Online Health Chat with Dr. Judith Volkar
February 14, 2012
Cleveland_Clinic_Host: Balancing the everyday routines of life, work, children, finances, and other stresses does not seem to leave much motivation for sexual intimacy. Decreased sexual desire is a problem for a substantial number of women. It can cause personal as well as relationship distress. Yet, women often are too embarrassed to discuss the subject with their health care providers, and many feel their physicians are not comfortable talking about this subject with them either.
Female sexual response is substantially different than male sexual response. It is more affected by relationship issues, stress, and other factors. Hormonal fluctuations play a substantial role as well. The aging process, with the loss of estrogen at menopause, will cause significant physical changes. But none of these factors means that sexual intimacy has to disappear!
There are a variety of therapies available to help bring back your sexual relationship and restore intimacy. Often, a review of medications can uncover a culprit that is contributing to the loss of libido, and certain medical conditions can be a factor as well.
Judith K. Volkar, MD, is a staff member in the Cleveland Clinic Center for Specialized Women’s Health (link to clevelandclinic.org/womenshealth), where she also serves as the Quality Officer. She is a board certified Obstetrician/Gynecologist, a Fellow in the American Congress of Obstetrics and Gynecology, and a North American Menopause Certified Practitioner. She also holds an MBA in Healthcare Management.
Dr. Volkar provides clinical care for menopause management, menstrual bleeding disorders, incontinence, hormone therapy, and sexual dysfunction at the Cleveland Clinic main campus.
Prior to joining the Center and moving to Cleveland in the fall of 2010, Dr. Volkar was the principal physician in a private Ob/Gyn practice in Johnstown, PA, and spent 15 years as a staff physician for the University of Pennsylvania Medical Center. Dr. Volkar served as Vice-Chair of the Department of Obstetrics and Gynecology at Conemaugh Memorial Hospital in Johnstown, PA, where she became an outspoken advocate for women’s health care in the community.
Dr. Volkar has published and lectured on topics about the current treatments available for migraines, menstrual migraines, treatment of decreased libido, heart-healthy menopause, and strategic planning for a non-profit women's center. She also shares her medical expertise through local and national news media, community education events, and Speaking of Women’s Health, a national women’s health program managed by Cleveland Clinic that consists of health conferences, a Web site, and monthly e-mail communications.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Dr. Judith Volkar. We are thrilled to have her here today for this chat. Let’s begin with some of your questions.
You’re Not Alone
sal4: Do lots of women complain about decreased sex drive? How normal am I?
Judith_Volkar_MD: Overall in a large study, about 44 percent of women complained about a sexual problem in general. Within that group, only 12 percent of women said that the problem was particularly distressing to them. Decreased libido is most often a symptom in the 45 to 65 age group, although it can be present in any age group. So, it is pretty normal and is a problem that needs to be addressed if it lasts more than 6 months and it bothers you and causes you distress.
conmed: I have no interest in initiating sex, but once we get going, I am fine. Is this common?
Judith_Volkar_MD: Yes, this is very common. Women are much more motivated for sexual intimacy by emotional intimacy rather than by visual cues.Men, on the other hand , are more motivated by visual cues and erotic material. Romantic intimacy gestures lead to emotional satisfaction in women, this makes women more receptive to sexual stimuli; and, therefore, leads to arousal. Many women do not have a strong innate “drive” for sexual activity, but that does not mean that they do not want sex, it just means they need the right motivation. There was even a study just published in USA Today that confirmed that what is missing for sexual drive in women is romantic intimacy. The psychiatric term is institutionalization of the relationship. It really means we have busy lives and the romance is taking a back seat!
samIam: I am young and I feel like I have no sexual drive. How common is this?
Judith_Volkar_MD: Your lack of sexual drive can be influenced by the fact that you may well be stressed or busy. For example, it is harder for a woman to make the change from being a mother to a sexual partner than it is for the father to make that same change. This is due to how our neurotransmitters function in our brains. Women have an increase in neurotransmission for increased sexual drive around the time of ovulation. If you are on a birth control pill, it suppresses your ovulation, and that suppression of ovulation in some women can decrease the neurotransmitters that cause sexual drive. Of course, fear of pregnancy could decrease your sexual drive as well. It is a fine balancing act!
Jordan: Can some of my medications be a cause for decreased libido?
Judith_Volkar_MD: Absolutely. Antidepressants are the number one cause of decreased sexual desire. There are others as well. Blood pressure, cholesterol, heart, seizure medications, and even birth control pills for some people, all can decrease sexual desire. You shouldn't quit your medications just because they cause this side effect. You should talk to your doctor, and you might be able to adjust the medications.
mazie: What medical conditions cause problems with sexual desire?
Judith_Volkar_MD: There are many medical conditions that can cause problems with sexual desire: high blood pressure, diabetes, thyroid disease, cancer, rheumatoid arthritis, just to name a few. It doesn't mean that people with these problems don't have a sex life. It just means they might not function as well, or as quickly, as people without these problems. For example, diabetes can decrease your nerves’ ability to feel things. So a person with diabetes might need more sexual foreplay than a person without diabetes.
soulmyster: What is the shelf life of Viagra® (sildenafil citrate)? How much potency will be lost after that time?
Judith_Volkar_MD: This is a question to ask your pharmacist. If it is past the expiration date, I would throw it out.
pToots: Does a medication like Viagra® work for women?
Judith_Volkar_MD: Viagra® works as a medication that causes an erection in men. It is not a medication for decreased libido. In women, it has been used in a non-FDA-approved (off-label) fashion. For example, women who take antidepressants can suffer from orgasmic dysfunction. Viagra® has been used off-label to help these women. Viagra® has also been used in paraplegic women for similar problems. The drug manufacturers of Viagra® studied this drug in women for low libido and found that it had no efficacy.
HappyDaysAreHereAgain: I have been on Wellbutrin® (bupropion) and Prozac® (fluoxetine) for a number of years. I am now menopausal (hysterectomy for cancer) and have zero interest. I do not want to play around with my medications because they work - so what do I do?
Judith_Volkar_MD: I certainly understand not wanting to change medications that are working well for you and would not advise doing that. Based on the type of cancer, you may or may not be able to add hormone therapy to help with your low libido. You should check with your physician to determine if adding hormone therapy is an option for you.
You can still work on the emotional aspects of your relationship, making sure you understand your and your partner’s wants and desires. Just because you don't have an innate 'drive' does not mean you cannot respond to intimacy gestures and have a sexual relationship.
adamsd2: Does Effexor® (venlafaxine) affect libido?
Judith_Volkar_MD: As an antidepressant, it can have some effects on libido and arousal. Talk to your doctor if you are experiencing a problem. Some antidepressants have more of an effect than others. Therapy still needs to be individualized.
d_ann_s: I sought help with lack of libido five years ago after being told by three doctors that "it was all in my head" or caused by stress and motherhood. Dr. Cheryl Kingsburg was a breath of fresh air. That was when I learned about HSDD. She said that there were no FDA-approved medications, but counseled me on the female arousal cycle and gave me some ideas to jump-start arousal for my body. I am now five years into premature peri-menopause at age 42, and over the past 14 months, my libido has completely disappeared. At this point, it's a chore to have sex even monthly. I've had no past trouble reaching orgasm, no lack of lubrication that I noticed, and no other physical issues that would keep me from performing or enjoying sex. I do have hypothyroidism, which is under control with Synthroid (levothyroxine). I also take vitamin D and calcium supplements plus black cohosh daily. Are there ANY approved medications yet for HSDD or anecdotal evidence of off-label effectiveness with anything? Do you have any other advice that can help me?
Judith_Volkar_MD: Sadly, there still is not an FDA-approved medication for hypoactive sexual desire disorder (HSDD). The fact that you have gone through premature menopause and things are worse does lead one to conclude that your decreased libido is definitely influenced by your hormonal status. While there are no FDA-approved medications, knowledgeable physicians will often use medications in a non-FDA-approved fashion. For example, testosterone gel is only an FDA-approved medication for males. Some physicians will use a small amount of that medication to treat low libido in females, because women need 10 percent of the dose that men need.
venny: Now that I am through menopause, it hurts when I have sex. Why is this?
Judith_Volkar_MD: As women go through menopause, estrogen gets very low. Your vaginal tissue needs estrogen to function properly. Without estrogen, the tissue gets very thin and dry, and sex becomes very painful. You could even have bleeding during intercourse because the tissue is so thin and fragile.
Lubrication and moisturizers can help but are often not enough. Vaginal estrogen can help plump up the cells again and make it no longer painful.
twinsma02: For years I have suffered from my effects of PCOS. Could my lack of desire just be a hormone imbalance and how can I find out?
Judith_Volkar_MD: Polycystic ovarian syndrome (PCOS) does affect your hormones. In some women, because their testosterone is elevated, they actually have more of a sexual drive. It can also lead to other side effects, including affecting your overall sense of well-being.
If you have PCOS, you should see a physician for proper management of it. For example, some women with PCOS have diabetes or pre-diabetes, and this can affect their sexual response.
Isabella: Is it possible for a woman to naturally remain lubricated throughout her life?
Judith_Volkar_MD: Almost all women, once they are past menopause, have decreased vaginal lubrication. For some women, using over-the-counter lubricants and vaginal moisturizers is enough to counteract the vaginal dryness. Replens® is a vaginal moisturizer and KY® Brand Silk-E® is a lubricant that can be used. For some women, this is not enough and they need estrogen supplementation. You can receive vaginal estrogen in a very low dose that will only help your vaginal dryness and not have whole body effects.
Peso: How safe is vaginal estrogen?
Judith_Volkar_MD: Vaginal estrogen is really very safe for the general population. Our bodies makes estrogen naturally until we reach menopause.
If you had or have an estrogen-based cancer, you want to talk to your oncologist about the safety in your particular situation. Some oncologists are fine with it, and others do not recommend it.
Talking With Your Doctor
LucyintheSkies: How do you bring up the topic of decreased sexual desire to your doctor? I am really embarrassed and feel like it would mean that I am having trouble in my marriage? What do you suggest?
Judith_Volkar_MD: Actually, your doctor should bring it up to you, because it is part of your overall health picture. You should feel comfortable talking to your physician about this. A good physician will not assume you have trouble in your marriage, but will work with you to figure a solution to your problem. If your doctor can't help you with this particular situation, or you feel uncomfortable talking to him or her about it, then you should find another physician you can talk to. It doesn't mean you have to switch all of your care, but it may be beneficial to seek another opinion for this problem.
twinsma02: Are there any herbal remedies to boost a woman's sex drive? Would they interfere with prescription medications such as Prozac® and Wellbutrin®?
Judith_Volkar_MD: The biggest problem with herbal remedies is that there is no regulation in that industry. That means that what is on the label is not necessarily what is in the box. There are very few studies that have been done on herbal remedies. The studies that have been done have found no increase in sexual desire. Before you take an herbal medicine, you should talk with your prescribing physician to make sure there is no interference with your particular medications. Herbal supplements can have harmful side effects as well. Just because something is 'natural' does not mean it is safe.
Peso: My mom had ovarian cancer so I'm concerned about any hormone therapy. Is there something "natural" I could take?
Judith_Volkar_MD: I'm sorry to hear about your mother. Ovarian cancer is not influenced by hormone therapy, but by other factors. If you are suffering from low hormones, you should have a discussion with your physician about the safety in your particular case. There is nothing that is 'natural' that is any safer than what you could get as a prescription medication.
Tuesday213: My husband and I want to try adult toys in the bedroom. I'm worried that he will want to have them all the time. How can I tell him maybe we should try something else?
Judith_Volkar_MD: Spicing up your life in the bedroom is a wonderful idea. Just because you try something once does not mean you are committed to using it all of the time. Think of it like you might try an exotic dessert once in a while, but you don't have it every night after dinner. Having a discussion about your sexual likes and dislikes can actually put you in the mood for sexual activity. You might even want to have a 'code word' that takes away the emotions from having to say 'no' that you don't want to try something at that moment.
twinsma02: I am more interested in having my orgasm than trying to enjoy foreplay with my husband. Why does the extra effort bore me?
Judith_Volkar_MD: This is difficult to answer without knowing your entire situation. Make sure your emotional relationship is where you want it to be. Maybe you've gotten into a rut with your foreplay and you need to change things a little bit, or try something new. Ask your husband how he feels and this can generate a discussion on your wants and desires.
twinsma02: I find my husband very attractive but don't really enjoy performing oral sex on him. Is it abnormal to not be turned on by the sight or taste of his penis?
Judith_Volkar_MD: Some women do not enjoy giving or receiving oral sex. It is a personal taste question. There is no normal or abnormal here.
theodore: Do men go through the same thing - decreased libido? Is there anything that can be done or is something wrong with me?
Judith_Volkar_MD: Sexual desire decreases as we age in both men and women. It also decreases as the length of the relationship increases in both genders. There are a variety of factors that affect both genders. It doesn't mean that there is anything wrong with you. It means that you and your physician have to look at all the possible causes and figure out solutions for you.
Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialist Dr Volkar is now over. Thank you for taking the time to answer our questions today.
Judith_Volkar_MD: Thank you all for participating in this Valentine's Day web chat. I've enjoyed answering your questions today. Sometimes, just the very thought of thinking about sex and talking about sex makes you more likely to be sexually responsive. Schedule some time for you and your partner to have some intimate moments, not necessarily driven towards sexual activity, but just to check in with each other. You might be surprised where it takes you.
Cleveland_Clinic_Host: To make an appointment with Dr. Volkar or any of the specialists in Cleveland Clinic’s Center for Specialized Women’s Health, please call 216.444.4HER. Visit us online at clevelandclinic.org/womenshealth.
You may request a remote second opinion from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit eclevelandclinic.org/myConsult.