Asking for a friend: Why does a woman's sex drive go away?

Pop culture would lead us to believe that we should all want sex all of the time, but that simply isn’t the reality for a lot of women.

Gynecologist Richard Heywood, DO, at Falmouth Women’s Health talks to patients all the time about this topic. The two most common times that women don’t desire intimacy as much are after childbirth and after menopause.

“I think those are big stress points in relationships and in a woman’s natural life cycle,” Dr. Heywood said. “There is nothing that more effectively turns off your interest in being sexually active than stress.”

Dr. Heywood’s frame of reference for how he counsels patients about sexuality is influenced by the book “Come as You Are,” written by sex therapist Emily Nagoski, Ph.D. In the book, Nagoski explains that there is no such thing as a “sex drive.” A drive is a motivational system that helps people deal with life-or-death issues. With that in mind, hunger is a drive. If we don’t eat, we will die. Nobody has ever died from not having sex or reproducing.

Postpartum

“I spend a lot of time talking to and counseling women on this,” Dr. Heywood said. “With the younger patients that have just had a baby, I like to say before having this baby, you had a priority which was the potential to make a baby. So, you had an interest in reproducing and an interest in having intercourse. Now that you have that baby, your priority has shifted to let’s take care of this baby, not make another one - at least initially.”

It can sometimes take up to a year or two after childbirth before some women feel like being intimate with their partner. Dr. Heywood always reassures his patients that this is normal and that they are not broken. They just have different priorities.

The combination of physical exhaustion and changes to their body after childbirth also contributes to a lack of interest in intercourse. Some women feel less desirable than they did before pregnancy, which adds to the stress.

Then there are the mechanical issues. It’s not uncommon for women to experience urinary incontinence after childbirth. Some women have prolapsed or fallen uteruses that cause discomfort. These women may need surgical treatment from a gynecologist, like Dr. Heywood.

Other women might have pain from the lacerations that occurred during childbirth. Sometimes the corrective sutures to fix those lacerations result in an “over repair,” he said. Pelvic or vaginal muscle spasms could also be an issue. In those cases, Dr. Heywood recommends a round of physical therapy with a focus on the pelvic floor.

“Right after having a baby, vaginal dryness is also an issue,” he said. “For a lot of people, pain with intercourse is a huge problem. If you have intercourse and it hurts, you’re not ready to do that again.”

Dr. Heywood always recommends a silicone or silicone hybrid lubricant to his patients. They are not absorbed into the body; they aren’t irritating and they don’t cause yeast infections or allergic reactions. Water-based lubricants start out slippery but they quickly dry and get sticky.

“A lot of times the pain or mechanical discomfort from intercourse may improve with (lubricants),” he said.

One of the tips Dr. Heywood offers patients is that when they feel ready to resume intercourse, he suggests scheduling a specific date night at whatever interval is comfortable for both partners. That way, both partners can build up anticipation and get in the right headspace for intimacy. It also decreases stress because the woman isn’t constantly rejecting her partner.

You can plan a candlelit game night, a long walk or cuddle on the couch and watch a movie to help make you feel closer to your partner. Any favorite activity you can do together helps create intimacy, Dr. Heywood said. “It’s those little things that remind you why you’re together in the first place” he said.

Post-Menopause

Changing hormone levels and the resulting pain that can occur during intercourse after menopause can make older women not want to have sex.

“The most common cause of pain during intercourse after menopause is vaginal dryness,” Dr. Heywood said. “The gold standard treatment for that is vaginal estrogen. Using vaginal estrogen topically does not carry the same risk-profile as using systemic oral hormone replacement.”

He jokes with older patients that the old adage that you have to use it or lose it is actually true when it comes to sex.

“You have to maintain the system or you’re going to have difficulty trying to use it later,” he said, explaining that this does happen.

Dr. Heywood has patients who are many years post-menopause and may not have been sexually active for years. When they find a new partner and want to resume intercourse, there may be some work that needs to be done to make sex enjoyable. The vaginal estrogen and lubricants will help, but some women might need physical therapy or vaginal dilators.

“Along with vaginal dryness, you lose the elasticity of that tissue, and you lose abrasion resistance as well,” he said.

Some older patients say they truly just aren’t interested in having intercourse. His follow-up questions are: “Is that okay with you? Is it stressing you out or do you not care?”

He also points out that even if an older patient doesn’t want to have intercourse, vaginal estrogen has other benefits. It prevents urinary tract infections, which are very common in older women. It also helps prevent spontaneous vaginal bleeding that can occur when the tissue becomes too thin and fragile from atrophy.

“I tell patients using vaginal estrogen to use the cream because it’s the least expensive and it’s accessible,” he said. “I have them use a small amount daily for a couple of weeks and then we’ll back off to using it just a couple of times a week. For a lot of women that can be just enough maintenance to keep that tissue healthy, prevent symptoms and maintain quality of life.”