Your Libido in Perimenopause

By Suzanne Fenske, MD, FACOG, ABOIM, MSCP

Your libido changes throughout life phases, and perimenopause can be a significant transition affecting so many aspects of life for many women. If you’re in your 40s or 50s and noticed your desire has tanked, perimenopause can be one factor, and it’s time to discuss sexual wellness with your TārāMD provider.

Today’s article will dive into your midlife libido questions, offering guidance and next steps. Keep reading as we explore:

• What is libido?
• Perimenopause and midlife libido changes – what does the science say about hormones and libido?
• Female libido supplements – fancy marketing or evidence-based?
• What’s an integrative approach to libido issues?

Defining Libido and Low Libido

Your libido is your sexual desire and interest in sexual expression. Libido stems from the brain; it’s the motivation to seek or respond to a sexual experience.

A woman’s desire can be spontaneous, arising from thin air, or more commonly, responsive, responding to a sexual experience. Interestingly, genital arousal does not always correlate with desire.

When post-menopausal women are asked about desire:

• 94% report experiencing arousal
• 24% report never feeling desire
• 41% infrequently feel desire
• 13% report sex is not very important to them

Your libido, and whether it’s at a healthy level, has to do with your feelings about desire. You only have a low libido when you feel it’s low, and it’s only a problem if you feel it’s a problem. Your libido is unique to you and doesn’t need to fit into a specific box. What a relief!

Midlife Hormones and Libido Changes

Perimenopausal hormone changes may influence libido. More commonly, women report a significant decline in libido, especially during late perimenopause. It’s important also to note that some women experience an increased libido in midlife.

In perimenopause, the brain-ovary communication begins to break down, and estrogen levels often fluctuate more wildly, with higher highs and lower lows. In later perimenopause, estrogen levels trend lower. As cycles become irregular, progesterone levels are lower, and during cycles without ovulation, there is no progesterone at all. In the background, testosterone slowly declines with age.

Understanding the hormonal landscape of perimenopause helps us understand libido changes.

Estrogen is involved in sexual motivation and behavior. Higher estrogen levels correlate with higher desire. When estrogen levels fall in later perimenopause and into the post-menopause years, libido may fall along with it. Additionally, low estrogen drives vaginal dryness, discomfort, and pain, which may lead to sex avoidance. Low estrogen may cause hot flashes, poor sleep, depression, fatigue, and other symptoms that interfere with desire.

Testosterone is an important hormone for arousal, and higher testosterone also correlates with higher levels of desire. For post-menopausal women with Hypoactive Sexual Desire Disorder (HSDD), testosterone therapy is a standard treatment.

While we often think of estrogen and testosterone first in terms of libido, other hormones can also play a role. Low progesterone may contribute to poor sleep and anxiety, impacting desire. High cortisol and cortisol dysregulation from stress can lead to low DHEA, which you need to make testosterone. All hormones work in a symphony, and reproductive hormone changes in perimenopause can have cascading effects.

Hormones can play a significant role in libido, but there are often several factors at play. Other root causes of low libido include:

• Stress – stressful circumstances and lower stress tolerance are common in perimenopause
• Sedentary behavior and low exercise levels – increasing exercise can increase desire
• Inflammation – inflammatory conditions increase the risk for sexual dysfunction
• Body image concerns – Body shape composition changes are a feature of perimenopause and aging
• Mental health concerns – does your body feel safe enough to prioritize desire?
• Relationship concerns – relationship issues can show up as low libido. In one study, having a partner was associated with lower desire in women.

Libido Supplements for Women

When your libido is low, it’s easy to want a quick fix with supplements. But there are so many libido supplements on the market, and it’s difficult to know what’s hype and what might be worth trying.

From an integrative perspective, we strive to understand the root cause of each woman’s concerns and address the underlying factors. We often use supplements in our practice and find many options helpful when it’s a good fit for an individual. Here are some supplements with supportive evidence for female libido:

• Maca root – Is a member of the broccoli family and grows in the Andes Mountains. It has a long history of use in herbalism for fertility and vitality. Research suggests it positively affects sexual desire in healthy menopausal women.
• Tribulus terrestris – Is a common medicinal herb around the globe used as an aphrodisiac and for other purposes. Research suggests it supports overall female sexual function, sexual arousal, and orgasm.
• Panax ginseng – Is a native herb to South Asia and well-known for its adaptogenic properties, supporting stress adaptation, energy, and cognition. Research suggests it also improves sexual arousal and desire compared to placebo.
• L-arginine – Is an amino acid involved in the production of nitric oxide, the molecule that dilates blood vessels. Research suggests L-arginine improves sexual function, lubrication, orgasm, and mood in women with depression. L-arginine is often in combination libido products, along with other nutrients and herbs.

An Integrative Approach to Low Libido

We often find low libido has more than one cause. In midlife, we want to comprehensively test hormones to get a picture of the entire hormonal landscape. Additionally, it’s important to address the lifestyle, relationship, and stress pieces that impact desire.

When the primary contributor of low libido is low hormone levels, bioidentical hormone replacement therapy is an option worth considering. Many different options have evidence-based support for libido and sexual function:

• Estrogen
• Estrogen plus progesterone
• Estrogen plus testosterone
• Testosterone only
• Vaginal estrogen

The bottom line is that there isn’t a one-size-fits-all hormone therapy for libido concerns, and there is so much room to personalize the protocol for each woman. This is exactly how we approach BHRT at TārāMD.

There are additional medications to consider, peptide therapy, and oxytocin. We can combine supplements with other therapies when appropriate and address sleep, stress, movement, and other root-cause factors. Our patients also work with our in-house Female Sexuality and Empowerment Coach. The combination of sexual wellness and an integrative OBGYN who’s also a menopause specialist delivers the best care and results to our patients.

An integrative approach to female libido is a whole-body, whole-person approach, and we are thankful to have so many tools in our toolkit. If you aren’t feeling like yourself and you wish you felt more desire in your life, we can help.

References

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