In short
Low desire is the most common sexual concern women report, and it only counts as a disorder if it distresses you.
- 39 per cent of women report low desire. It causes distress in 10 to 14 per cent.
- Distress is highest between 45 and 64, at 15 per cent, and lowest over 65, at 9 per cent.
- Desire does not have to come first. For many women in long relationships, desire follows arousal rather than preceding it.
Relationship factors predict sexual function in midlife better than hormone levels do.
Condition Overview
How common is it?
Very. In the largest United States study, over 30,000 women, 39 per cent reported low desire, making it the most common sexual problem by some distance.
Distress is the part that matters. Of that 39 per cent, 10 to 14 per cent had distress associated with it. Overall, 43 per cent of women reported any sexual problem, and 12 per cent met criteria for a sexual dysfunction, meaning a problem plus personal distress.
Does desire have to come first?
No, and this is the single most useful thing to know. The old model of desire, then arousal, then orgasm does not describe most women’s experience.
For many women in long term relationships, desire is not present before sexual activity but appears with arousal in response to pleasurable activity. Satisfaction also does not require reaching every phase, including orgasm.
Women are also often motivated by reasons other than desire: emotional closeness, or strengthening a relationship.
What predicts it?
| Relationship factors | The strongest predictors. In a longitudinal study across the menopause transition, sexual response was predicted by prior function, change in partner status and feelings for the partner, more than by hormones |
| Emotional wellbeing | Among the best predictors of sexual distress in a national sample of nearly 1000 women |
| Fatigue and stress | Major, and under studied. The typical improvement in sexual interest on holiday says a great deal |
| Physical health | More strongly associated with sexual problems than age alone in women aged 57 to 85 |
| Medication | SSRIs, antipsychotics and benzodiazepines all reduce desire |
| Pain | Sexual pain frequently causes low desire rather than the other way round |
Is it about age or about menopause?
Harder to separate than it looks. Distressing sexual problems peak at 45 to 64 at 15 per cent, and fall to 9 per cent over 65, which is not the pattern you would expect if it were simply age.
Where low desire arrives at menopause alongside vaginal dryness, painful sex, hot flushes and disrupted sleep, treating those symptoms usually improves the desire.
Is it testosterone?
Usually not. In most studies androgen levels do not correlate with female sexual function, and ovarian testosterone production stays relatively constant across natural menopause.
In one study of over 2900 women aged 42 to 52, no association was found between sexual function and testosterone, DHEA-S or the binding protein.
When to See a Doctor
- Loss of interest in sex is bothering you, which is the part that makes it worth treating
- It changed at a identifiable point: after a baby, after starting a medication, or around the menopause
- Sex has become uncomfortable or dry, which often causes the loss of desire rather than following it
- You started an antidepressant and desire or orgasm changed afterwards
- You have been offered testosterone and want to know what the evidence actually shows
- Pain with sex, bleeding after sex, or a new lump or lesion, which need examination rather than a desire discussion
- Milky discharge from the breasts, which needs prolactin checked
- Low mood, loss of interest in everything, or thoughts of self harm, which need assessment now
How Dr. Felix Assesses This
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1
When it changed and what changed with it
Onset and context identify the cause more often than any test. Low desire appearing with vaginal dryness, hot flushes and disturbed sleep points to menopause. Appearing after starting an SSRI points to the medication.
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2
Whether it is actually distressing you
This is the diagnostic criterion, not a formality. A low level of desire that does not bother you is not a disorder, and treatment aimed at a number rather than at distress helps nobody.
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3
Everything that is not desire
Arousal, orgasm and pain are separate problems that often masquerade as low desire. Pain in particular commonly causes it, and treating the pain restores the desire.
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4
Health, medication and the relationship
Physical health, mood, fatigue, sleep, medication and the relationship itself, which is the strongest predictor of sexual function in midlife and is asked about directly rather than skirted.
Treatment Options
HRT Consultation
What this appointment decides Three things, in order. Whether your symptoms are hormonal. Whether hormone therapy suits your medical history.…
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Women’s Hormone Optimization
What does hormone imbalance usually turn out to be? In a classic series of 262 women with cycles that had…
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Bioidentical Hormone Therapy
What does bioidentical actually mean? Technically, a bioidentical hormone has the same molecular structure as a hormone your own body…
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Low Libido Treatment
Treatment by cause Low testosterone Replacement, once confirmed. The most reliably treatable hormonal cause Raised prolactin Treated in its own…
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Why Early Treatment Can Matter
What actually helps?
- Treating menopausal symptoms where the desire fell alongside dryness, pain, flushes and poor sleep. Improving those usually improves desire
- Treating pain, which is often the cause rather than the consequence
- Reviewing medication, particularly SSRIs, antipsychotics and benzodiazepines
- Treating the mood disorder, if there is one
- Addressing the relationship, which the evidence consistently ranks above hormones in midlife
Why the route of oestrogen matters
Oral oestrogen raises the binding protein and lowers free testosterone. Transdermal oestrogen at normal doses does not.
In a study of recently menopausal women, transdermal oestradiol improved the overall sexual function score against placebo while oral oestradiol did not. That is a practical reason to choose the patch or gel where sexual concerns are part of the picture.
What about testosterone, honestly?
Randomised trials in over 1500 menopausal women with distressing low desire and no other cause found that a testosterone patch increased satisfying sexual activity, desire and arousal against placebo.
The effect size was about one additional satisfying sexual event in four weeks. Two manufacturer trials of a testosterone gel found no significant effect despite similar blood levels. Clear benefit in other studies only appeared at doses approaching the male range.
So it is neither useless nor a solution, and it is not offered as a routine measure.
What is not the answer
- Systemic DHEA in women without adrenal insufficiency, which does not appear to improve sexual function
- Compounded hormone mixtures
- Treating a hormone level rather than a symptom, when levels correlate poorly with function
Why Early Treatment Can Matter
What actually helps?
- Treating menopausal symptoms where the desire fell alongside dryness, pain, flushes and poor sleep. Improving those usually improves desire
- Treating pain, which is often the cause rather than the consequence
- Reviewing medication, particularly SSRIs, antipsychotics and benzodiazepines
- Treating the mood disorder, if there is one
- Addressing the relationship, which the evidence consistently ranks above hormones in midlife
Why the route of oestrogen matters
Oral oestrogen raises the binding protein and lowers free testosterone. Transdermal oestrogen at normal doses does not.
In a study of recently menopausal women, transdermal oestradiol improved the overall sexual function score against placebo while oral oestradiol did not. That is a practical reason to choose the patch or gel where sexual concerns are part of the picture.
What about testosterone, honestly?
Randomised trials in over 1500 menopausal women with distressing low desire and no other cause found that a testosterone patch increased satisfying sexual activity, desire and arousal against placebo.
The effect size was about one additional satisfying sexual event in four weeks. Two manufacturer trials of a testosterone gel found no significant effect despite similar blood levels. Clear benefit in other studies only appeared at doses approaching the male range.
So it is neither useless nor a solution, and it is not offered as a routine measure.
What is not the answer
- Systemic DHEA in women without adrenal insufficiency, which does not appear to improve sexual function
- Compounded hormone mixtures
- Treating a hormone level rather than a symptom, when levels correlate poorly with function
What responds
Treating menopausal symptoms, treating pain, changing a medication, treating a mood disorder, and addressing the relationship.
What gets missed
Pain causing the low desire, an SSRI causing it, and a relationship difficulty that no hormone panel will show.
Distress is the criterion
A low level of desire that does not bother you is not a disorder. What is treated is the distress, not the number.
Cost & Consultation Investment
The consultation is quoted individually and any tests are quoted before they are ordered. The panel is short, because hormone levels correlate poorly with sexual function in women and broad screens mostly generate results that need chasing. Saliva hormone testing and compounded hormone mixtures are not used. Where onward referral to a psychosexual therapist is the right step, that is said plainly.
Frequently Asked Questions
It is extremely common. 39 per cent of women report it, and it only meets criteria for a disorder when it causes personal distress, which applies to 10 to 14 per cent.
Not necessarily. For many women in long term relationships, desire appears with arousal rather than before it. The older desire-then-arousal model does not describe most women's experience.
Probably not relevantly. In most studies androgen levels do not correlate with female sexual function, and ovarian testosterone production stays fairly constant across natural menopause.
The honest answer is a little, in a specific group, at a defined cost. Trials in menopausal women with distressing low desire showed roughly one additional satisfying sexual event in four weeks, and gel trials found no effect at all.
Almost certainly. Sexual pain frequently causes low desire rather than resulting from it, and treating the pain, often genitourinary syndrome of menopause, usually restores the desire.
In midlife, the evidence says yes. Across the menopause transition, sexual response was predicted by prior function, change in partner status and feelings for the partner more than by hormone levels.
SSRIs cause low desire and difficulty reaching orgasm in women, and antipsychotics and benzodiazepines also contribute. There are specific strategies for managing this rather than simply stopping.
Evidence
Where this information comes from
Every figure on this page is taken from the sources below. All of them are free to read, so you can check them yourself.
This page is general medical information and does not replace a personal consultation. Trial results are averages across large groups, not a prediction for any one person.