Low sexual desire in women: the role of reproductive hormones

The Heteronormativity Theory of Low Sexual Desire in Women Partnered with Men

Low sexual desire in women partnered with men is typically presumed to be a problem-one that exists in women and encourages a research agenda on causation and treatment targeting women. In this paper, we present a distinct way forward for research on low sexual desire in women partnered with men that attends to a more structural explanation: heteronormativity. A heteronormative worldview assumes that relationships and structures are heterosexual, gender (usually conflated with sex) is binary and complementary, and gender roles fit within narrow bounds including nurturant labor for women. We propose the heteronormativity theory of low sexual desire in women partnered with men, arguing that heteronormative gender inequities are contributing factors. We outline four hypotheses and their predictions related to: inequitable divisions of household labor, blurring of partner and mother roles, objectification of women, and gender norms surrounding sexual initiation. We discuss some mechanisms-social, physiological, and otherwise-for the heteronormativity theory, especially related to stress, objectification, and nurturance. We close by noting some limitations of our paper and the ways that the heteronormativity theory of low sexual desire in women partnered with men provides a rigorous, generative, and empirical way forward.

The Bio-Psycho-Social Dimension in Women's Sexual Desire: 'Argumentum ad novitatem'

Sexual desire includes complex motivation and drive. In the context of biological and cognitive- emotive state art of science, it is often a neglected field in medicine. In regard to the treatment, study on women's sexual function received less attention compared to the men's sexuality. In the past, this endeavor was relatively not well disseminated in the scientific community. Recently, there was a revolutionized surge of drug targets available to treat women with low sexual desire. It is timely to review the relevant biological approach, especially in the context of pharmacotherapy to understand this interesting clinical entity which was modulated by numerous interactive psychosocial inter-play and factors. The complex inter-play between numerous dimensional factors lends insights to understand the neural mechanism, i.e. the rewards centre pathway and its interaction with external psychosocialstimulus, e.g. relationship or other meaningful life events. The function of hormones, e.g. oxytocin or testosterone regulation was described. The role of neurotransmitters as reflected by the introduction of a molecule of flibenserin, a full agonist of the 5-HT1A and partial agonist of the D4 to treat premenopausal women with low sexual desire was deliberated. Based on this fundamental scientific core knowledge, we suggest an outline on know-how of introduction for sex therapy (i.e. "inner-self" and "outer-self") where the role of partner is narrated. Then, we also highlighted on the use of pharmacological agent as an adjunct scope of therapy, i.e. phosphodiasterase-5 (PDE-5) inhibitors and hormonal treatment in helping the patient with low sexual desire.

Average Associations Between Sexual Desire, Testosterone, and Stress in Women and Men Over Time

Sexual desire and testosterone are widely assumed to be directly and positively linked to each other despite the lack of supporting empirical evidence. The literature that does exist is mixed, which may result from a conflation of solitary and dyadic desire, and the exclusion of contextual variables, like stress, known to be relevant. Here, we use the Steroid/Peptide Theory of Social Bonds as a framework for examining how testosterone, solitary and partnered desire, and stress are linked over time. To do so, we collected saliva samples (for testosterone and cortisol) and measured desire as well as other variables via questionnaires over nine monthly sessions in 78 women and 79 men. Linear mixed models showed that testosterone negatively predicted partnered desire in women but not men. Stress moderated associations between testosterone and solitary desire in both women and men, but differently: At lower levels of stress, higher average testosterone corresponded to higher average solitary desire for men, but lower solitary desire on average for women. Similarly, for partnered desire, higher perceived stress predicted lower desire for women, but higher desire for men. We conclude by discussing the ways that these results both counter presumptions about testosterone and desire but fit with the existing literature and theory, and highlight the empirical importance of stress and gender norms.

Multifaceted Sexual Desire and Hormonal Associations: Accounting for Social Location, Relationship Status, and Desire Target

Sexual desire is typically measured as a unitary erotic phenomenon and is often assumed by biological and biomedical researchers, as well as the lay public, to be directly connected to physiological parameters like testosterone (T). In the present study, we empirically examined how conceptualizing sexual desire as multifaceted might clarify associations with T and contextual variables. To do so, we used the Sexual Desire Questionnaire (DESQ), which assesses multifaceted dyadic sexual desire, to explore how contextual variables such as social location, relationship status, and desire target (e.g., partner vs. stranger) might be meaningful for reports of sexual desire and associated hormonal correlations. We focused on women (N = 198), because sexual desire and testosterone are generally unlinked in healthy men. Participants imagined a partner or stranger while answering the 65 DESQ items and provided a saliva sample for hormone assay. Analyses showed that the DESQ factored differently for the current sample than in previous research, highlighting how sexual desire can be constructed differently across different populations. We also found that, for the Intimacy, Eroticism, and Partner Focus factors, mean scores were higher when the desire target was a partner relative to a stranger for participants in a relationship, but equally high between partner versus stranger target for single participants. DESQ items resolved into meaningful hormonal desire components, such that high endorsement of Fantasy Experience was linked to higher T, and higher cortisol was linked with lower endorsement of the Intimacy factor. We argue that conceptualizing desire as multifaceted and contextualized when assessing hormonal links-or questions in general about desire-can clarify some of its complexities and lead to new research avenues.

Sexual Desire in Sexual Minority and Majority Women and Men: The Multifaceted Sexual Desire Questionnaire

Sexual desire is increasingly understood to be multifaceted and not solely erotically oriented, but measures are still generally unitary and eroticism-focused. Our goals in this article were to explore the multifaceted nature of sexual desire and develop a measure to do so, and to determine how multifaceted sexual desire might be related to gender/sex and sexual orientation/identity. In the development phase, we generated items to form the 65-item Sexual Desire Questionnaire (DESQ). Next, the DESQ was administered to 609 women, 705 men, and 39 non-binary identified participants. Results showed that the DESQ demonstrated high reliability and validity, and that sexual desire was neither unitary nor entirely erotic, but instead was remarkably multifaceted. We also found that multifaceted sexual desire was in part related to social location variables such as gender/sex and sexual orientation/identity. We propose the DESQ as a measure of multifaceted sexual desire that can be used to compare factor themes, total scores, and scores across individual items in diverse groups that take social context into account. Results are discussed in light of how social location variables should be considered when making generalizations about sexual desire, and how conceptualizations of desire as multifaceted may provide important insights.

Qualities Midlife Women Desire in Their Sexual Relationships and Their Changing Sexual Response

The present study focused on the association between the particular sexual qualities midlife women desired in themselves and their husbands and the changes in sexual response they were experiencing. In a U.S. sample of 280 women participating in the ongoing Midlife Women's Health Survey, 40% reported a change in their sexual response, more often as decrements than increases, although desiring more nongenital touching was frequently noted. Respondents wanted more change in their own than in their partners' sexual qualities. In addition, the desire to change sexual qualities in oneself and in one's husband was significantly related to many changes in sexual responsivity. These findings are discussed in the context of a woman-defined sexuality at midlife.

Darwin's legacy: an evolutionary view of women's reproductive and sexual functioning

On the Origin of species, published just over 150 years ago, has deeply influenced thinking in both scientific and wider communities. Darwin's legacy includes recognition of the fact that all organisms evolve; that variation within and between species is natural and normal; and that an evolutionary approach to understanding the sources and consequences of this variation comprises theoretical frameworks, testable hypotheses, and rigorously collected evidence. With an eye toward facilitating communication and productive collaboration among researchers from different intellectual traditions who nonetheless share a common interest in women's reproductive and sexual functioning, we discuss evolutionary concepts and models, summarize the known variability in ovarian functioning and consider the implications of this variability for conducting sex research, and evaluate the relative merits of various biomarkers that serve as proxy measurements of a woman's reproductive and hormonal status. With these perspectives and methods from reproductive ecology at hand, we examine several contentious issues: the links between hormones and sexuality in premenopausal and perimenopausal women, the causes of premenstrual syndrome, and the existence (or not) of menstrual synchrony. In none of these cases is as much known as is often claimed. In each, there are abundant opportunities for innovative, albeit challenging, research.

Review of low libido in women

Low libido is the most frequently reported sexual dysfunction. This is an important and complex problem with multiple causes. At present the interpretation of data on this topic remains a challenge, as the subject population is diverse and various tools are used in assessment. Coupled with this, several definitions are in use with differing emphasis on distress resulting from this state. Developments in the understanding of psychopharmacology are shedding light on the pathways involved in normal sexual response and these are being utilized in the development of treatments. This article reviews the current definitions, aetiology and treatment options and explores the recent developments in low libido in women.

Disorders of Sexual Desire and Arousal

Desire and arousal disorders are very common. These disorders can cause significant distress to a patient. A successful approach depends on an accurate diagnosis, which is dependent on history. Laboratory evaluation is usually not helpful, whereas psychosexual therapy is helpful in many cases. Although there is some evidence that drug therapy is helpful in some cases, no drug has been approved for the treatment of these disorders.

Androgen insufficiency in women

Androgens are directly secreted by the ovaries and adrenals in women, and androgen precursors from these glands are converted in a variety of peripheral tissues into androgens. The major androgen in women is testosterone, and its action in target tissues can be mediated through the androgen receptor or through the estrogen receptor after aromatization to estradiol. Low sexual desire that causes personal distress (or hypoactive sexual desire disorder [HSDD]) is the most common form of female sexual dysfunction, and androgen insufficiency is one cause of this problem. In addition to a low libido, the clinical construct of the female androgen insufficiency syndrome includes the presence of persistent, unexplained fatigue and a decreased sense of well-being. Although there is conflicting information about the relationship between serum testosterone concentrations and sexual desire, multiple randomized, double-blind, placebo-controlled treatment trials have demonstrated that testosterone improves libido significantly more than placebo. Doses that provide physiologic to slightly supraphysiologic serum free or bioavailable testosterone concentrations are safe and associated with only mild androgenic side effects of acne and hirsutism. Oral, but not parenteral or transdermal, testosterone may decrease high-density lipoprotein cholesterol. At present, no testosterone preparation has been approved by the FDA for the treatment of low sexual desire (HSDD), so all such therapy is considered to be off-label use at this time.

"Feeling frumpy": the relationships between body image and sexual response changes in midlife women

This study investigated the relationships between self-rated attractiveness and self-reported sexual response changes (over the past decade) and current sexual satisfaction in 307 heterosexual, midlife women. Results indicated that regardless of the woman's specific age, she was more likely to consider herself more attractive when she was 10 years younger and her self-perceived attractiveness did not significantly differ based on her menopausal status. The more a woman perceived herself as less attractive than before, the more likely she was to report a decline in sexual desire or frequency of sexual activity. The more she perceived herself as attractive, the more likely she was to experience an increase in sexual desire, orgasm, enjoyment, or frequency of sexual activity. There were no significant statistical relationships between a woman's perception of her own attractiveness as she aged and her current sexual satisfaction.

Prospective study on sexual behavior of women using 30 μg ethinylestradiol and 3 mg drospirenone oral contraceptive

The aim of the study was to determine the changes, if any, on the sexual behavior of women using an oral contraceptive containing 30 microg ethinylestradiol (EE) and 3 mg drospirenone (DRSP). Eighty healthy volunteer women (age range, 19-31 years), with regular menstrual cycle length (mean 27.6+/-3.1) and ovulation, participated in this prospective study. Sexual behavior was assessed using the self-administered Personal Experience Questionnaire, at baseline and at 3, 6 and 9 cycles of pill use. Women reported increased (i) sexual enjoyment (p < .001), (ii) orgasm frequency (p < .05) and (iii) satisfaction with sexual activity (p < .05) during all periods of pill intake with respect to baseline. Both arousal and frequency of sexual activity improved at the sixth and ninth cycle of pill use (p < .05) with respect to baseline. Moreover, women reported decreased genital pain associated with intercourse during pill intake (p < .05). Desire did not change during the use of the pill (p = NS). The mild dose of EE may have improved vaginal lubrication, sexual arousal and decreased dyspareunia. Consequently, women may have experienced increased sexual performance. In addition, improved sexual activity could have been the result of the effects of DRSP, with its antimineralocorticoid effects which could improve pill compliance, with a more satisfied sexual life.

Sexual desire in later life

The has been relatively little research on sexuality in later life, particularly among persons over 60 years of age. The existing literature consists of studies of small samples, much of it from a biomedical perspective. This literature suggests that age, hormone levels, specific illnesses, and various medications negatively affect sexual functioning in older persons. The study reports results from a survey of a large sample (N=1,384) of persons age 45 and older that included measures of a variety of biological, psychological and social factors that potentially influence sexual functioning. We report bivariate and multivariate analysis conducted separately for women and men. We find that the principal influences on strength of sexual desire among women are age, the importance of sex to the person, and education. In this sample of the population of older persons, attitudes are more significant influences on sexual desire than biomedical factors.

Androgen replacement therapy in women

OBJECTIVE

Review of literature with regard to androgen replacement therapy in women.

DESIGN

Review of the MEDLINE database and references from articles.

CONCLUSIONS

Androgens affect sexual function, bone health, muscle mass, body composition, mood, energy, and the sense of well-being. Androgen insufficiency clearly has been demonstrated in patients with hypopituitarism, adrenalectomy, oophorectomy, and in some women placed on oral estrogen therapy which increases sex hormone-binding globulin (SHBG) levels and lowers the free and bioavailable forms of T. Symptoms of androgen insufficiency in women may include a diminished sense of well-being, low mood, fatigue, and hypoactive sexual desire disorder with decreased libido, or decreased sexual receptivity and pleasure that causes a great deal of personal distress. The preponderance of evidence from clinical trials supports the correlation of decreased endogenous androgen levels with these symptoms and alleviation of many of the symptoms with the administration of T or, in some cases, DHEA. There are no Food and Drug Administration-approved androgen preparations on the market for treating androgen insufficiency in women. The safety profile of androgens in doses used for the treatment of hypoactive sexual desire disorder has been excellent with only mild acne and hirsutism being noted in a minority of patients.

Preclinical models of sexual desire: conceptual and behavioral analyses

The epidemiology, etiology and proposed treatments for the sexual desire disorders are briefly reviewed before turning to an analysis of preclinical models. We suggest that the concept of sexual desire in the human is equivalent to sexual motivation as employed in the scientific literature. Many animal tests for sexual motivation have been described over the years. Most of them are based on the evaluation of the rate or speed of performing learned operant responses. These are not ideal measures for inferring the intensity of sexual motivation. We present a test for sexual incentive motivation, which has been used in male and female rats. No learning is involved, and the test is rather insensitive to variations in ambulatory activity and it does not employ rate measures. A procedure that recently has attracted much attention, paced-mating behavior in the female, does not seem to be as useful as could be expected. In fact, it does not appear to be superior to tests for sexual receptivity (lordosis). The lack of established, clinically efficient treatments for sexual desire disorders makes it difficult to evaluate if any model has predictive validity. However, the model proposed here may be isomorphic and homologous to the human condition.

Sexual behavior of women taking low-dose oral contraceptive containing 15 μg ethinylestradiol/60 μg gestodene

The objective of this prospective study was to assess the effects of a low-dose oral contraceptive (OC) containing 15 microg ethinylestradiol and 60 microg gestodene on sexuality. Forty-eight healthy volunteers (age range, 18-35 years), having regular menstrual cycles with ovulation, participated in the study. Sexual behavior was assessed using the self-administered Personal Experience Questionnaire, at baseline, and at 3, 6 and 9 months of pill use. Women reported decreased sexual desire (p < 0.005) and sexual activity (p < 0.05) at the 9th month of pill use, and diminished sexual arousal at the 3rd month of pill intake (p < 0.05), with respect to baseline. The frequency of orgasm did not change during OC use (p = NS). Moreover, sexual enjoyment was worse at the 3rd, 6th and 9th month with respect to baseline (p < 0.001). The low dose of ethinylestradiol could cause decreased vaginal lubrication, and diminished sexual arousal could be due to hypoandrogenism. Women may expect increased sexual performance when they take the pill, as compared to before starting contraception. Consequently, they could have an unexpected effect with pill use, though sexuality may remain the same.

Hormones, mood, sexuality, and the menopausal transition

OBJECTIVE

To determine the extent of changes in women's sexual functioning and well-being during the menopausal transition and the relationship to hormonal changes.

DESIGN

Prospective observational study.

SETTING

Population-based sample assessed at home.

PATIENT(S)

438 Australian-born women 45-55 of years who were still menstruating at baseline. Of these, 226 were studied for effects of hormones on sexual functioning.

MAIN OUTCOME MEASURE(S)

Short Personal Experiences Questionnaire (SPEQ) and Affectometer 2 scores and annual blood sampling.

RESULT(S)

From the early to late menopausal transition, the percentage of women with SPEQ scores indicating sexual dysfunction increased from 42% to 88%. Mood scores did not change significantly. In the early menopausal transition, women with low total SPEQ scores had lower estradiol level but similar androgen levels to those with higher scores. Decreasing SPEQ scores correlated with decreasing estradiol level but not with androgen levels. Hormone levels were not related to mood scores.

CONCLUSION(S)

Female sexual functioning declines with the natural menopausal transition. This decline relates more to decreasing estradiol levels than to androgen levels.

Controlled studies on women presenting with sexual drive disorder: I. Endocrine status

A single mid-cycle blood sample was obtained from 15 premenopausal female patients presenting with lifelong absence of sexual drive and from a control group of women with intact sexual drive. Serum levels of testosterone, 5-dihydrotestosterone (5-DHT), 17 beta oestradiol, sex hormone binding globulin, and prolactin were measured and indices of free testosterone and 5-DHT were derived. During the menstrual cycle in which the blood samples were obtained, the study subjects kept a diary of their sexual desire and activities. The only endocrine parameter that is significantly different between the two groups is free testosterone, which is lower in the patients than in the control women. Associations between endocrine parameters and indices of sexual behavior were examined. In the control group, average daily sexual thoughts correlates positively with total testosterone, free testosterone index, and free 5-DHT. Feeling of "need for sex" correlates positively with free 5-DHT index and free testosterone index. Experience of sexual thoughts correlates with need for sex, and average frequency of masturbation correlates negatively with age. In both groups, average coital frequency correlates with free testosterone index.

Life-long absence of sexual drive in a woman associated with 5-dihydrotestosterone deficiency

A case of a woman who presented with life-long absence of sexual drive is reported. Although her history contained psychological factors that might have been etiologic in her presentation, she had not responded to sex therapy or cognitive-behavior psychotherapy undertaken at other clinics. When seen by the author, she was found to have poorly developed external genitalia. The only abnormality discovered on endocrinological evaluation was a reduced level of 5 dihydrotestosterone. Treatment with dihydrotestosterone gel applied to her vulva generated sexual drive and her ability to become sexually aroused.

Women's sexuality: behaviors, responses, and individual differences

Classic and contemporary approaches to the assessment of female sexuality are discussed. General approaches, assessment strategies, and models of female sexuality are organized within the conceptual domains of sexual behaviors, sexual responses (desire, excitement, orgasm, and resolution), and individual differences, including general and sex-specific personality models. Where applicable, important trends and relationships are highlighted in the literature with both existing reports and previously unpublished data. The present conceptual overview highlights areas in sexual assessment and model building that are in need of further research and theoretical clarification.

The evaluation of some factors influencing the sexual life of women affected by breast cancer

Although there is clinical evidence that cancer patients become less interested in sexuality and develop some difficulties in sharing feelings and thoughts with their spouses, systematic information on the factors influencing intimacy are lacking. The aim of this study is to explore the importance of variables such as reaction to illness and scarring, and marital satisfaction on the patients' capability to resume an enjoyable sexual life following surgery and radiation for the treatment of their tumors.

The female androgen deficiency syndrome

We evaluated the sexual functioning of 11 women who developed demonstrable androgen deficiencies after undergoing chemotherapy with cytotoxic agents and/or bilateral salpingo-oophorectomies for a variety of medical conditions. For comparison, we evaluated the sexual status of 11 subjects with comparable medical, menopausal, marital, and sexual histories, whose levels of circulating testosterone were within normal limits. The results of this clinical study confirm and extend the observations originally made by Waxenberg and his colleagues in 1959, that testosterone deficiency in women produces a marked decrease in libido and sexual responsiveness. Our findings further indicate that the female androgen deficiency syndrome is often indistinguishable from psychogenic desire disorders on clinical grounds alone.