Our unique genetic make up creates a default libido after puberty in males and females alike. Life stages in females steer the course of hormone balance at puberty, pregnancy and menopause, whilst male libido is not impacted by this number of life stages having a steady hormone balance after puberty, following a natural & gradual decline of some hormones until middle age. Environmental factors however can change libido for both sexes, by interacting with hormone levels both directly and indirectly. Examples include medications, diet, exercise, stress and sleep.

Hormones involved in libido for women

Oestrogen & perimenopause

Oestrogen and testosterone as well as cortisol levels can influence libido in females.(1) From 35 onward female oestrogen levels naturally decline, usually at a slow and gradual rate until menopause has been reached. When perimenopause has been entered, fluctuations in oestrogen are often experienced, causing peaks and troughs in libido as well as mood in general, vaginal dryness, night sweats and flushing. The combined effects of the symptoms described don’t make for heightened desire in many cases, with women avoiding physical intimacy as a result.

On the flip side of this of course is that the fluctuations mean that women may also experience increased libido at times, following this erratic pattern of hormonal change. During clinic sessions women report that the increase in libido is welcomed when in a relationship whilst single females find this quite irritating! Equally, the inconsistencies of libido changes can leave their partners a little confused and perhaps unsure of how and when to pursue physical intimacy. Indeed, for all parties, the unpredictability of many of the shifts menopause brings is often the hardest aspect of this transition.

Testosterone

Testosterone impacts libido in females in conjunction with oestrogen. The interplay between testosterone and oestrogen shifts is complex however and simply replacing or treating with testosterone is not the first line of treatment. The British Menopause Society state that transdermal oestrogen (gel or patch form of HRT) can be beneficial in addressing libido issues as this can increase the proportion of circulating free testosterone without requiring exogenous testosterone (testosterone HRT treatment) (2).  For this reason, NICE guidelines suggest that conventional HRT is trialled by women before testosterone treatment is considered. In practice women are encouraged by GPs to trial HRT for 12 months before testosterone is considered as therapy.

Cortisol & menopause

Lets talk about cortisol. One of the main stress response hormones, cortisol plays a crucial role in daily life. Waking (Impacting circadian rhythm), motivation (fear or flight), movement, physiological (blood sugar maintenance, blood pressure management) & physical ability (blood flow to muscles in readiness for movement) as well as bone formation control, metabolism of nutrients and energy levels. It covers many aspects of life and triggers changes in other hormones, bringing about new sets of symptoms such as anxiety, poor sleep & weight gain when chronically high levels are produced over time.

When sex hormones such as oestrogen & testosterone are in decline cortisol is often raised. This adds a further complexity to the balance of hormones we are hoping to achieve. Stress in itself can lower libido for many and raise for some but ongoing longer term stress seems to have a significant effect in libido lowering, whatever the underlying cause. (3)

The table below outlines some researched interventions we can apply to support us through perimenopause and beyond. Notice the overlap and interplay between each category as we link lowering some to increase others.

*Please note that whilst many natural remedies are supportive in treating a low libido at menopause, many herbal preparations conflict with medications and are contra-indicated for use. For safety, please do not take these if you take medications without the approval of your GP or specialist.

What about progesterone?

Progesterone has a notable calming effect on the brain, and diminished levels of this hormone can result in heightened anxiety, irritability, and mood fluctuations, symptoms of depression or feelings of sadness, weight gain and bloating (water retention) within the body. Other manifestations of low progesterone include fatigue, diminished libido, and hot flushes.

It’s the balance of progesterone in relation to oestrogen however that is most pertinent and this of course is an individual nuance that may take several tweaks in HRT application to treat successfully. Simply adding more of either hormone can bring about a new set of symptoms in itself. Patience and willingness to trial new doses and applications of HRT seems to be key here in getting the most from hormone therapy if you choose this path.

A person centred, holistic and integrated approach is in my experience, the most effective one in helping women feel better now, whilst supporting future health outcomes.

References

1 Alessandra Graziottin, Libido: the biologic scenario, Maturitas, Volume 34, Supplement 1, 2000, Pages S9-S16, ISSN 0378-5122, https://doi.org/10.1016/S0378-5122(99)00072-9. (https://www.sciencedirect.com/science/article/pii/S0378512299000729)

2 08-BMS-TfC-Testosterone-replacement-in-menopause-DEC2022-A.pdf

3 Thomas HN, Hamm M, Hess R, Borrero S, Thurston RC. "I want to feel like I used to feel": a qualitative study of causes of low libido in postmenopausal women. Menopause. 2020 Mar;27(3):289-294. doi: 10.1097/GME.0000000000001455. PMID: 31834161; PMCID: PMC7047535.