Sexual Desire and Sexual Response in the Hormone Jungle and Hormone Desert Oasis

Trish Morse
(Ph.D. in literature, University of Chicago, editor of biological science journals)

This is a report from the front lines of research where just the first shots have been fired. They had to hold a conference in 2000 to pin down the terms they might use to begin discussing female sexual dysfunction. (47) So, they really don't know for certain how to help. So, what follows is really a sketchy map of possibilities, not well-worn paths out of this particular thicket.

So far, what the medical researchers know is based on inference, animal studies, and observation of women (including their own reports). With men, they can measure erections. With women, they don't have a standard test for what works or not. They haven't even done controlled studies of testosterone use in women, let alone of the alternatives.(3) So, take the suggestions in this article with a large grain of salt!

In surgical menopause there seem to be two sources of difficulty: lack of hormones, especially testosterone, and problems with the blood supply and nerves in the pelvis. From a biologist's point of view, sexual desire is different from sexual arousal, so some things that help blood flow will help sexual response, but won't do anything for sexual desire. (13)

Problems with Arousal

The first phase of sexual response starts in the brain with the neurotransmitters. They send a message down the nerves that relaxes the blood vessels that lead to the pelvis and start swelling the vagina, begin vaginal lubrication, and send blood to swell the clitoris. So one of the approaches to helping response is to help blood flow. Clogged blood vessels obviously cause problems, decreasing sensation and arousal, so ways can be found to increase blood flow. Nerve damage to the area is something to discuss with your doctor.

Loss of Libido

Sexual response is to some extent a matter of plumbing, but libido is a complex interaction of many problems, many of which are subjective. It's well-known that depression, anxiety, and chronic stress interfere with both sexual desire and sexual response.(13) And then there's the question of whether the problem is with a particular partner, where anger or fear of rejection shut down a response, or whether masturbation and general sexual thoughts and fantasies are affected too. (16) Of course, acute and chronic health problems, alcohol, drugs, strokes, arthritis, renal disease, diabetes, and others have direct effects on neurotransmitters, energy, blood circulation, and one's sense of being attractive (7, 16, 29). Virtually any illness can affect sexual desire but so can a lot the drugs that deal with illnesses and conditions. Drugs that fight high blood pressure, antipsychotic drugs, antineoplastic drugs, SSRI antidepressants, tranquilizers, diuretics, and antihistamines can all stop libido cold, as can anti-inflammatories and some ulcer medications.(7, 16, 36) And the drugs and surgery involved in cardiac bypass operations, organ transplant, radiation therapy, and chemotherapy will cause problems.(16) Most of all, the mind is the largest sex organ&emdash;so loss of self-esteem and other emotional problems can take a heavy toll.

Menopause

Dropping hormones cause serious changes in sexual response: decreased incidence of skin flush, decreased muscular tension, decreased breast response (nipple erection and swelling), delay in reaction time of clitoris, delay or absence of lubrication, decreased vaginal expansion in length, and decreased congestion in outer third of vagina.(7) It takes longer to get to a climax too: the excitement phase is longer (blood flow and engorgement reduced, lubrication delayed and reduced), (8) the plateau phase is longer (vasocongestion of breasts decreased), and orgasmic capacity is reduced (lower number and intensity of vaginal contractions).(7) In addition, without estrogen, there is a tendency to have a compromised vaginal pH making intercourse difficult. (8) Postmenopausal women reported a 61.5% decrease in sexual desire.(8)

Surgical Menopause

Surgical menopause, the sudden removal of the ovaries, without HRT may make the situation much worse. For some women, the uterus does play a role in orgasm. A study of couples having sex inside an MRI imager (!) showed that the uterus does rise on the brink of orgasm.(17) Keeping the cervix might help.

According to a study done at Cook County Hospital in Chicago, on average, after ovaries are removed, a woman will produce about 65% less estrogen, 75% less progesterone, and up to 80% less androgen than before.(31) Oopherectomy causes a 50% drop in androgen production, (14) and 22% to 66% of women report some kind of problem with sexual function.(15) Ovarian production of testosterone continues a long time after natural menopause. While the other androgens reach the low end of the levels of natural menopause, it was testosterone that plummeted. In another study, women without ovaries who had blood levels of testosterone at 10 nanograms per milliliter or less lost libido and the ability to orgasm. Women who maintained a level of 30 ng/mL or higher kept libido and the ability to orgasm.(3) So those might be some levels to shoot for.

The best study of sexual function of women in surgical menopause (4, 5, 6), one where they tested women before surgery and then afterward, put women with TAH/BSO's into four groups. There was also a control group of women who kept ovaries. Each group got different injections of hormones: estrogen alone, testosterone alone, estrogen and testosterone, and no hormones in a placebo. The estrogen alone group and the placebo group had a significant decrease in frequency of sexual fantasy and arousal. The controls (hysterectomy, kept ovaries) had no change or improvement. Both the testosterone and the estrogen and testosterone groups experienced a significant increase in desire and response or at least the same levels.(13, 16) They also found that testosterone plays a big role in a sense of well-being.(13)

The Lack of Testosterone

They finally have a name for this--female androgen deficiency syndrome--but they are still arguing over exactly what the symptoms and consequences are.(48) So no one can actually diagnose a condition they can't yet define. It's not known exactly how testosterone is used by women's bodies or what forms of androgen (as with estrogen, there are various kinds) are needed for what results.(48) They especially don't know what effect long-term use of testosterone has on breast, liver, and cardiovascular health.(48)

The researchers are only guessing, but they're pretty sure that women need testosterone to have either sexual desire or sexual arousal.(8) Some researchers are defining the signs of testosterone deficiency as global loss of desire, lack of fantasy and dreams, decreased clitoral sensitivity to stimulation, decreased arousal and capacity for orgasm, diminished sexual energy and sense of well-being, loss of muscle tone, and dry brittle scalp hair or dry skin.(8) The problem is that most of these are subjective and can't be measured except by questionnaires. As of 2000, there were 10 studies that found a clear benefit to replacing testosterone for these problems.(8)

But we know that testosterone improves libido in women who have had their ovaries removed, with or without estrogen replacement. Estrogen replacement alone and progestin replacement alone had no effect on libido. (15, 49) Testosterone alone also helps with atrophic vagninitis.(1)There is no evidence yet that it helps premenopausal women,(16) though it's interesting that androgen levels peak at ovulation, creating desire.(13) Menopausal women who take testosterone report that it increased the sense of stimulation, increased the sensitivity of the labia and clitoris, helped nitric oxide create blood flow to the clitoris and vagina, and increased the intensity of orgasm.(13) Some of the results for older women, however, aren't as clear.(43) It could be that other health conditions cause problems for them.

Most forms of testosterone replacement were designed for men. Since the levels aren't really known, an adjustable dose would probably be a good idea (since the doctors are really guessing, and the side effects can be hard to shake off). Testosterone comes in a transdermal patch (for men), injection, transdermal pellets, pills, or cream.(29) A new form AndroGel, a clear colorless gel, actually warns that "AndroGel is not indicated for use in women, has not been evaluated in women, and must not be used in women."(49) Sounds as though they're worried about their legal liability, which shows how concerned they are about the unknowns of testosterone replacement. If testosterone is used at too high a level over a period of time, then the side effects can be lingering or permanent. The side effects are hirsutism (male pattern hairiness), facial oiliness, acne, deepening voice, hostility, weight gain, male pattern baldness, elevated liver functions, and lower HDL. It also plays a role in a rare cancer. epedicellular carcinoma.(16) WebMD has suggested that a low-dose, 2% testosterone cream compounded by a pharmacist might be the best to try since it's gentle and adjustable.(1)

One thing does seem clear from what studies there are, if a woman had little sexual desire before menopause, then testosterone will probably not create much improvement. There may be other issues and physical problems behind the lack of libido.(16)

Estrogen

While estrogen that isn't balanced can cause problems with sexual desire and response (perhaps mainly by tying up what testosterone there is with sex hormone binding globulin [3,15, 8]), it does play a role in making sex enjoyable. Estrogen keeps vaginal pH lower, increases the number of lactobacillus (good bacteria), decreases the number of bad beasts in the vagina, and increases blood flow (helps dilate blood vessels), so it helps vaginal health and response.(8) When blood levels of estrogen drop below 50 picograms per milliliter, women report vaginal dryness and pain with sex.(8) It's possible that the type of estrogen may make a big difference with libido, too. Conjugated equine estrogen (Premarin) had no effect on the low sexual desire reported in a group of surgically and naturally menopausal women, (9, 10) while surgically menopausal women who used ethynl estradiol experienced an improvement in sexual desire and response (11).

Estrogen also has a benefit because it primes the central nervous system to make the skin sensitive and the other sense organs more aware.(13) Low estrogen changes the sense of smell, which might lower the response to pheromones (the chemical messengers that communicate attraction between people).(13) Low estrogen dries out the mouth, which again might interfere with picking up the pheromones in the air.(13) And lack of estrogen interferes with the sweat glands to send out your own pheromones.(13)

Atrophic Vaginitis

The health of the vagina is very estrogen dependent.(7) So, when estrogen replacement isn't possible, there are a number of things that can help. Calendula, comfrey, or St. John's Wort creams may decrease the burning, itching, used, once or twice a week externally.(1) Naturopaths recommend olive oil, wheat germ oil, or sesame oil. A square quilted cotton makeup pad is soaked in one of these oils, squeezed out, and inserted in the vagina overnight once a week.(1) Vaginal itching can be eased with an oatmeal bath--cooked oatmeal placed in a strainer and held under the tap as the tub fills. One can also buy a natural colloidal oatmeal product.(1) Yogurt helps maintain vaginal pH.(1) Chasteberry as a tea might help but it dampens libido, so probably isn't a good choice.(1) Zinc and evening primrose oil might also help.(1) There are a few things that can make it worse. Antihistamines, decongestants, and any drug the dries out membranes can make it worse, and petroleum based products can lead to infections.(1) Tamoxifen also seems to be a problem.(2) And testosterone alone, without estrogen, might help.

Progesterone

Other than balancing estrogen so that oxytocin will be high and sex hormone binding globulin lower, progesterone doesn't play much of a role apparently&emdash;except that it's needed in the brain to help with dopamine (one of the feel good chemicals that might be necessary for libido).(18) High progesterone may actually inhibit testosterone.(13) So as usual, balance is the key.

Other Pieces of the Puzzle

Prolactin is a major piece of the sexual puzzle. High prolactin decreases sexual desire.(13, 37) The pituitary gland makes prolactin when estrogen is high and progesterone drops (and the body thinks it's breastfeeding time). It's actually released after orgasm to give the body a rest.(37) Some of the other causes of high prolactin are anesthesia (especially surgical), elavil, throazine, tagamet, estrogens, fluphenazine, haloperido, reglan, monoamine oxidase inhibitors, codeine, and morphine.(33) Alcohol also may increase prolactin or decrease testosterone or both.(38) Two things that battle prolactin are vitamin B6 and zinc.(38) Ginseng might also lower prolactin.(38) And maca might help balance the pituitary hormones. Usually, high prolactin causes a lot of breast tenderness, so there are clues that this might be part of the problem.

Oxytocin is also a pituitary hormone. It may increase sexual desire, but it definitely creates the desire to bond with another person and to have sexual contact, and it gives that sense of satisfaction after sex.(13) It may also sensitize the skin.(13) Massage increases oxytocin levels.(55)

Dopamine is released when mammals are stimulated, triggering a reward message in the brain. When it rises, it apparently can trigger a search for the target of desire. Testosterone increases dopamine by regulating nitric oxide synthase (so boosting NO synthase is a good thing in the absence of testosterone replacement).(35) Serotonin (boosted by estrogen) inhibits dopamine.(37) so getting estrogen in balance with progestesrone helps too.

Choline is a precursor of the neurotransmitter acetylcholine. It's essential for memory, muscle control, and cardiovascular health. Even moreso, it transfers the sexual arousal messages to the genital arteries,(19) leading to engorgement in the vagina, and lubrication. It also helps release nitric oxide, which is necessary for clitoral swelling.(19)

THINGS THAT CAN HELP

Now we're in the dicey section. The following substances either can help with different pieces of the puzzle or they get listed a lot and I provide the not very convincing "maybe." None of them help with the whole picture. The ovarian hormones do that. But each can help in its own way, so pick and choose&emdash;and as I said before, use caution. Most of these have not been studied that well.

Adrenal Glands

Not something to take, but something to boost, the adrenal glands can produce quite a bit of androstenedione, which is a precursor of testosterone (estrogen and progesterone too). This way you provide your own replacement. The best help for the adrenal glands is to decrease stress (try something like yoga or meditation), avoid toxins (including caffeine and nicotine), get enough sleep, get proper nutrition, and get enough folic acid. (40) Manganese helps the adrenal glands (about 5-10 mg),(40) as does vitamin B1 (thiamin).(40) Dr. Linda Page, a naturapath who has specialized in libido, recommends an adrenal tonic of siberian ginseng, licorice, sarsaparilla, and extra vitamin C.(39)

Arginine

Arginine is a precursor to nitric oxide (NO),which is how viagra works, by relaxing blood vessels. (19, 20) NO is produced in clitoral tissue, part of the increase in blood flow. (19) NO is also made in the brain where it helps with pheromone recognition.(19) However, the only real scientific studies, small and unpublished, which aren't very good, don't show a lot of effect.(28, 22) It may have an indirect effect since it makes other herbs in combination more effective apparently. It may also be the case that it works only in people who have a deficiency. Arginine is generally good stuff. It releases growth hormone (good for muscle mass, weight loss, and memory).(19) It helps with wound healing, secretion of hormones in general, interstitial cystitis, and hot flashes.(19, 26, 41) It may also lower blood pressure.(41) Nitric oxide is also needed to make dopamine, so arginine would help sexual libido too (as well as depression [34]). It's found in dairy products, meat, chocolate, and whole soy protein, as well as whole wheat, brown rice, chicken soup, and raisins.(29)

Aromatherapy

Dr. Linda Page recommends sandalwood and yang-ylang to develop the mood.(32)

B Vitamins

B1 helps with adrenal health.(40)

B3 increases the blood flow to the skin and mucus membranes.(39)

B6 fights against the effects of too much prolactin and helps zinc also battle prolactin.(38, 39) It also monitors the balance between estrogen and progesterone.

Folic acid also helps with adrenal health.(40)

Bee Pollen

Dr. Linda Page recommends bee pollen for the B vitamins, essential fatty acids, and amino acids. It especially provides lecithin, which provides choline, which is part of nerve transmission.(39)

Chocolate

There are 300 compounds in chocolate, and a number of them relate to sexual desire and response--including magnesium, polyphenols, arginine, and mood-boosting xantines. The most important one is phenylethylamine (PEA), which lifts mood, releases dopamine, and creates a sense of sexual euphoria and desire.(36)

Damiana (Turnera aphrodisiaca)

There's been almost no scientific study of damiana, but Dr. Andrew Weil recommends it for women having libido problems. The one tiny study I could find showed that it goosed up a few sexually sluggish rats.(28) It's been available as a food flavoring in the U.S. since 1874. The ancient Mayans used it for "giddiness" and as an aphrodisiac.(29) It contains arbutin, which is a urinary antiseptic,(27) and it might be a bit of an antidepressant. The FDA lists it as "generally recognized as safe" so it should be safe to try. The most encouraging theory is that it stimulates testosterone production in women.(29) According to herbalists, it can induce erotic fantasies, vaginal lubrication, and erect nipples.(36) Dr. Collins suggests 500 mg, 1 to 3 times a day.(40)

DHEA

Dehydroepiandrosterone is an androgen made in the adrenal glands. If the adrenal glands are healthy, they can make enough on their own. It's a precursor for testosterone and estrogen. There can be male pattern side effects,(22) liver damage, ovarian cancer, liver cancer, (23) and cholesterol problems, so take it with a doctor, who can prescribe a regulated form.(1) While long-term effects aren't known (12), 67% of men and 82% of women said it improved their sense of well-being in a short study.(12) Libido seems to take a while to respond to it.(12) Another small study with no real controls or placebo said there was a strong increase in sexual thoughts and satisfaction when taking DHEA and an increase in well-being.(19) Another study found it was helpful in women over 70 but not in ordinary women (would surgical menopause be at similar levels?).(22) On the up side, it might help with osteoporosis, lupus, depression, and chronic fatigue syndrome.(23) The Natural Pharmacist recommends 50 to 200 mg a day or a 10% cream, but also repeated the recommendation that it should be taken with a doctor.(23)

Diet

Dr. Linda Page has a website with what she claims is the diet to increase libido after menopause.(39) What she recommends are lots of fruits and vegetables, seafood, and sea greens (sea palm crunhies, nori, wakame, dulse, or kombu.), which all boost metabolism and are loaded with essential fatty acids that help the skin, keep the vagina lubricated, and help balance hormones. She particularly recommends broccoli and cantaloupe to help the adrenal glands, a fresh green salad every day, and miso soup. She says to avoid high fat, salty, sugary, and trans-fatty acid foods. She also recommends oysters, turkey, mushrooms, wheat germ, seeds, and sprouts because they all have high levels of zinc, which lets pheromones sink in.(39)

Dong quai

Dong quai is sometimes touted as a sexual enhancer but apparently it's main role is to relax the muscles of uterus, so not likely to help women with hysterectomies.(36)

Exercise

Exercise improves blood flow, which is necessary for arousal. People who exercise have higher levels of desire and an enhanced ability to achieve orgasm.

Gingko biloba

Gingko might help in several ways. One of them is with the release of nitric oxide and the increase in blood flow during arousal. (19) Even more there's an interesting preliminary finding that gingko will help with the loss of libido caused by taking SSRIs (might help with the estrogen boost to serotonin too).(22, 24) One small study of women and men taking an SSRI who'd lost their sexual desire and response found that both responsed, but 91% of the women improved while only 76% of the men did.(19) It helped with desire, lubrication, orgasm, and resolution.(19) They've also gotten a lot of reports that geriatric patients taking it for memory had better six.(19) It is a blood thinner so don't take it with warfarin, heparin, aspirin, garlic, policosanol, and vitamin E at high doses.(22) It has lots of other benefits for women in surgical menopause too. It helped with memory loss, bloating, tinnitus, and vertigo. It's helped with macular degeneration too.(24) It might be a protector of nerve cells, not just a blood thinner.(25) Dr. Collins says women should use it if they have low estrogen or low testosterone and recommends 40 to 80 mg a day.(40)

Ginseng

Ginseng might lower prolactin levels.(38) Dr. Page&emdash;siberian ginseng because it helps with adrenal glands. Ginseng also provides more nitric oxide than arginine, so it might help blood flow, though again, this is more of a cardiovascular problem than a hormonal problem. (28) Korean red ginseng was in one study for men. Asian and Siberian ginseng don't seem to have been studies at all for libido.

Kava kava

Kava kava might help indirectly if tension is a problem.(29)

Lose Weight

I know! I know. But overweight is known to reduce libido and a 20 pound loss increases it.(29) Dr. Larrian Gillespie theorizes that as body fat reduces, the amount of sex hormone binding globulin drops, and there's more free testosterone.(29)

Maca (Lepidium meyenii)

Maca is a staple food plant of the Andean Indians, domesticated over 3,600 years ago. It's very nutritious and regarded as a treat since it grows slowly in the harsh conditions and can be made into desserts and even a fermented drink. The chemical composition has been studied thoroughly by botanists, both as an impressive food source (including arginine, magnesium, zinc, B vitamins) and as an aphrodisiac that enhances fertility.(52) It has a lot of enthusiasts among holistic doctors in South America. One researcher determined that it works, not through plant hormones or phytoestrogens, but through alkaloids, which act on the hypothalamus-pituitary axis. The hypothalamus is essential to sexual arousal and the cascade of neurotransmitters and hormones. The pituitary gland produces prolactin and oxytocin. It boosts the adrenal glands, which gives a feeling of energy and vitality.(54) So it seems like a good thing to try. Apparently, you can use it for special occasions. Dr. Linda Page recommends it two or three times a day for two to three days before a big weekend.

Magnesium

Magnesium is needed for hormone manufacture, apparently, so there should be enough around for the adrenal glands to work with.(40)

Royal Jelly

Dr. Linda Page says it boosts acetylcholine, a neurotransmitter essential for nerve transmission. (39)

Thyroid Balance

Low thyroid inhibits libido(13) so making sure that thyroid levels are good is important. If a T4 only drug is taken (like synthroid) selenium is a good supplement. It helps it convert to T3 and provide more libido.(29)

Tribulus terrestris

There are no well-documented studies of "puncture vine,"(21) a plant native to Africa and India. It does have a chemical called protodioscin, which might lead to DHEA.(21) It might balance cholesterol and activate production of testosterone. Herbalists seemed to think it would relieve menopausal symptoms by balancing estrogen and testosterone.(36) Dr. Linda Page recommends it. (32)

Viagra

Viagra showed some of the same problems as arginine, which isn't surprising since they're closely related. It too uses nitric oxide (NO) to relax smooth muscle fibers and allow blood flow to the clitoris and vagina.(19) A study that used viagra for women having arousal problems found that there wasn't much difference between a placebo and viagra for sexual desire, sexual arousal, or pain during sex.(51) Viagra causes headache, flushing, nausea, abnormal vision, and indegestion&emdash;all mild, but it doesn't seem worth it.(51)

Wellbutrin

Though it's been acknowledged for awhile that Wellbutrin (Bupropion or Zyban) doesn't take libido away the way the SSRI antidepressants do, there is the beginning of evidence that it actually improves both sexual desire and sexual response, even in people who are not depressed. Though a placebo worked quite well, Wellbutrin worked better for both men and women, particularly in overall sexual satisfaction. And, because it boosts dopamine, it is likely to help with weight loss too.(56)

Wild Oat Extract

Dr. Linda Page says that wild oat extract, 300 mg, 3 days a week, will lead to multiple orgasms for women.(32) However, most seem to think it applies to men, not women.

Yohimbine

Yohimbe is a tree; yohimbine is the drug derived from the tree. One small study of yohimbine and arginine found an increase in measured physical arousal (lubrication) in 23 women. But the women themselves didn't notice anything particular.(22) but neither seem effective on their own.(22) However, yohimbine is dangerous. I've included it here only because it shows up in various elixirs on the Web and in health food stores. Luckily (I guess) the FDA found little or no yohimbine in 11 of 18 brands of supplements it tested.(28) It was testing because yohimbine is an FDA drug to widen the pupils of the eyes. It can raise blood pressure dangerously and can mess with brain chemicals, so only take it with the advice of your doctor.

Zinc

Zinc is critical, especially if the adrenal glands are being encouraged to add in some testosterone. Zinc is needed for the manufacture of hormones. Low levels of zinc are connected to low sexual desire.(29) Chronic stress wipes out zinc and desire.(31) And of course, estrogen replacement uses up zinc. Zinc also reduces levels of prolactin, which crushes libido.(38) Also, according to Dr. Linda Page, zinc helps pheromone reception, which helps libido, because the sense of smell depends on zinc.(39) It also helps adrenal function. (39)

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