual dysfunction that you see in your practice?
Answer. The most common sexual dysfunction I see is pain with intercourse due to vaginal atrophy and the resulting lack of lubrication, leading to vaginal dryness in post menopausal women. We are actually seeing an epidemic of this problem in the United States because so many millions of women were frightened away from using estrogen by the misrepresentation of the Women’s Health Initiative study (see above), that they stopped their hormone therapy and won’t even use local vaginal estrogen that works just in the vagina and doesn’t get absorbed into the body. Within six months of stopping estrogen (or within six months of natural menopause), the vagina begins to loose its elasticity or “stretchibility”, and the opening begins to narrow. While the vaginal tissue normally stretches to accommodate the penis during intercourse, with vaginal atrophy this accommodation is less and can cause discomfort or pain. When the natural lubricating ability of the vagina is also decreased, the situation and pain can be even worse. That’s why many women find that they need to use a sexual lubricant to facilitate intercourse without pain. The problem is, “who wants to have sex if it hurts?” Pain can easily diminish your sex drive so that you have sex less frequently, which can cause further vaginal atrophy from “disuse”…hence the advice to “use it or lose it!” This self-perpetuating problem is a more common cause of decreased sex drive than lack of testosterone. And, nothing treats vaginal atrophy better than estrogen, occasionally combined with some gentle dilator therapy. I can’t tell you how many women come to my office complaining of decreased sex drive, who say, “Oprah told me to come see my doctor for testosterone to increase my sex drive.” They don’t need testosterone to increase their drive. They need estrogen to get the vagina back to being comfortable sexually after which their sex drive returns.
What’s the most important thing for women to understand about female sexual dysfunction?
Answer: First of all, it’s not a sexual dysfunction if it doesn’t bother you. Consider this…she has little or no sex drive…he has a prostate problem, and the medication he takes for it diminishes his ability to maintain an erection, so he’s not anxious to have sex either. Neither of them is distressed about not having sex, so they may have some sexual problems, but they don’t have sexual dysfunction! It has to cause distress in at least one of the partners to qualify as dysfunction.
As I’ve mentioned in my books, “Men need a place, women need a reason.” Women have sex in a context, within the context of what’s going on in their lives, so everything has an impact on a woman’s sexuality. Whereas men are far more sexually driven by a quest for orgasm, women are far more complex and driven by a quest for intimacy. Women’s sexual desire and responsiveness is dependent on many factors including foreplay, “after-play”, and even “between-play”. Patients have said, “If my husband will help me with the wash or help me out with the garbage after dinner, that will make me more amorous, more sexual towards him.” Also, while for most women, spontaneous desire has been the norm, some women no longer notice spontaneous desire, but instead need to be stimulated sexually prior to noticing the onset of desire. This is called “responsive desire”…because she has to respond to stimulation before she accesses her desire to have sex. So she doesn’t lack sexual desire, it’s just different. All these things enter into it. In a private consultation, we look into each woman’s individual sexuality and concerns.