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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