I see a version of the same woman in my practice almost every week, and by now I can usually tell how the visit will go before we begin. She’s somewhere between 45 and 65, she keeps a schedule that would exhaust an air traffic controller, and she begins with “I know you have other patients with more serious problems, like cancer, but….” as if wanting to want sex again were too frivolous to bring to a physician.
She tells me she loves her partner. She tells me nothing is wrong, exactly. Then she tells me that the last time desire arrived on its own, without being summoned or negotiated or penciled into the calendar, was so long ago that she has started to wonder whether that part of her has closed for good, and whether anyone, including her, is allowed to mind.
A few days ago, I wrote about why desire goes dark after 35 and here’s the next iteration that I promised: the workup I run in my medical practice, in the order I run it, refined across thirty years of sitting across from women like her. I know from those years that low desire is almost never a single problem. It’s usually three to five problems stacked on top of one another, a medication side effect here and a dry, painful vulva there, a nervous system that hasn’t felt safe since the second baby, a thyroid running slow, a testosterone running low, a household task list that’s asymmetric. A decent good workup takes them apart one at a time, starting with the ones that are easiest to solve, though it’s the ones that are more difficult to solve that interest me the most.
The timing of this essay matters, because yesterday, October 19, was the last day the FDA would accept public comments on testosterone for women, a docket the agency opened in August and kept open after its September 17 workshop, where regulators sounded more willing than they have in two decades to see a product approved for women [1, 2]. I wrote about that meeting in My Full Testosterone Protocol. Ten months ago, the agency also extended flibanserin to postmenopausal women younger than 65, which means that for the first time a woman past menopause with distressing low desire has an FDA-approved medication written on a label for her body [3, 4]. Most of the women I meet haven’t heard either piece of news, and I believe the gap between what medicine now permits and what women are told is one of the quiet reasons desire stays lost far longer than it has to.
While that docket was closing, dozens of you were filing a different kind of public comment in response to my last essay, and I’ve read every one. One woman wrote that she gave her husband sex for years to keep the peace while they raised two children, and that when she was tired all the time, he decided she must have a thyroid problem. She went to the doctor to satisfy him. Her thyroid was fine. She was, in her words, an overworked teacher with two kids and a husband convinced something was wrong with her, and the first explanation anyone reached for was a broken gland instead of the weight she was carrying. Another reader told me she didn’t understand how deeply each of those nights had stripped away a piece of her until after she left her marriage. A third described years of feeling like “a disappointment and a problem,” raised on the instruction to “keep your man happy.” Those stories will never reach a federal docket, and every one of them belongs in a workup. The first woman’s story has a second half, too. It took her years to enjoy sex again, and it took her husband years to see that he’d been part of the problem, and now, with the children grown and her classroom behind her, they set aside one evening a week that begins with an hour of talking before anything else. Further down, I’ll walk you through both FDA-approved desire drugs and tell you plainly why, so far, I haven’t reached for either one, and why stories like hers are part of the reason.
Before I order a single lab, I want to know which part of the sexual response is struggling, because desire, arousal, orgasm and pain overlap in ways that can fool an experienced clinician, and treating the wrong one wastes months a woman doesn’t have to spare. Low desire means you rarely think about sex or want it. Low arousal means you want it, but your body doesn’t follow. Pain means it hurts, and many of the women I see have some of all three, braided together so tightly that each one keeps feeding the others.
Next I ask whether it’s new or lifelong, since acquired low desire, the kind that shows up after years of a desire you recognized as your own, points toward something that changed: your hormones, a medication, pain, the weight of what you’re carrying, or the relationship itself. I ask whether it shows up everywhere or only with one person or in one setting, because generalized low desire tends to point toward biology while situational low desire tends to point toward context. And I ask the question that decides whether we’re talking about a diagnosis at all, which is whether any of this bothers you. Distress is what turns low desire into a diagnosis, and if you’re at peace with wanting less, nothing here needs fixing [5, 6]. You’ll see the diagnosis called two names: the current psychiatric manual folds desire and arousal together as female sexual interest/arousal disorder, while the FDA labels and most of the drug trials still use hypoactive sexual desire disorder, or HSDD, which is the term I’ll use here [5, 7].
I start with the Decreased Sexual Desire Screener, five yes-or-no questions that take about two minutes and were built for a busy clinic visit [8, 9]. Then I ask the question most clinicians skip, the one that tends to open the whole conversation: “When did sex start to feel like one more thing on your list?”
**Bottom line: **Name and describe the problem precisely before you treat it, because desire, arousal, orgasm and pain each have their own fix, and only your distress can tell us whether there’s anything to fix at all.
Below the paywall line is the rest of the workup in the precise sequence I use: the moves I work through with a woman and her prescriber when an antidepressant is flattening her desire, the ten-test desire panel I order and the one “normal” result that fools almost everyone, the hormone sequence from local estradiol to testosterone with the starting dose and recheck window I use, both FDA-approved desire drugs with their doses, their trial results and the reason I haven’t used either one, the nervous-system work whose evidence holds up beside the pills, and a twelve-week plan with a one-page summary you can print and hand to your clinician. I wrote it the way I wish someone had written it for me in my forties, when I was both the depleted woman in the chair and the physician who couldn’t find a single document that put the pieces in order. Every month the pieces stay scattered, the vaginal tissue thins further, a medication side effect hardens into a way of life, and the nervous system learns a little more firmly that touch means bracing.
