Why Is My Libido Low? Understanding Sexual Desire and The Connections to Menopause and Stress

So many couples find themselves feeling disconnected from each other, especially after high-stress seasons like the holidays or from the ongoing demands of caregiving or their careers. Being out of sync sexually can make your relationship feel strained, as bonding emotionally and physically with the person we love most is fundamentally healing. Unfortunately, the busy nature of modern life can make it difficult to prioritize intimacy, and a lack of desire often leads to feelings of inadequacy and tension for both partners. You may feel exhausted from the mental load of "doing it all"— working, shopping, carpooling, and caretaking— leaving no energy left for the bedroom. Unfortunately, going through menopause certainly doesn’t help things and there are a few reasons why this period of hormonal change can make one’s libido decline. 

If you’re in perimenopause or menopause and your sex drive is low, or non-existent, it is important to: first, give yourself a break; second, educate yourself to better understand why this is happening to you; and last, don’t be afraid to seek professional help. 

Also, please know, you are not alone! 

What causes low libido during menopause?

During menopause transition both lower estrogen levels, which can cause physical discomfort, vasomotor symptoms and sleep-disruptions, and declining testosterone, which is a key hormone for the drive centers of the brain, can contribute to low libido. Additionally, any chronic stress can trigger a "survival response" in the brain, which deprioritizes sexual desire in order to conserve energy for perceived threats or protect oneself from exhaustion.

Why is low libido so common in menopause?

Low sexual desire is a common concern, especially during the menopause transition. Research shows that low sexual desire affects approximately 26.7% before menopause and 52.4% after menopause. The prevalence of Hypoactive Sexual Desire Disorder (HSDD)—defined as low desire lasting over six months that causes personal distress with no clear external cause—is highest in those with surgical menopause (1). HSDD is defined as having low desire that lasts for over 6 months, that causes personal distress and has no clear cause. 

Understanding "Receptive Desire" 

Low sexual desire can sometimes simply be the result of a common change in our sexual response over time to what is called “receptive desire”. With receptive desire you may stop fantasizing about or initiating sex, but when a partner initiates sex, you respond with normal arousal initially and often secondary desire follows. However, even knowing this is a normal variation or adjustment in libido  as we age, it can still cause distress for you and if that is the case, it’s important to address.

Identifying the Root Causes of Low Libido 

I remember another sexual health expert I heard from many years ago discussing the difference between the sexes and sexual desire. They said, for biological men, sexual desire is like a light switch and can quickly go from on to off to on again. Whereas for biological women, desire is more like an old-timey Ham radio with multiple dials that all must be lined up to be just right for reception. That made me chuckle at the time as yes, as a doctor taking a history for a patient with low libido, it can sometimes seem very complicated when you consider the many different medical and psychosocial reasons for one’s sex drive to be inhibited. Things like:

• Psychological/Relationship Issues: Past trauma or current partnership tension.

• Medical Conditions & Medications: Depression, certain antidepressants (SSRIs), birth control pills, anti-androgens, and anti-hypertensives.

• Menopause Symptoms: Sleep disturbances, night sweats, hot flashes, weight gain, and mood swings.

• Physical Pain: Discomfort during sexual activity.

These factors are important to know about as you can do something about them!

Caring for Your Physical and Mental Health Can Improve Your Sex Drive

To improve your sex drive, you must first address your baseline health. Think about things you can work on with your medical doctor or a therapist-- Are you dealing with any health issues you need to focus and improve on to start? Are you on medications that might need to be discontinued or changed?  Or do you need to work on any past trauma or psychological issues  or improve any relationship issues with a marriage or sex therapist? 

Treating Menopause Symptoms Can Improve Your Sex Drive

Second, treat any sleep disruptions and vasomotor symptoms with either hormonal or non-hormonal medications. These can help you feel physically better overall and rest your sleep deprived brain which helps some in menopause feel more energized with a spontaneous return of interest in sex. Treating these common symptoms can also help mitigate the metabolic changes that happen in menopause transition that lead to weight gain and just feeling uncomfortable in your own skin. Feeling uncertain about your appearance or not having control over your changing body, can be very disconcerting and add to a lack of confidence with and avoidance of sexual encounters.

Treating Genital Pain and Genitourinary Syndrome of Menopause (GSM) and Improving Orgasm Can Improve Your Sex Drive

It is crucial to treat any physical discomfort. If you experience vaginal dryness, decreased lubrication, or pain with touch/penetration and are not on hormones while in menopause, you likely have Genitourinary Syndrome of Menopause (GSM).

With a GSM diagnosis, it is vital to support the atrophic vaginal, vulvar, and clitoral tissue. While systemic hormone therapy helps, it rarely treats the genital tissues as effectively as:

• Lubricants and moisturizers:  to provide both immediate and long term friction relief.

• Local Hormone Therapy: to rebuild tissue health using vaginal estradiol or DHEA.

• Topical Vasodilators: to increase blood flow when there is clitoral and vulvar atrophy, using topical creams, such as Alloy’s O’mazing cream, which when applied right before sex can improve arousal, lubrication and orgasmic response creating  a pleasurable "positive feedback loop" to the brain of endorphins and oxytocin, a bonding hormone.

Keep in mind recovery can take some time if there’s been long standing loss of hormone support or contributing dermatologic or health conditions, like diabetes or hypertension,  limiting good blood flow.  I will address some causes of and treatments for sexual and vulvar pain more comprehensively in a future blog. 

The Brain-Body Connection: Survival vs. Desire

Last, there is a very important factor to consider: stress. After all, your most important sex organ is your brain and a very primary role of our brain is to help us survive. I like to say: "Sex is important for our species' survival, but not for our individual survival." When your brain feels overtaxed or unsafe, it shuts down non-essential activities—like sex—to conserve energy. Additionally, for biological women, our brains are still wired like our ancestors to avoid reproduction when we are under duress. Stress hormones can shut down the hypothalamic-pituitary-ovarian axis, dropping estrogen levels, which reduces both ovulation and the sex drive. This protective mechanism kicks in whether the stress is a "famine" or modern-day stressors like caring for sick parents, a toxic workplace, or financial worries.

A Path to Recovery

With all this in mind, I’d like to remind any of you dealing with low libido, to please give yourself a break and to not think there is something wrong with you. This is a biological neuro-hormonal response that is out of your control. Your sex drive is like your appetite -- you have hunger or you don't. The brain is too powerful when it comes to survival-based responses and will override your hopes and wishes for having a desire for sex when it comes to the self-preservation reflex. Sometimes, our brains will even go to the extreme of causing feelings of aversion to protect us! And just like you can't will yourself to feel hunger, as that is a physiologic set of signals that informs your brain to have a craving to eat and makes your stomach growl; you also can't will yourself to desire sex or lubricate naturally if your brain has shut that drive center down due to those circulating neuro-hormones due to stress or pain … no matter how amazing a relationship and in love you are with your partner and no matter how much you loved having sex in the past. 

So, in those menopause transition years, getting on hormone therapy or any other treatments that reduce your body’s feeling of being “off” balance from the symptoms and improves your sleep, decrease discomfort with sexual activity and enhance your sexual responses, are going to reduce the stress on your body and allow your brain to sense that you are safe and that you have enough energy to engage in this highly physical and cognitive activity called sex. Once that reset happens, which can take some time, the libido switch – or dials –  can often get turned back on without other medications needed.

However, if you are still not feeling normal interest in sex after all these other things have been addressed, then you may have a condition called hypoactive sexual desire disorder (HSDD) and are at a point where prescription medications should be offered. Both flibanserin and bremelanotide are the two FDA approved medications for HSDD and “off label” bupropion and testosterone can be considered for treatment. While Alloy physicians do not prescribe medications to treat HSDD, we do support your use and recommend consultation with a sexual health expert in your area, located by searching on the ISSWSH.org website. In the meantime, I hope you found this information helpful in some way for your understanding of this very common condition, low libido, that so many of us experience in our lives, especially during menopause transition! Here’s to a New Year with happiness and healthy sex drives for all ! 

Frequently Asked Questions: Menopause and Libido

1. Is it normal to lose your sex drive during menopause?

Yes. Over 50% of those in menopause  report a decline in sexual desire. This increase is connected to the drop in estrogen and testosterone, which can lead to physical discomfort and sleep disruptions  making it difficult for the body to transition out of a stress-response state and into a state of desire.

2. Can hormone therapy help increase my libido?

Menopausal hormone therapy (MHT) can be highly effective for increasing libido by addressing the root causes of low desire. By treating vasomotor symptoms, disrupted sleep and pain with intercourse, MHT reduces the physical stressors that triggerr the brain to shut down sexual interest.

3. What is the difference between low libido and HSDD?

While low libido can be temporary or situational and not always be distressing to the individual, Hypoactive Sexual Desire Disorder (HSDD) is a clinical diagnosis. It is defined as a persistent lack of sexual interest lasting six months or more that causes the individual significant personal distress.

4. Does vaginal estrogen help with orgasms?

Yes. Localized vaginal estrogen or  DHEA can help restore tissue health and improve blood flow to the vulva and clitoris. When combined with vasodilators like Alloy’s O’mazing cream, it can improve sensitivity and clitoral responsiveness, making orgasms more attainable and pleasurable.

5. Why does stress affect women's sex drives more than men's?

A biological woman’s  brain is wired to prioritize survival and safety. Under high stress (high cortisol), the brain sends signals to the body to deprioritize and halt "non-essential" functions like reproduction and the sex drive. This "survival reflex" can override even a healthy, loving relationship until the body feels safe and rested again.

Sources:

1. West SL, et al. Prevalence of Low Sexual Desire and Hypoactive Sexual Desire Disorder in a Nationally Representative Sample of US Women. Arch Intern Med. 2008;168(13):1441–1449.