Help your female patients get their groove back

By Judah Issa

Low sex drive. Your female mid-life patients might believe it's just a normal part of aging, but it's time to help them put that myth to bed. "It's terribly important not to leave people with the notion that they can expect this problem when they get old," says Dr Christine Derzko, a gynecologist and professor at the University of Toronto. "There are women in their late 30s and 40s — the perimenopausal period — who have low libido and others who have normal libido. Age is not the only factor."

Causes can range from kids to illness to life stresses, according to Dr Derzko. "But they need not be taken as final." A little sex talk with your patients will help get to the root of their problem and set them on the path to at least one kind of fulfillment.

MECHANICAL FAILURE
"The first thing to do with your patient is to make sure there's nothing mechanically wrong," says Dr Derzko. Hormonal changes with age can kill the woman's sex drive, as can some meds, so these must be ruled out before tackling the more common psychological causes.

Vaginal dryness "Ask your patient 'Have you noticed that you lubricate less during intercourse?' Pointing out vaginal dryness is an excellent way to raise the issue of libido with your patients," says Dr Derzko. "Let them know it's a common problem, and it's easily correctable."

Estrogen deficiency is usually the culprit in this case, and it can be treated with prescription vaginal creams or estrogen tablets inserted locally, says Dr Derzko. Over the counter lubricants can also be used to alleviate dryness before sex, she adds.

Warn your patients that tampon use also leads to vaginal dryness. Especially if they're more absorbent than needed to control menstrual flow, according to a Health Canada statement. OTC moisturizers make a good remedy and a single application will last up to three days.

Hormonal malfunction Thyroid problems and an increase in prolactin secretion — the hormone responsible for feelings of sexual gratification after intercourse — lower a woman's sex drive by decreasing the levels of estrogen, notes Dr Derzko. "Some drugs, like anti-depressants, will hike up prolactin levels, so getting rid of the depression might make her more interested in sex, but the drug will also suppress her libido."

Low testosterone — whether caused by age or oral contraceptives — also makes the sex drive head south in some women. "Hormone replacement therapy (HRT), for women in this age group, taken orally reduces the amount of testosterone in circulation," says Dr Derzko. If their libido has gone down perimenopausally, tell your patients to go off the Pill and try IUD or the transdermal patch instead. If it's age-related, some women may benefit from adding off-label testosterone therapy to their HRT regimen — a cream applied locally often does the trick.

Can't get no satisfaction "Ask your patient about her level of sexual satisfaction," says Toronto sex therapist Joan Marsman. Women experience a decline in clitoral sensitivity as they get older, and with lessened pleasure comes lessened desire. Here's a quick and simple tip you can give your patient: do Kegel exercises. They improve vaginal elasticity and boost pleasure, and best of all, they can be performed anytime, anywhere.

PSYCHOLOGICAL FACTORS
"Men have sex, but women make love," says Dr Derzko. "A Viagra-type pill won't do the trick — looking at a woman's sex drive has to be more comprehensive." And there are a number of lifestyle, emotional and psychological factors involved in low libido.

Too tired for sex "Having sex at night probably starts by carrying out the garbage in the morning," says Dr Derzko. Ask your patient to describe her daily routine. If she's running herself ragged, then sleep may trump sex at the end of the day. Tell your patient to pencil sex into her schedule. She may balk at the lack of spontaneity, but if she doesn't make the time for it in her busy life, then the 'urge' is likely to remain elusive.

Mind-body disconnect "Women in their late 30s or 40s become more comfortable in the situation they're in, more comfortable with their partner. It's not that they don't enjoy sex, they just don't think about it," says Dr Derzko. But then they face frustration from their partners, adds Ms Marsman.

Remind your patients that the brain is a sex organ too, both Dr Derzko and Ms Marsman stress. "The mind-body connection is important," says Ms Marsman. Encourage your patients to fantasize and use erotic imagery and scenarios with self or partner, she adds.

Personal problems "Find out what has changed in her life or her relationship," Ms Marsman suggests. "Some people might take this as an affront, so you have to use a lot of sensitivity," Dr Derzko adds. "You can ask 'How are things between you and your husband?' " If there's an issue there, then referring the patient to a sexual therapist or psychologist might help her resolve the problem.

And because a woman's libido is frequently linked to her self-image, here's some parting advice you can offer your patients, "Get enough sleep, and exercise to feel good about yourself, and create the time and space needed to feel sexy and be sexual," says Ms Marsman.