An opinion editorial about the female libido by Dr Megan Ogilvie, ERH Associates Endocrinologist

Around two decades ago, during my training in the United Kingdom, I had the privilege of working with Professor John Monson, a remarkable endocrinologist and an incredibly kind and dedicated person.  He once told me, 

“Ask women about their libido, Megan.  Most women appreciate the opportunity to think about it, and you are likely to be the first doctor to ask”. 

Female libido was not a subject I knew much about back then, and is not something that gets much attention during general medical training.  But Prof Monson’s advice made me think about how to approach this topic and what advice I could offer women when they were brave enough to talk about it during a consultation. And below I’ll share what I’ve learnt about about female desire and libido over the years since then.

Ebb and flow 

Female libido is a complex and delicate thing.  It is often the first thing to change when something is amiss in your life.   Many factors can influence it. It is entirely normal for libido to ebb and flow at different stages of our lives, and this is only a problem if you are concerned about this change and would like something different. Don’t let the world of social media, movies and the internet set unrealistic expectations!   Common times in women’s lives for libido to change include after having children and also over the menopausal transition.   

Libido and hormones during perimenopause

Hormonal changes matter.  In the perimenopause fewer ovulatory cycles mean that there is a loss of the ovulatory rise in testosterone.   An overall decrease in oestrogen levels can cause changes in vaginal tissue integrity and sensation and sexual response of these tissues.  This change can lead to an irritated vagina and uncomfortable sex -and when sex is painful it is no surprise that this negatively  impacts libido.  In addition, changing oestrogen levels can lead to exhaustion and flushes, neither of which tend to feel particularly sexy! 

Thoughts, emotions and libido

But hormones are only one part of the picture.  The brain also plays an important role in the female libido.  A common statement I hear in my clinical practice  is 

“I have no libido.  I could not care if I never had sex anymore, I feel sorry for my husband/partner”.  

When I hear a woman say this, I often wonder if she has given herself the space to consider her own sexual desires, or if she feels that she can voice if she does want sexual pleasure for herself.  The impact of body image on libido is another example of how thoughts can play a role.  Qualified sex therapists have a lot to offer in this space and I frequently recommend this in my clinical practice.   When a woman or couple have been brave enough to attend a session, they often return to tell me that it was excellent and wish they had gone several years earlier.  

I often quote Helen Conaglen – a sex therapist from the Waikato who has now, unfortunately, retired.  

“Every two years have an affair with your partner”. 

I think this is wonderful advice to reframe your approach.   Imagine what you would do if you were having an affair, and then spend the next few months incorporating those actions into your relationship -bring the spark back.      

These are all things to ponder before you reach for testosterone replacement.  As reproductive endocrinologists here at ERH Associates, we sometimes prescribe testosterone cream for women who have low libido and are perimenopausal or menopausal or who have had surgical removal of the ovaries or in the context of pituitary disease. Testosterone cream in this context is typically added as an adjunct to standard MHT (menopausal hormone therapy).  

It is worth noting that testosterone supplementation doesn’t always increase the libido.  In scientific studies, testosterone replacement has been shown to improve libido for about 60% of women.   I really want the women for whom I prescribe testosterone to gain benefit from it, and this is why we need to consider the whole picture – not just the hormone levels.   

For many peri-menopausal women, using MHT and testosterone supplementation will open the door to desire, but you have to be prepared to walk through that door and create space in your life to do so.

If you are interested in diving deeper, there are some helpful resources available:

•   “Where did my libido go?” by Rosie King who is an Australian sex therapist, is a great place to start
• The book “Come as you are” by Emily Nagoski is also well worth a read
• The “Good Sex” podcast are a series of interesting “bare-all” discussions about what makes healthy, happy, confident sex for consenting adults 
• Esther Perel is a Belgian sex therapist who has done podcasts, TED talks and also has valuable insights in this area
• We also cover libido and sexual function in our own App-based course about menopause coming soon: find out more here.