Sexual satisfaction is a complex process that vexes many women and their doctors

Reprinted from THE AGING WELL ISSUE, February 9, 2010

My patient Debra practically waltzes into my office. She is giggling and barely waits for the door to close before she announces: “I am having sex again and really enjoying it. Not only that, but I’m actually having random lusty thoughts.”

What a change from a couple of months ago, when sex was no more interesting to her than office furniture. Her husband is also delighted, she tells me. He plans to shower me with chocolates and flowers because I brought his wife back from the land of no libido.

This patient and I started discussing her faltering sex life about two years ago, somewhere around her 49th birthday — a time many women come to me with concerns about their sex lives. There were so many possible causes: her stressful job, her husband’s stressful job, the demands of a rambunctious 6-year-old who still appeared unannounced in the parental bed, her husband’s widening girth, her own steady march into menopause . . . .

I made all kinds of suggestions, and Debra tried them all: couples counseling, more exercise for her and hubby, sleep training for the nocturnal son, stress reduction and mindfulness techniques, aphrodisiacal foods and herbs, and books on improving sexual relationships with terms like “joyful lovemaking” in the title. There were glimmers of hope but nothing substantive. Finally, we entered the world of hormones. Despite her midrange-normal estrogen and testosterone levels, I gave her an off-label prescription for testosterone: a dab to her buttocks daily. Now, two months later, she comes steaming into my office.

I am happy for my patient (and pleased about the forthcoming chocolates), but her report provides me with yet another vexing data point as I struggle to help women of all ages (and especially those in midlife) who are distressed about the quality of their sex life. According to a recent sexual health study at Harvard, that’s about one in eight women nationally.

A woman’s sexual experience depends on a complex interplay of her neuroendocrine system, her multiple sex organs and any number of social circumstances, and it stands to reason that there might be many places where the process can go awry.

Still, from my inexpert perspective as a family physician, there seems to be no rhyme or reason to treating sexual problems: I see women whose lab results mirror Debra’s yet who have no response to hormones and manage to boost their love life with exercise, therapy, books or lingerie.

Equally perplexing are those with rock-bottom testosterone levels who are off-the-charts randy. Numerous large testosterone trials only serve to further my confusion, as most women who take the hormone report that their love making has increased by no more than two sessions per month.

In an attempt to develop a standard approach, I called Rosemary Basson, director of the Sexual Medicine Program in the Department of Psychiatry at the University of British Columbia in Vancouver. She has interviewed 6,000 women throughout the course of her 22-year career in sexual medicine.

The first step, she said, is to encourage women to change their understanding of sexual dysfunction. Contrary to what is conveyed by the media, romance novels and our current medical texts, Basson’s research suggests that it is normal for some women not to experience desire at the outset of a romp. In other words, if you are someone who would choose Sudoku over lovemaking but actually enjoys sex once your partner gets you going, then you are not disordered. Accepting that, Basson has found, leads many women to report much higher satisfaction with their sex lives.

Of course, this new understanding does not help all women. For those who still feel things are not right, Basson suggests they consider the following question: “What is interfering with your state of mind?” Depression should be treated with therapy and/or medication, pain can be addressed through a variety of therapies, and dissatisfaction with a partner might improve with couples counseling. Poor self-image, which is often a major factor for women who report sexual problems, can be greatly improved through mindfulness therapies.

James Simon, a professor of obstetrics and gynecology at George Washington University, believes that a subgroup — perhaps 3 to 6 percent of all women — suffer purely from a deficiency in brain neurotransmitters. He identifies them as good candidates for flibanserin, an experimental dopamine-type drug that, like Viagra, was serendipitously noted to have positive sexual effects during its failed trial as an antidepressant.

The initial flibanserin trial with premenopausal women produced results that were roughly similar to testosterone, an average of two more “sexually satisfying” encounters per month. (Women in the control group also reported one more encounter per month, so the mere act of taking a placebo can have a libidinous effect.)

When I asked Simon, who is recruiting for clinical trials funded by the drug’s manufacturer, about the significance of this small number, he replied that my question is typical of someone who is not an expert in sexual health:

“For the women who experience this increase, this is a highly significant number.”

I think back to my own patient. What could account for her new euphoria? Was it all attributable to one to two extra sex sessions per month? Or, as Simon asserts, when it comes to raising the female libido, perhaps “one plus one does not equal two,” with behavior changes plus a medication having a far greater effect than either treatment alone.

Basson agreed that a neurochemical drug has the potential to help boost arousal in a small percentage of women, but overall she sounded skeptical. “Look,” she explained, “if there was a drug that was so potent that it could overcome all misgivings we have about ourselves, our sexual image, our uncertainty about our sexual partners, the kids banging at our bedroom door, you could not make it legal. It would be slipped into drinks. What are people looking for?”