What is Low Libido? Update: we have PT-141 troches!!
Low libido is a reduction in someone’s desire for sexual activity. It affects both men and women. It is not at all unusual for someone’s interest in sex to fluctuate over different periods of their life due to illness, sleep disruption, stress, medications, hormonal changes, and more- as I’ll describe throughout this article. Low sex drive in men or women becomes “a problem” when it affects a person’s sense of well-being, causes stress, or creates tension in their primary sexual relationship.
What causes low sex drive in men and women? Several lifestyle factors, hormonal shifts, and well, you-name-it. I’m going to break this down into a list of causes and then the fixes for men, women, and sometimes both men and women. Here’s how I’ll proceed.
Causes of Low Sex Drive in Women and Men
- Chronic Medical Conditions
- Emotional and Psychological Factors
- Depression and Psychiatric Issues
- Excessive Exercise
- Poor or Inadequate Sleep
- Stress and associated high cortisol
- Bedroom Boredom
Causes of Low Sex Drive in Women
- Oral contraceptives
- Gynecologic Conditions
Causes of Low Sex Drive in Men
- Low Testosterone
- Low Estrogen
- High Estrogen
Solutions for Men
Solutions for Women
Solutions for Low Libido for both Men and Women
What Causes Low Sex Drive in Men and Women?
High blood pressure: Over time, high blood pressure can affect how well blood can reach and then pass through small arteries, such as penile and clitoral tissue, causing sexual dysfunction and therefore impacting libido.
Heart disease: This can also lead to damaged blood vessels and decreased blood flow to the genitals, decreasing arousal or lubrication.
Diabetes: High blood sugar levels can cause both vascular and nerve damage. This can cause erectile dysfunction in men and decreased blood flow to the genitals in women. In addition, women with diabetes may experience more vaginal candida (yeast) and bladder infections. Both of these conditions can cause dyspareunia (painful intercourse) or, at a minimum, make sex uncomfortable.
Inflammatory bowel disease: Intestinal cramping and bouts of diarrhea are real mood killers for obvious reasons.
Pain: Any sort of pain will obviously nuke sexual desire.
Osteoarthritis: People with any notable degree of joint pain or stiffness might find it more difficult and therefore less enjoyable to participate in sexual activities.
Cancer: Treatments for cancer, including surgery, radiation, or chemotherapy, can lower libido. Of course, body image issues will also often play a role, especially for women with breast cancer and men with prostate cancer.
Obstructive sleep apnea: Research shows a direct correlation between untreated obstructive sleep apnea and symptoms of low libido in women and men.
If you actually listened to the “side effects portion” or TV ads or read through all the side effects of every single drug you ever put in your mouth, I guarantee you; you’d think more than twice. Fatigue, headache, nausea are mentioned constantly, and while “sexual dysfunction” might not be listed, do you think you’ll be “in the mood” if you have nausea from a pharmaceutical? Meanwhile, there are commonly used pharmaceuticals that specifically lead to a loss of libido. Here are some of the “big players.”
Antidepressants, oddly enough, are one of the main culprits. I say “oddly enough” because depression often causes a lack of sexual interest. So when you take a depressed person and give them antidepressants that make them even less interested in sex, you’re not doing them any favors. So here are the ones to watch for.
Serotonin and noradrenaline reuptake inhibitors (SNRIs) are the most popular category of antidepressants currently prescribed. Many of them will lower the sex drive in women and men. These drugs include venlafaxine (Effexor), desvenlafaxine (Pristiq), and duloxetine (Cymbalta).
Running a close second and prescribed more by primary care practitioners are the selective serotonin reuptake inhibitors (SSRIs). These drugs and even a couple of drugs noted above are also used for menopausal symptoms (groan). Popular drugs in this category include escitalopram (Lexapro), citalopram (Celexa), fluoxetine (Prozac, Sarafem), sertraline (Zoloft), fluvoxamine (Luvox), and paroxetine (Paxil).
Non-functional doctors use tricyclic antidepressants (TCAs) to treat depression, some types of anxiety, fibromyalgia, and certain types of chronic pain. Examples include desipramine (Norpramin), doxepin (Sinequan), amitriptyline (Elavil), amoxapine- clomipramine (Anafranil),nortriptyline (Pamelor), imipramine (Tofranil), protriptyline (Vivactil) and trimipramine (Surmontil).
To round out the list without naming every drug on the market, let me mention (while we’re on the subject of mental health) that some medications used in Schizophrenia will raise prolactin levels and therefore depress libido. Then there are the very commonly used medications finasteride and dutasteride used for prostate enlargement. Next, as I’ll get into more, oral contraceptives might be a problem. Finally, many medications that lower blood pressure also results in low libido. A prime example of a blood pressure medication used to lower blood pressure, calm tremors, and even decrease anxiety is a beta-blocker such as metoprolol.
Lastly, alcohol or recreational drug use can cause low sex drive in women and men. And, it’s a bit of a mixed bag when it comes to “weed,” which will be discussed later.
Emotional and psychological factors
Most people do not have a so-called “psychiatric diagnosis.” But that doesn’t mean none of us have “issues”- in fact, most of us do deal with emotional and psychological factors that can hinder our desire for sex. Let’s start with relationship problems. A lack of trust, poor communication, any form of abuse, or stresses from financial, parental, or child-related issues can lower sexual desire on the part of one or both sexual partners. In addition, mental health issues resulting from undiagnosed depression, anxiety, eating disorders, poor self-image, or even prior sexual abuse can diminish a person’s interest in sexual activity.
Depression, Anxiety and other Mental Health Issues
Sexual disorders are prevalent problems in patients who have been diagnosed with psychiatric disorders. As mentioned previously, medications such as antidepressants and antipsychotics will induce sexual dysfunction. A comprehensive review article looked at sexual disorders in psychiatric diseases such as bipolar disorder, schizophrenia, depression, obsessive-compulsive disorders, anxiety, and eating disorders.
Panic disorder and obsessive-compulsive disorder are both correlated with less frequent sexual contact. Decreased sexual desire and sexual aversion are strongly associated with all types of anxiety disorders. The diagnosis of bipolar disorder significantly increases the risk of sexual dysfunction. In the manic phase, there is an increase in libido associated with risky sexual behavior. Depressive phases of this disorder or frankly depressive disorders are associated with low libido and dissatisfaction with sexual activity. In patients with eating disorders, libido and the level of sexual activity decreases, and the level of sexual satisfaction decreases as well.
The prevalence of sexual dysfunction in patients with schizophrenia is quite high among both those treated and untreated. Women who have schizophrenia have anorgasmia, decreased libido, vaginal dryness, and therefore dyspareunia (painful intercourse). Men who have schizophrenia have a decreased sex drive, difficulty maintaining an erection, and delayed orgasm. The bottom line: if you are seeing a mental health professional, make sure to discuss your sexual needs with them.
Too much exercise
Lack of studies in females means just that: there is a lack of studies. However, it is well-documented in men that those who exercise at higher levels tend to have lower libidos. Thus, in men, higher levels of intense and greater durations of endurance training regularly are significantly associated with decreased libido scores.
Most adults need 7 to 8 hours of good-quality sleep per night. Good quality means that the “sleeping hours” don’t include frequent arousals and are long enough for the individual to feel refreshed upon awakening. Yes, there are some (very rare) individuals who (genetically) require less than 7 to 8 hours of sleep each night. Lucky them. Most of us, when sleep-deprived, are simply pushing ourselves to sleep less. When we do this, we struggle to stay awake during the day, tend to have bouts of fatigue, and definitely suffer from a lower libido than if we were well-rested.
The hormone cortisol increases under stress-a good thing for your body in the short term. However, long-term high cortisol levels can lead to all sorts of physical problems. Physical problems, including immune system dysfunction, cognitive impairment, and much more, make this one of the most correctable and common functional medicine issues we see. High cortisol can also cause you to feel fatigued because the resultant decrease in mitochondrial ATP production interferes with regular sleep patterns. You can see where this is all going, right? Obviously, low libido is part of the end-game of this issue as well.
Fatigue can result from the two things discussed above: inadequate sleep and/or too much stress. Of course, many conditions interfere with sleep and many situations that may cause you to be stressed. If one of these issues is causing your fatigue, you need to address them before you regain your sex drive. If you have a “fatiguing illness,” that’s an entirely different story. I’ll explain.
Fatigue due to Mitochondrial Dysfunction
Mitochondria (the organelles of respiration throughout the body) produce energy in the form of ATP, which your body then uses for fuel. Your brain, muscles, and heart cells contain more mitochondria than other organs such as the lungs, kidney, or liver. When your mitochondria are working “full tilt,” your energy levels are high, your brain is focused, and your muscles and heart are at peak performance. The creation of new mitochondria (mitochondrial biogenesis) is required for optimal aging and health. As you would predict, mitochondrial dysfunction tanks your energy and contributes to numerous symptoms and diseases. So-what causes this problem?
Mitochondrial dysfunction, characterized by a loss of efficiency in the synthesis of ATP, is a hallmark of aging, and essentially, of just about all chronic diseases. Loss of mitochondrial function can cause fatigue and even other symptoms in just about every chronic disease you can imagine. Examples of fatiguing illnesses with mitochondrial dysfunction include all toxin-related illnesses such as mold mycotoxin illness, anything lumped into the “wastebasket” of chronic fatigue syndrome, fibromyalgia, and autoimmune diseases, for starters. As a “side note,” when I treat these diseases, I also “treat the sick mitochondria” so patients regain energy quickly.
We’re all adults here. I put this header here so you’ll think about this topic and perhaps even discuss it with your partner. You don’t need me telling you what this means. You know.
Low Sex Drive in Women
Causes of low libido in females can include anything that alters or interferes with the normal production of “female hormones” associated with libido, including estrogen, progesterone, testosterone, and possibly (but not probably) oxytocin. Let’s start by discussing the possible role of “the pill.”
Birth Control Pills
Common sense would tell you that when you interrupt normal hormonal functioning, you’d have sexual dysfunction. Not so fast! How about the psychological factors associated with knowing that sexual activity, using good oral contraceptives will generally not result in pregnancy? Do anxiety levels about pregnancy play a role? Studies have not examined that, but I suspect that it’s a factor. One very comprehensive study examined the libidos of women taking oral contraceptives in 30 studies. The results were basically “all over the place” as follows.
When used correctly, oral contraceptives (OC’s) provide very effective contraception and are widely used for “fertility control.” As I mentioned, a review paper looked at 30 studies to examine the correlation between OC’s and libido in women. In the uncontrolled, prospective studies ( 4), it was found that most women reported little change in libido during OC use. In the retrospective, uncontrolled studies (17), most women reported increased libido during OC use. In the prospective and cross-sectional controlled studies (4), women using OCs reported increased and decreased libido compared to non-OC users. The findings from randomized, placebo-controlled studies ( 5) were completely mixed. The takeaway here is that “I got Nuthin.” There is, however, good data on menopause.
Most women experience a decrease in sex drive during menopause due to initially- drops in progesterone, then estrogen, and then testosterone. When a woman’s estrogen drops low enough, it not only suppresses her sex drive but also causes vaginal dryness and painful intercourse. In addition, a decreased production of testosterone has been linked in many studies to a decrease in female sex drive. Conversely, replacement of these hormones with bio-identical equivalents (BHRT) can often restore a woman’s normal libido.
Hormonal changes that occur during and after pregnancy can affect a woman’s sex drive. These changes affect everyone differently. Some women may have an increased libido, while others might have little to no interest in having sex. Women’s hormones usually fluctuate during the postpartum months, which may affect sex drive during this time. Factors such as body image, breastfeeding, and fatigue all play a role in post-pregnancy sex drive.
Medical conditions such as endometriosis, causing gastrointestinal cramping, pelvic cramping, or other symptoms can certainly dampen sex drive. In addition, post-menopausal women experience increased bladder infections due to the loss of lubrication of the bladder-also due to low estrogen levels. This type of burning pain, coupled with the other symptoms of bouts of cystitis certain dampen sex drive. In fact, any pelvic muscle problems or chronic pelvic pain will obviously result in low sex drive in women.
Causes of low libido in males
Testosterone is the well-known sex hormone that males produce in their testicles. Testosterone is responsible for a range of male characteristics, including facial hair, muscle mass, libido, sperm production, erectile function, and bone mass. Low testosterone can be caused by trauma to the testicles, tumors, chemotherapy, and/or radiation for prostate or testicular cancers. In addition, anterior pituitary adenomas or toxins and pituitary damage due to traumatic brain injury can cause low testosterone in men. Furthermore, prior testosterone or anabolic steroid use can disrupt the testicular-pituitary axis, causing low T in later life. Lastly, any sort of chronic illness or heavy medications can lower testosterone levels as well.
If a male has his testosterone replaced and is being treated too vigorously with aromatase-inhibitors, giving them virtually “no” estradiol levels, this can negatively impact male libido. In addition, occasionally, we find that a low progesterone level in a man will lower his libido and disrupt his sleep.
On the other hand, testosterone which is endogenously produced but shuttled via the enzyme aromatase into estradiol as a conversion product, will impact libido when it gets too high. This is also found when testosterone is prescribed by inexperienced doctors who fail to check and then control estradiol levels.
Treatments-General advice for men and women
The treatment for low libido depends (obviously) on the cause of the problem. An easy example is if a doctor sees that a patient is taking a medication causing sex-related side effects. Another “no-brainer” would be to simply treat any underlying medical conditions that reduce someone’s sex drive.
Sometimes, it’s a matter of making the right “lifestyle changes” such as getting adequate sleep, exercising, cutting down on alcohol, eating a healthy diet, and losing weight. One easy caveat: the healthier you feel, the better your libido will be.
If there is a psychological barrier to sexual relations, talk therapy or sex therapy can be helpful. Therapy can help people improve their self-esteem, deal with previous trauma, and strengthen their relationship with their partner. In addition, research has found that cognitive-behavioral therapy can be beneficial for some women with low sex drive. Then, of course, we must fix the hormones.
Hormonal therapy for Women
Both estradiol and testosterone have been implicated as the steroid critical for modulating women’s sexual desire. Studies demonstrate that post-menopausal estrogen-only therapies produce increased sexual desire. Testosterone at supraphysiological, but not so much-physiological, levels- enhances the effectiveness of low-dose estrogen therapies at increasing women’s sexual desire, as demonstrated by most clinical studies.
Because effective therapies might require supraphysiological amounts of testosterone, it remains unclear in the literature whether testosterone contributes to the modulation of women’s sexual desire. Nevertheless, in countless reports of sexual satisfaction, women say that physiologic doses of testosterone help their sex drive.
Regarding the benefits of progesterone, it’s not safe to give estrogen without giving progesterone-anyway. However, in the years leading up to menopause, where progesterone levels are low: replacement alleviates symptoms of PMS which can arguably negate any sexual feelings a woman is having, and we don’t need a host of studies to prove this to me-and you? Next, let me dispel the myths about the magic of oxytocin.
Oxytocin for Women
Oxytocin has been the subject of countless articles, looking for evidence of sexual arousal with (mostly) intranasal preparations. While it can indeed increase the feeling of “bonding” with one’s sexual partner, there is no evidence that this hormone heightens sex drive in women. However, oxytocin gel can be useful for women (such as breast cancer patients) who cannot use hormone therapy with estrogen or testosterone. Here’s why.
Many postmenopausal women suffer from vulvovaginal atrophy, causing uncomfortable or downright painful intercourse. Several studies comparing lubricant jelly to oxytocin gel have been quite promising. Vaginal oxytocin gel appears to improves vaginal atrophy as well as all aspects of sexual function in postmenopausal women. Next- what happened to that “female libido pill” we heard about a couple of years ago?
Flibanserin for Women
Flibanserin (Addyi) is a famous pill that got a lot of press in 2019. It is a 5-hydroxytryptamine (5-HT1A) agonist and a 5-HT2A antagonist. It is approved by the FDA and is currently indicated for treating hypoactive sexual desire disorder in premenopausal women.
But here’s some data you might want to know before getting a prescription. In late 2019, a pooled analysis of three well-done clinical trials was published with the summary of results stating that 100 mg per day of flibanserin was “well-tolerated,” “improved sexual desire,” with results being consistent across different subgroups of women.
However, examination of various medical groups’ data revealed that treatment with flibanserin, on average, resulted in just one-half of an additional sexual encounter per month. In addition, there was a clinically significant increased risk of nausea, dizziness, somnolence, and fatigue. Needless to say, this drug, while still available, has fallen greatly in popularity and prescribing rate.