feet_facingFinally the kids are grown and the house is empty— you can have sex whenever you want it, wherever you want…  but you no longer want it. What’s that all about?

As I mentioned before, female-initiated sexual encounters peak around ovulation and new relationships, so what’s a girl to do when she has neither of those anymore?  The first thing she needs to remember is that women are DIFFERENT from men. Sexologist Alfred Kinsey described the male sexual response as a linear equation: desire leads to arousal, then to plateau, and finally to orgasm and satisfaction. But Kinsey never studied women, and if he had, he would have found that they are very different sexual beings.

The female sexual response is a complicated and dynamic process that is influenced by physiologic, psychological, sociocultural, and interpersonal factors. Rosemary Basson, M.D., director of the University of British Columbia Sexual Medicine Program, has put forth an alternative, intimacy-based model in which complex factors motivate women to actively seek sexual stimuli and/or are receptive to the sexual advances of their partners, and then they experience responsive desire and arousal until satisfaction is attained. In other words, women respond in a circular fashion— desire leads as much to arousal as arousal leads to desire. This means we can either forego sex because the natural instincts for desire have lessened or we can listen to our bodies and decide that sex is exactly what we want and need!

Additionally, women are intelligent beings with a strong frontal lobe (for thinking) AND a strong hippocampus/amygdala (for emotions). We certainly know that sex feels good. We also know that sex can create greater closeness between two individuals. We love to be loved, and we enjoy giving love, too. In our busy, complicated, modern lives, the key to have a fulfilling sex life is to make the space to connect, relax, and enjoy time spent with your partner. And it is very important to candidly discuss your changing sexual needs and desires.

I often hear from women in midlife that they have no sex drive. I always advise my patients that instead of raising a white flag, they should fight for a sex life with their partner that will help change that dynamic. It’s a joint decision, not a unilateral one. How much sex a couple has together has to be agreed upon. Some couples even schedule sex; for example, Monday-Wednesday-Friday, weekends only, during vacations only, and even every day … the point is to make an agreement that works for both partners.  Discuss ways to enhance your sex life, including trying lubricant and sex toys or changing the patterns of your normal sexual engagement. The point is to work with your partner to figure out how to have a more fulfilling intimate life.

Hormones may play a role in diminished sex for women as well. The reproductive hormones estrogen, testosterone, and even progesterone all increase desire. Oxytocin has a beneficial effect on orgasm. Lack of estrogen after menopause can be associated with painful sex, inadequate lubrication, thinning vaginal mucosa, and a narrowed vagina, as well as increased vaginal pH with associated increased risk of infections. Low estrogen has also been associated with reduced sensory perception, including vibratory sensation, diminished peripheral blood flow (required for the arousal response), and altered ability to develop pelvic floor-muscle tension (required to have an orgasm). Androgens (testosterone and DHEA) have also been looked at for their effect on sexual response. Losing the ovaries surgically, which may lead to a significant decline in testosterone levels, can also negatively affect sexual response. In numerous studies, however, scientists have not been able to prove direct correlations between testosterone levels and sexual dysfunction. Among all the androgens studied, only DHEA (which can be converted to testosterone) showed a weak correlation with sexual desire in the aging woman.

Neurotransmitters may also affect the sexual response. The neurotransmitter serotonin has a negative effect on sexual desire and downstream arousal. Dopamine increases desire and subjective excitement. Norepinephrine increases sexual excitement and orgasm. This explains why depression, as well as treatments for depression, can affect sexual response.

The following medical issues and medications can lead to sexual dysfunction:

MEDICAL ISSUES

  • Depression: Decreased desire
  • Diabetes: Impaired arousal and orgasm
  • Thyroid disease: Decreased desire
  • Cardiovascular disease: Impaired arousal
  • Neurologic disease: Impaired arousal and orgasm
  • Androgen insufficiency: Decreased desire
  • Estrogen deficiency: Impaired arousal

MEDICATIONS

Psychotropic medications

  • Antiepileptic drugs
  • Antipsychotic medications
  • Benzodiazepines
  • Monoamine oxidase inhibitors
  • Selective serotonin reuptake inhibitors (SSRIs) & Serotonin-neurotransmitter reuptake inhibitors
  • Tricyclic antidepressants

Antihypertensives

  • Alpha-blockers
  • Beta-blockers
  • Diuretics

Cardiovascular medications

  • Digoxin
  • Lipid-lowering agents

Hormones

  • Antiandrogens
  • Estrogens
  • Gonadotropin-releasing hormone agonists
  • Oral contraceptives
  • Progestins

Other

  • Amphetamines
  • Histamine H2-receptor blockers
  • Narcotics

(Source: Modified from Basson R, Schultz WW8; Kingsberg SA, Janata JW.)

Sex can be a lot of things to individuals but it is often about stress reduction and a release of tension. It is about love. It is about caring. It is about being loved, and loving. It is about being vulnerable and respecting that your partner is also vulnerable. It is about pleasure, both giving and receiving.  As you age and things change, communication is essential. Talk to your partner, and consider talking to your doctor or therapist if you need additional help getting your sex life back on track.