Exploring Women's Sexual Desire: From Myths to Medical Insights

What Happened to My Sexual Desire?

This is the most common question I hear in sexual medicine. And no, you are not broken.

We have been told so much misinformation and lies about sexual desire in women, it's no wonder many of us feel like we aren't measuring up. Expectations are high and unreasonable. We are supposed to thrive at work, effortlessly take care of our families, keep ourselves healthy and fit, sacrifice our mental well-being for others, function on little sleep, and still not only be magically eager for sexual activity but initiate it.

Many women feel that their sexual desire isn't normal because it doesn't fit the ideal they've bought into, doesn't match what their friends experience, or differs from what their partner experiences.

Despite all the noise around women's sexual desire, there is a legitimate medical condition called hypoactive sexual desire disorder or HSDD. HSDD can be addressed with a knowledgeable healthcare provider. Treating HSDD is not telling someone to relax, have a glass of wine, or go on a date night.

Set Yourself Up with Facts

Sexual desire is the positive anticipation of sexual activity. It is not the liking or the turned-on part, which is sexual arousal. Sexual desire is the wanting part of how our sexual response unfolds. Sexual desire can show up before sexual arousal, or after as the wanting of something to continue or intensify.

There are two normal and healthy ways for us to experience sexual desire. The most common is not actually what we have been told or thought sexual desire is supposed to be. It is called responsive sexual desire. Responsive desire occurs when we create conditions that are sex-positive and sex-facilitating. Lowering our stress level, getting enough sleep, sharing the mental and physical load of taking care of our home and, feeling good in our skin, or just sending the kids to grandparents. Responsive desire is primarily what we experience in long-term relationships.

Spontaneous sexual desire is that seemingly effortless pixy dust that shows up when we see an attractive person, our partner comes home after an absence, or when binging on Netflix. It feels easy and something we don't have to work for. Spontaneous desire is more frequent in new relationships and is not something most of us can reliably count on for the long haul. In fact, only about 15% of women exclusively experience spontaneous desire.

Responsive and spontaneous desire are both normal.

Desire discrepancy is when our level of sexual interest is different from our partner(s). This is the most common challenge that brings couples to sex therapy. Having a higher or lower frequency of desire from a partner does not mean either's level of desire is abnormal, it's just different. Desire discrepancy can create tension and strain on a relationship so it's important to intentionally cultivate conditions conducive to sexual desire and build communication skills.

Where Does Sexual Desire Come From?

There are chemical messengers, called neurotransmitters, that regulate sexual desire in our brains. Think of these as being our sexual accelerator and sexual brakes. Neurotransmitters that facilitate sexual desire include dopamine, melanocortin, oxytocin, and norepinephrine. The neurotransmitters that inhibit sexual desire include opioids, serotonin, and prolactin.

Although this delicate balance of facilitating and inhibiting sexual desire is not completely understood, it is believed that hypoactive sexual desire disorder occurs when there is a predisposition towards inhibition, meaning the sexual brake is more active than the sexual accelerator. Too much brake, not enough gas.

Do You Have Hypoactive Sexual Desire Disorder (HSDD)?

HSDD is the persistent and recurrent lack of interest in sexual activity. It can happen after a period of satisfying sexual desire (acquired) or be lifelong. HSDD may also be generalized (present in all situations) or in specific circumstances (situational). It is important to understand the different types of HSDD because we address these with different recommendations and strategies.

Generalized, acquired hypoactive sexual desire disorder is most responsive to medical interventions like medications.

Ask yourself the following questions to see if you might be experiencing generalized, acquired HSDD:

1. In the past, was your level of sexual desire or interest good and satisfying to you?
2. Has there been a decrease in your level of sexual desire or interest?
3. Are you bothered by your decreased level of sexual desire or interest?
4. Would you like your level of sexual desire or interest to increase?

A knowledgeable and experienced sexual medicine specialist can further evaluate your sexual desire challenge by asking about your medical history, the medications you take, pregnancy or recent childbirth, whether you are in perimenopause or post-menopause, your partner's sexual functioning, mood disorders, stress, and other aspects. While usually unnecessary, a physical exam or laboratory tests may be included.

HSDD Treatment

The cornerstone of all treatments for sexual problems, low desire included, is education. Few of us received accurate and healthy sex education. We may not understand how desire, arousal, and orgasm unfold for us individually. We may not recognize what factors are disruptive to our sexual desire. We may not have the words or the skills to communicate with our partner(s).

The next step is to address any underlying medical issues and stressors by optimizing those to the best of our ability.

Psychological interventions can be extremely effective. These can include sex therapy, individual or couple's therapy, stress-reducing strategies, and at home practices focusing on building intimacy, connection, and physical touch skills.

Medication therapy can complement other interventions. This is the focus of sexual medicine. There are currently three medications most commonly prescribed as first-line treatment for generalized, acquired HSDD. Other medications may sometimes be considered second-line therapy but are typically less effective.

Flibanserin (Addyi) was the first FDA approved medication for generalized, acquired HSDD. It is an oral pill taken daily. It works by influencing those brain neurotransmitters and facilitating the sexual accelerator. Flibanserin may be more effective in those who have SSRI antidepressant induced sexual dysfunction. While not a magic bullet, flibanserin can be quite effective for some women. Unfortunately, it is not always covered by insurance and can be expensive.

Bremelanotide (Vylessi) is an FDA approved self-injection that is used on demand when someone wants to facilitate their sexual desire. It comes in a pre-filled syringe and is injected subcutaneously in the thigh about 45 minutes before desired sexual activity. Like flibanserin, it is believed to be effective by targeting sexual neurotransmitters in the brain. It has similar effectiveness rates to flibanserin. Insurance coverage is limited, and the medication can be expensive.

Testosterone can be used off-label for HSDD and has research supporting its effectiveness, especially in post-menopausal women. It is typically applied topically, using small doses of gel formulations frequently used in men. Despite not being a FDA approved medication for women, testosterone can be effectively and safely prescribed by a knowledgeable provider who understands how to monitor treatment. Testosterone is less expensive than flibanserin and bremelanotide even without insurance coverage.

Where to Find Treatment

Some primary care and gynecology providers are specially trained and experienced in treating HSDD. If not, your provider may be able to suggest a sexual medicine specialist.

CentraCare offers sexual medicine services to women and men. Our sexual medicine providers have been specifically trained in managing sexual problems and have years of experience.