Sexual desire and your hormones

• until recently researchers would have considered it too embarrassing or controversial.
• this isn't a life-threatening area of medicine.
• until recently, no drug company realised that there was money to be made from such research. (This is now changing, and the rush is on to market a drug that will 'turn women on'.)
• it's very difficult to measure desire scientifically (there aren't any units of desire).

• our ovaries produce large amounts of the female sex hormones - oestrogen and progesterone
• they also produce small amounts of the male hormones - testosterone and androstenedione.

• FSH (which stands for follicle stimulating hormone) controls the formation of eggs by the ovary.
• LH (which stands for luteinising hormone) controls the production of sex hormones by the ovaries. A Swiss gynaecologist (see below) has recently told us that he believes LH is strongly linked to desire.

• the level of oestrogen rises slowly during the first half of the month, often dips sharply at ovulation - which occurs around about day 14 - and gradually falls off just before the period.
• the level of progesterone rises sharply after ovulation, and then falls off just before the period.

But since we all go though the same hormonal changes, why don't we all feel sexy - or not sexy - at the same point in the cycle? The truth is that nobody knows.

My own personal – and totally unscientific – theory about those of us who claim to feel increased desire just before the period is that what we're really thrilling to is the sensation of having sex when our womb lining is thickest.

We seem to feel extra sensitivity in our vaginas – possibly because of some kind of pressure or sense of engorgement resulting from the thicker womb lining – and this enables us to enjoy the feeling of a penis inside us more than usual.

This enjoyment, however, may have little to do with increased libido. . Instead it may simply be a response to different physical feelings in our genitals.

What about libido?
It's important to realise that libido (desire) is a completely different thing from physical arousal in the genitals.

This might seem incredible, but many women who say they have no libido are actually able to become physically aroused and have orgasms without much difficulty. What they do find difficult - or impossible - is to feel any passion or any desire for sex.

Often women ask if Viagra could help 'turn them on' to sex. The answer is no. In men, Viagra is used to treat erectile dysfunction - that is to say a lack of ability to get an erection. Viagra is of little use to men who are not interested in sex, because it has no effect on desire.

Currently, trials are progressing to test Viagra on women, but the research is about whether Viagra causes helpful physical changes in the sex organs. It has been reported that in a few women, the drug will increase vaginal lubrication and swelling of the tissues round the vulva. But there is no possibility that it will turn uninterested women into sex bombs. And to date (2006), Viagra is still not licensed for the treatment of women.

Professor Alan Riley of the University of Central Lancashire - one of the UK's leading experts in sex problems - says that lack of desire is the number one sex problem in women today and that it's extremely difficult to treat.

Over 25 years ago, the American professor Dr Helen Singer Kaplan wrote a ground-breaking book called Disorders Of Sexual Desire. In it she stated that: 'In human females, (o)estrogen does not enhance sexual desire.' She also said that testosterone is the 'libido hormone' for both genders. Furthermore, she speculated that the hormone LH might in time be used clinically to increase libido.

Well, what has happened in the world of female sexuality since? Testosterone has been used at different times by different experts since the 1960s to try to 'kick start' the female libido. But no one has demonstrated any wonderful results. If they had then testosterone would have become a mainstream treatment, which it very definitely has not.

However … in 2006 the drug companies have begun to promote the idea of testosterone again. Various papers have recently been published which suggest that testosterone might be the answer to what the Americans now routinely call 'FSAD' (see above).

So over the next couple of years, you can certainly expect to see lots of newspaper articles suggesting that:

• vast numbers of women have FSAD
• the cause of this is hormonal – namely lack of testosterone
• there's a truly marvellous new treatment, involving taking testosterone via skin patches, or whatever.

David later visited him at his clinic in Lugano, where he explained that his work has suggested that high levels of LH make a woman 'horny', while low levels make her apathetic about sex.

We await with interest publication of Dr Jemec's results in a medical journal. However, at the present moment I must stress that no treatment with LH is available.

Hit and miss
So, at the time of writing, the situation is still extremely muddled and women in this country (the UK) who have loss of libido are quite unlikely to find a doctor who will test their hormones, or offer them hormonal treatment on the NHS.

However, there is one small exception in the case of loss of libido at the menopause. For this problem, an HRT-type drug called 'tibolone' does now have an official licenselicence in Britain.

But in general, since we cannot absolutely attribute lack of sex drive to hormones - and since there is very little hormone treatment available even if we could - perhaps we need to look at the problem another way.

The first thing to say is that if you feel very definitely sexier on some days of the month than others, make sure that you and your partner capitalise on them! These are the times of the month when you should come home and go straight to bed with your loved one, some smoked salmon sandwiches and a bottle of wine - or a tub of luxury ice-cream. And if you have children, you should arrange for them to go to Granny's or to a sleep-over at a friend's house.

By planning to have lots of sex when it's going to be great, neither you nor your partner should mind so much that there are days when all you want to offer is a quickie or a cuddle.

But what if your sex drive is pretty dormant all through the month?
Well, the sorry fact is that you may be a bit bored in your relationship, or tired, or feeling resentful towards your partner.

When we are newly in love, we usually have no problems with libido. In fact we often feel as if we're permanently 'on heat'! (There are a few women who have no apparent desire in the early stages of a relationship, but they tend to have psychological problems about allowing themselves pleasure through sex.)

Of course, when we first start a relationship, everything is new and exciting so our brains are very stimulated. So maybe the answer is to work on our brains - not our hormones - to spark off our sex drives.

Unfortunately, there is a tendency for relationships to become routine after a while. Sex, which before happened on occasional dates, is there on tap once people move in together. Interestingly, once we get used to the idea that we can 'have it' anytime, we tend to have it less.

Also, both partners in a relationship generally go out to work, with many working extremely long hours. So masses of people are tired, stressed and don't get round to eating properly - they are in a rut.

It does seem likely that loss of libido has as much to do with these factors as it has to do with hormones. So any woman whose sex drive isn't up to much should take a very careful look at her lifestyle.

Here are some tips that should improve the situation.

• Try to add some fresh romance into the relationship and spend quality time together.
• Visualise your partner as he used to look in your early days of dating and allow yourself to feel the excitement you used to feel.
• Exercise your mind sexually by reading erotic books or thinking sexy thoughts - especially on the days you think you might make love
• Assess how much sleep you're getting as fatigue is the biggest enemy of libido.
• If you're tired all the time see your doctor in case you need an iron supplement.
• If you're overweight and very lethargic, see your doctor in case you have an underactive thyroid.
• If your diet is composed of rushed sandwiches and processed foods, buy a book on nutrition and re-think what you are fuelling your body with.
• If nutrition seems likely to be at least part of your problem, consider contacting the Natural Health Advisory Service – formerly knows as the Women's Nutritional Advisory Service.

Many sex experts trying to deal with loss of libido believe that hidden hostility towards the partner has a great deal to do with a lack of sex drive.

Often when a woman is blaming her hormones for her lack of desire, closer inspection of the relationship reveals all sorts of stresses, strains and anger. If such a woman is fed up because her man is never romantic to her, or never takes her out, or never thanks her for a beautifully cooked meal, or always expects her to take responsibility for contraception, it's hardly surprising that she doesn't feel like rewarding him in bed. Therefore, she loses interest.

Addressing this kind of problem is much harder than deciding 'it's all to do with hormones'.

We often see patients who come to us because they believe that hormonal problems are at the root of their unsatisfactory love lives. . After some counselling, it's common for us to find that the woman has gone off sex because of some flaw in the relationship. Perhaps the man is too bossy, or overbearing, for example. Sometimes therapy can put this right especially if both the man and the woman can accept that this is in effect a relationship rather than a purely sexual problem.

Occasionally, one or both partners refuse to face up the fact that there is no magic pill to cure their problems and that they need instead to make changes in the relationship – and when that happens, they usually stop coming for therapy.

Of course, there are specific times in a woman's life when she may have most difficulty with lack of desire. For example: after the birth of a child, after a termination, after miscarriage, when suffering from pre-menstrual tension and around the menopause.

After giving birth
Women are told to abstain from penetrative sex after the birth of a child – until they have their full medical check when the baby is about six weeks old. But many women feel a complete lack of desire for sex for several months after that. This is likely to be due to a number of reasons such as fatigue, poor nutrition, anxiety and depression.

It's also because a woman frequently becomes almost obsessed with her child and doesn't seem to have much time for her partner, especially sexually. This is clearly what nature demands. It ensures that the child is well looked after. It also helps to prevent a further pregnancy so that the new baby won't have to share mum with other new siblings too soon.

But is any of this to do with hormones? Many experts think that it is. They particularly attribute postnatal depression to an upset in hormones and tend to believe that the loss of libido is part of that illness. However, no one has yet managed to find any measurable change in blood hormone levels.

Some specialists do offer hormonal help at this time, but it is certainly not freely available all over the country. The best thing to do in this situation is to ask your GP, the practice nurse, or your health visitor what's available on the NHS in your area. There are also a few private clinics that offer hormone treatments.

However, many other doctors, psychiatrists and scientists believe that depression and loss of desire in the postnatal period can best be treated by anti-depressants - whatever its cause.

When I hear from a depressed young mum, I always put her in touch with the Meet-A-Mum-Association (details below), which is an organisation for women with postnatal depression. They can help by getting you support from other mums who understand what you're going through.

Generally speaking, the loss of libido gradually goes away as the mother gets used to being a mum, and as she grows stronger and less tired. . Men can help by being romantic and kind. The article on postnatal depression covers many aspects of the problem.

After a termination
Is lack of libido a hormonal problem after a termination? Well, it may be - especially in the days immediately following the procedure. After all, one minute you were pregnant - with all sorts of hormonal changes going on - and the next minute you weren't. Again, it's interesting to note that most doctors do not discuss this factor with their patients.

However, longer term, it's much more likely that lack of desire following a termination is more closely bound up with guilt and grief.

Nowadays, women frequently expect to sail through a termination believing that everything will be OK and that it's 'a woman's right to choose'. Some women in fact do sail through the experience. But plenty do not.

I see many women in my own psychotherapy practice who are suffering from depression and loss of desire after a termination, and I find that they recover best when they allow themselves to think about the pregnancy and the life that was once growing within them, and then to devise some kind of ritual for commemorating that life.

Once this process of acknowledgement and grieving has taken place, they tend to get better quite quickly.

For more help with this have a look at my article coping with a termination of pregnancy.

After a miscarriage
As after a termination, after a miscarriage a woman also has to adjust quickly to the fact that she was pregnant, but isn't anymore. This is a big psychological shift. It is also probable that her hormones are very upset at this time. Unfortunately, there's little information available about this.

It is normal after a miscarriage to feel very low and to lose your sex drive, but this is probably because of natural feelings of loss. It can often help to remember your dead baby's life in some way, for example by planting a rose tree or sponsoring a child overseas.

You can find out more by reading the factsheet on miscarriage.

Pre-menstrual syndrome
This is a big problem for many women and most doctors now agree that it is something to do with a woman's sex hormones.

One theory – put forward by the late Dr Katharina Dalton – has been that PMS is connected with progesterone. As we have already seen, this is one of our main sex hormones and we have high levels of it during the second part of our cycle until just before we begin to menstruate.

Some specialists believe that problems occur when the levels of progesterone are not high enough. However there is no consistent alteration in progesterone levels in PMS, and clinical trials have provided conflicting results.

Still, a considerable number of doctors do prescribe progestogens (synthetic forms of progesterone) even though the British National Formulary says that: 'no convincing physiological basis for such treatment has been shown'.

Unfortunately, progesterone itself doesn't work by mouth. . Dr Dalton herself used to prescribe natural progesterone, in the form of rectal suppositories – particularly if there was an element of pre-menstrual tension. They are still (2006) available via the NHS, under the trade name 'Cyclogest'. (Please note that they can have side-effects; do not try them without discussing possible untoward effects with your doctor.)

Confusing, isn't it? Lack of sex drive pre-menstrually is just one of many problems experienced by women with PMS. Incidentally, there is some evidence to show that if a woman does make love at this time - even if her inclination to do so is not strong - then she will actually feel better, because sex brings considerable release from tension.

Earlier I mentioned the role of nutrition in the treatment of loss of desire. And when it comes to loss of desire pre-menstrually there is now an increasing amount of help and advice on offer in the alternative sector.

Many health food shops can recommend food supplements and minerals that improve the condition. And the Natural Health Advisory Service (formerly known as the Women's Nutritional Advisory Service, or WNAS, claims success in treating PMS. By doing so, they found, almost by accident, that they were vastly improving women's levels of sexual desire, too. Their belief is that today's woman is simply not taking in the nutrients that she requires, and that this has a bad effect on the woman's hormones. They educate the woman about nutrition and claim a very high success rate. It should be noted however that this is not a free service. Full details of this organisation's charges can be found on the website - see the end of this factsheet for more information.

A word here about phytoestrogens (natural plant oestrogens). These are nothing new, but there has recently been a real surge of interest in them, particularly in relation to menopausal women. However, it may be that changing your diet to include more natural plant oestrogens could help your general health and sex drive prior to the menopause. Although, as we have seen, some experts think that PMS occurs because of insufficient progesterone, some women have found that by taking plant oestrogens, like red clover, they have experienced a reduction in PMS symptoms.

Does this mean then that PMS might not be caused by a lack of progesterone and could instead be something to do with oestrogen levels dropping too far before the period? No one seems to know.

Menopause
By the time you reach the menopause, there is a lot more information available about your hormones. However, much of it is unclear and conflicting. And, as I have already said, doctors are much keener to try to prevent bone loss or heart disease than to discuss whether or not our sex drives have failed.

A complicating factor is the question of side-effects of hormone replacement therapy (HRT). During the period 2002 to 2005, it became clear that the risks of HRT were considerably greater than we had been led to believe.

What about sex? When HRT first came on the market there was a lot of nonsense written about its sexy qualities. Nowadays experts play this aspect down. They tend to say that HRT makes a woman feel much healthier and more energetic and that her sex drive increases because of that.

Many menopausal women are now also experimenting with a diet rich in plant oestrogens and are taking food supplements like soya or red clover. One of the benefits of these dietary changes is that the vagina becomes much more moist. And though a dry vagina is not in itself indicative of loss of sex drive, it certainly makes sex uncomfortable and as a consequence a woman may turn against sex and lose interest in it.

The use of natural oestrogens in this country is in its infancy, but many women are claiming to feel various benefits from changing their diets to include them.

However, please note that in 2006 the Royal College of Obstetricians and Gynaecologists issued a report which warned that untoward effects and drug interactions can occur with some widely-used natural preparations for the menopause, notably St John's wort, vitamin E and Black Cohosh.

Conclusion
So, is loss of sex drive a hormonal problem?

Well, the jury is still out on that one – though you can expect to be exposed soon to a barrage of publicity about how testosterone can 'cure your lack of libido.' One thing is clear; there are a number of ways that this widespread difficulty can be improved - and I hope that having read all this information you will find some ways that you feel you can tackle the problem

Further information
Meet-a-Mum Association - an organisation for women with postnatal depression.

The Menopause Amarant Trust - an organisation for women who need help while going through the menopause, and advice about various hormonal options. Tel. 01293 413 000.

The Natural Health Advisory Service ( formerly the Women's Nutritional Advisory Service. Tel. 01273 487366. Website: www.naturalhealthas.com.