Hypoactive Sexual Desire Disorder (HSDD) is a deficiency or absence of sexual fantasies and desire for sexual activity. It is the diagnostic term for what we commonly know as low desire or low libido or just plain “not wanting to have sex”. There is so much press around HSDD as physicians, sexual health specialists, sex therapists and pharmaceutical companies debate the balance between physiological and psychological sources of low desire.

What causes Low Desire?

There may be any number of reasons why you have no sex drive, some of those may be physiological (that is, physical) and some of those may be psychological and often those two things may be affected by each other.

The physical factors often include hormone insufficiencies since hormones are a critical component of normal sexual response. Low levels of testosterone related hormones, estrogens and DHEA-S (most commonly associated with post-menopausal women) can have a significant impact on a woman’s sex drive. Even younger women may have low hormone levels and which results in a surprising and disappointing lack of desire for sex and intimacy.

Sometimes people are skeptical. How can hormones really matter that much? Especially when it comes to sex, people are very quick to say, “Oh, that’s ridiculous. It’s all about the relationship,” or, “it’s all about the person’s confidence.”

When kids go through adolescence we expect that they will all of a sudden have an interest in sex. After all they are “going through puberty.” What exactly is puberty? It’s an increase in those hormones that make you interested in sex! What about our natural response when we see a 16-year-old boy ogling a girl? Our first reaction is to be amused, assuming that his “hormones are raging.” In so many ways, we acknowledge that in teens, hormones are the engine that powers the sex drive.

But somehow, as soon as it comes to understanding the adult male and certainly female libido, we change our tune. Now it’s all about relationships, conversations, sexy underwear. Maybe it’s time we rethink the issue and accept that yes, hormones play a very significant role in our sex life. And not just in our teens but throughout our entire adult life.

Understanding the hormone balance is complicated and a very new area for most physicians. Therefore a woman who complains of no sex drive will require a full battery of blood tests run under the supervision of a physician who specializes in the area of female sexual dysfunction.

Other culprits might be the medications you are taking for other things. Certain antidepressants are known to reduce libido. Birth control pills can also throw off the balance of hormones and create a lack of sexual desire.

Psychological factors can be varied and complex. They may include a history of physical or sexual abuse, or simpler issues about body awareness and acceptance.

They may involve a woman’s own feelings about her body and sex, those sources in her religious or cultural environment, and they may also involve her partner’s feelings about her body and sex.

We also observe in our practice that spontaneous desire may be rarer for women than we originally believed it to be. It may actually be necessary for women to access or arrange the conditions conducive to desire and arousal; to deliberately provide for themselves by accessing those things that “turn them on”.

How is Low Desire treated?

We strongly advocate for an integrated approach to addressing women’s sexual desire and believe that there is no “magic bullet.” We know that a practical application of physiological testing and treatment in tandem with the psychosexual assessment, diagnosis and counseling work best. Treatments might include:

  • Hormones: We think of hormones as the “base coat paint” for sexual functioning. If women’s levels are absent or too low, often nothing sexual seems to work. Generally, treatment starts with testing current levels of Testosterone, Estrogen, SHBG –s as well as Prolactin. We want to discount any other conditions that may be causing the low desire. We will often treat with testosterone or estrogen therapy. This can take the form of topical treatments, patches, pumps, or pellets inserted into the buttocks.
  • Other Medications: We may suggest drugs that help with blood flow like Viagra, Levitra or Cialis. We might add in medications that help with neurotransmitters in the brain such as Flibanserin (or Addyi), which was recently approved by the FDA. We may recommend Oxytocin or another anti-depressant.
  • Devices: We may recommend a particular product or vibrator and explain exactly why we are recommending its use.
  • Counseling: This is a critical part of the work we do. Too many physicians give women testosterone and send them home. We work with women closely to gauge the impact of the testosterone on desire. We will only begin to give women practical suggestions, exercises and “homework” when we feel that the testosterone is beginning to work in their body and their interest has improved to the point where they can be successful.
My desire took a nose dive after the birth of my child. Is that common?

Pregnancy and lactation can wreak havoc with a woman’s hormone levels and they may not return to pre-pregnancy levels for a long time after the birth of a child, if ever. Hormones are a critical component of normal sexual response. Low levels of testosterone-related hormones, estrogens and DHEA-S can contribute significantly to a woman’s low sex drive.

Both vaginal deliveries and C-sections can put stress on different parts of the woman’s body by damaging nerves, stretching muscles or just causing irritation. Some of these symptoms may go away after some time; others may not.

The addition of children into a couple’s marriage and sex life is a complicated mix of joy and stress. Though often delighted at the birth of a child, women and couples are often not prepared for the additional stress a child puts on the body and the relationship. A complicated mix of psychological and physiological components often result in a woman who, although quite interested in sex prior to bearing children, experiences a low drive for sex after childbirth.

Psychological factors may also include exhaustion. (You can’t minimize the impact of being tired on your libido.) You may also want to explore changing feelings towards your body, how it may look and feel different since becoming a parent. Also, there may be changed feelings about your own sexuality now that you are a mother and you and your husband are no longer only a couple but parents as well.

With parenthood, often the ideal of “spontaneous” sexual desire gives way to the reality that parents may have to create sexual opportunities for themselves.

The enormous life change that parents experience from the birth of a child often does not allow them to make the time or space in their lives for those experiences or situations which would allow them to feel sexy. This reality can be upsetting to both parties until other avenues for sexual satisfaction take the place of the spontaneous rendezvous. In situations where a woman is unhappy with her sex life, an integrated approach that deals with both physical and psychological factors after childbirth will be the most successful.

As I've aged, my interest in sex has seemed to diminish. Can you tell me why?

It is not uncommon to hear women talk of experiencing low sex drive as they get older. For some women this is a perfectly acceptable development; for others it is a quality-of-life issue that they would like to address.

The physical factors may often include hormone insufficiencies. Hormones are a critical component of normal sexual response. Low levels of testosterone-related hormones, DHEA-S and estrogens are often associated with peri-menopausal and post-menopausal women.

Understanding the hormone balance is complicated and a very new area for most physicians. Therefore, a woman who complains of a low sex drive should have a full battery of blood tests run under the supervision of a physician who specializes in the area of female sexual dysfunction.

Additionally, changes in hormone level can have significant impact on lubrication, which can adversely affect sensation and pleasure during intercourse. This can have both a direct and indirect effect on a women’s sex drive.

The medications you may be taking can also be affecting your level of sexual desire, particularly if you are taking anti-depressants or drugs for other conditions.

On a psychological level, a woman may want to explore her feelings about her changing body and her changing life. Although menopause can be a time of freedom and exploration for a woman and her partner, it can also be a time that includes feelings of loss. These issues can all affect a woman’s sex drive.

As in most situations where a woman is unhappy with her sex life, an approach that deals with both physical and psychological factors will be the most successful.

Sexual Desire Inventory

The Sexual Desire Inventory is a questionnaire that asks about your level of sexual desire in cognitive terms, as opposed to previous measures that used predominantly behavioral methods. By desire, we mean interest in or wish for sexual activity. Originally published by I. P. Spector, M. P. Carey and L. Steinberg, the Sexual Desire Inventory is a brief 13-item scale with a possible score range from 0 to 101. Your score may indicate you’re suffering from low desire, a condition that may be helped by contacting a practitioner who specializes in the medical diagnosis and treatment of female sexual dysfunction.