The PGspot - The Libido Puzzle: Five Pieces That Shape Sexual Desire

Low sexual desire is often treated like a simple problem: the desire is missing, so let’s figure out how to get it back. But female sexual desire is rarely that straightforward. In this episode, we’re looking at the bigger picture behind decreased sexual desire and the many pieces that can influence whether sex feels appealing, accessible, or even worth considering.

We’ll explore five key areas to consider when assessing low desire. From hormones, medications, sleep, and stress to emotional connection, sexual experiences, relationship dynamics, and everything else competing for attention, each piece can affect the desire puzzle in different ways.

Because sometimes the answer isn’t simply “how do we increase libido?” The better question may be: What’s getting in the way of desire in the first place? In this episode we’ll take the pieces apart and look at the whole picture.

If you want to learn more about sexual health, sexual dysfunction, or how to improve your sex life, follow me on Instagram at @thepgspot or check out my website at doctorpattyj.com for blogs and resources related to sex positivity and real talk about sexuality.  As as always, stay curious, stay empowered, and stay you.

Transcript

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Welcome to the PG Spot, where our goal is to take the ex out of sex by breaking down the barriers that prevent open communication about sexual health. I'm Dr. Patty Jalomo, a dual-certified nurse practitioner, pelvic floor therapist, and certified sexual counselor. I'm here to provide expert insights, debunk myths, and empower you to embrace your sexual well-being. Whether you're looking for answers or simply curious, join us as we open up the conversation around sex, intimacy, and everything in between. I want to take this opportunity to acknowledge that some content may not be appropriate for all listeners. I'm a huge proponent of honest and accurate information regarding sexuality, but I'm also mindful that this should be age-appropriate. Therefore, if you are under 18, this may not be the podcast for you. Additionally, some of the language used in this podcast may be offensive to some listeners. Please take these things into consideration before going forward with your consensual participation in this podcast. The opinions expressed by myself or my guests are just that, and these opinions are neither expected nor required to be shared by all listeners. The information that is provided is for educational and entertainment purposes only and should not be mistaken for individual medical advice. If you would like to schedule a virtual visit for individual or couples sexual counseling or menopause management, you can contact me via my website at thepgspot.com. Thanks for listening, and let's get on with the show Hey, everyone. Welcome to "The PG Spot." I'm your host, Dr. Patty Jalomo, and today we're talking about something that I hear almost every single day in my practice. Women come in convinced that something's wrong with them because they don't want sex the way that they used to. Some women tell me they have no libido at all. Others say that they love their partner, but just never think about sex anymore. Many have already spent hours searching online, listening to podcasts, or scrolling through social media looking for the answer. They've wondered if it's their hormones, if they just need testosterone, if menopause is to blame, or if they simply need to just try harder, and almost every one of them eventually says the same thing: "I just don't feel like myself anymore." The truth is that low sexual desire is incredibly common, but the way we've been talking about it has become surprisingly narrow. We've created a culture that often treats libido like a hormone level that simply needs to be restored, as though desire has an on/off switch, and all we have to do is find the right medication to flip it back on. Hormones absolutely matter, and for many women, they are an important piece of the puzzle, but they are rarely the entire story. One of the biggest misconceptions about female sexuality is the idea that desire exists in isolation. It doesn't. A woman's interest in sex is influenced by her physical health, her emotional well-being, the quality of her relationship, the kind of sexual experiences she's having, and the context of her everyday life. When we focus on only one piece, we risk missing the real reason that desire's changed. That's why when a woman comes to see me for low libido, my first goal isn't to figure out which prescription to write. My first goal is to understand her story. Before we can talk about treatment, it's important to understand what's getting in the way of desire in the first place. Today, I'm going to walk you through the same framework that I use during an initial consultation. These five areas help me look beyond the symptom of low desire so we can better understand what's actually contributing to it. Along the way, we'll talk about spontaneous versus responsive desire, Emily Nagoski's concept of accelerators and brakes, the impact of mental load and resentment, why feeling unseen in a relationship can quietly erode desire, and why telling women to just have more sex may be some of the least helpful advice that they can receive. The key takeaway is this: having a low libido does not automatically mean that there's something inherently wrong or that the relationship is in trouble. It may just be that we've been asking the wrong questions. Over the past several years, we've seen an incredible shift in the conversation around women's sexual health. For decades, many women suffered in silence, believing that losing interest in sex was simply a part of getting older or something that they were expected to tolerate. Today, women are talking about libido more openly than ever before. As I've mentioned, they're listening to podcasts, joining online communities, and following menopause specialists on social media. Because of this, they're finally realizing that they're not alone, and this is actually a good thing. Women deserve accurate information, and they deserve to know that there are treatment options available. But as awareness has increased, I've also noticed another trend emerging. Somewhere along the way, we started looking for one simple explanation and one simple solution For many women, that explanation has become hormones. Just to be clear, hormones absolutely play a significant role in sexual desire. As a menopause specialist, I see firsthand how estrogen deficiency can contribute to vaginal dryness and painful intercourse, and how hormonal changes during perimenopause and menopause can affect sexual function. There are also women who are appropriate candidates for treatments like hormone therapy or other medications for low desire. Those treatments can be life-changing when they're used for the right person and the right reason. The problem is when hormones become the only lens that we look through to view low libido, we immediately assume that every woman with low desire simply needs a prescription, and then we risk overlooking the many factors that influence sexual interest. Desire doesn't happen in a vacuum. It's shaped by our physical health, our relationships, our emotional well-being, our daily stress, our sexual experiences, and even the invisible mental load that we carry from one day to the next. Think about it this way. If someone came into my office because they were exhausted all the time, I wouldn't automatically assume that they were iron deficient. Fatigue can certainly be caused by iron deficiency, but it could also be related to poor sleep, thyroid disease, depression, chronic stress, medications, a demanding schedule, or any number of other conditions. The symptom may be the same, but the underlying cause can be very different. The same concept is true for low desire. Two women may both tell me that they have no libido, but the reasons behind that experience may be completely different. One woman may be experiencing hormonal changes associated with menopause. Another may have untreated pain during sex. Someone else may be carrying years of resentment in her relationship. Another may simply just be so overwhelmed by work, parenting, caregiving, and the constant demands of daily life that her brain never has the opportunity to shift into a space where desire can even emerge. That's why I believe we have to stop asking, "How do we fix your libido?" And start asking, "What's getting in the way of your desire?" That one shift in perspective changes the entire conversation. Instead of assuming that every woman has the same problem, we become curious about her unique experience. And when we ask better questions, we usually find better answers. That's exactly why I use the same five-part framework with every patient who comes to see me for concerns about low libido. It helps me look beyond the symptoms and identify what's really driving the change in desire. More importantly, it helps us create a treatment plan that's individualized instead of relying on a one-size-fits-all solution. One of the first things I tell my patients is that there isn't a single question that can explain why someone has lost desire for sex. Female sexuality is simply too complex for that. Instead, I approach every evaluation with a framework that helps us look at the whole person rather than just focusing on just one possible cause. Over the years, I've found myself coming back to these same five areas again and again because they give me a much clearer picture of what's really happening. Sometimes one area stands out immediately. Other times, there are several factors working together. That's often the case because as we said, our sexuality doesn't exist in separate compartments. our physical health affects our relationships, our relationships affect our sexual experiences, and our everyday lives influence all of it The framework is basically looking at five areas, and that includes body, want, relationship, sex, and context. I don't necessarily move through these in a rigid order, but I make sure that we've explored each one before we start talking about treatment. The reason is simple. If we skip straight to trying to increase desire without understanding what's suppressing it, we may end up treating the symptom instead of the cause. So let's start with the first area, the body. The first question I ask myself is, could something physical, hormonal, medical, or medication-related be affecting her desire? This is where my medical training comes in. Before we assume that there's a psychological or relationship issue, we need to make sure that there isn't a physical explanation that's contributing to the problem. We'll talk about medications because many commonly prescribed drugs can affect sexual desire. Antidepressants, some blood pressure medications, hormonal contraceptives, and other medications can all play a role. We review medical conditions such as thyroid disorders, diabetes, chronic pain, depression, anxiety, and any other health concerns that may be affecting energy, mood, or sexual function. Sleep is another huge piece of the puzzle. Someone who's chronically sleep-deprived or exhausted may not have much left to give at the end of the day, and that's not a character flaw. It's just biology. For women in midlife, we might also spend some time talking about menopause and about genitourinary syndrome of menopause, or GSM. Vaginal dryness, burning, urinary symptoms, and painful intercourse can dramatically affect someone's interest in sex. If intimacy has become uncomfortable or painful, your brain quickly learns to associate sex with something to avoid rather than something to look forward to. hormones are part of this conversation too. for some women, they're a significant contributor to low desire. But they're one piece of a much larger picture. My goal isn't to determine whether hormones are the answer before we've explored something else. My goal is to understand how all of these physical factors may be interacting with the rest of her life. Sometimes we identify a medical issue that deserves treatment, and addressing it makes a remarkable difference. Other times, everything looks normal from a medical standpoint, which tells us that it's time to keep digging. If the body doesn't fully explain the loss of desire, then we need to ask a different question. This may actually be one of the most important questions in the entire evaluation. It's also the question that often catches women off guard because no one has ever asked them before. The question is, "Do you actually want sex, or do you wish you wanted to want sex?" At first, those questions sound almost identical, but they're very different. Some women immediately tell me, "I miss that part of myself. I miss feeling sexual. I miss wanting my partner and looking forward to intimacy." They aren't just distressed because sex isn't happening, they genuinely miss their own desire. They want that part of themselves back because it felt like an important part of who they were. Other women may simply say something like, "Honestly, I don't really miss sex. I just wish I wanted it because my husband wants it," or, "I feel guilty because I know I should want it more," or, "I don't wanna keep disappointing my partner." So those are very different conversations. In the first situation, we're talking about a woman who feels a personal loss. In the second, we're often talking about someone who's feeling pressure, guilt, obligation, or fear of letting someone else down. That distinction matters because the treatment may look very different. Sometimes the distress isn't coming from the absence of desire itself, it's coming from the belief that there's something wrong with her because her level of desire doesn't match what she thinks it should be. Maybe she's comparing herself to how she felt when she was 25, when she first met her partner, or before she had children. Maybe she's comparing herself to what she sees on social media or what she thinks every other woman is experiencing. I also like to explore where those expectations come from. Were messages about sex shaped by a strict religious upbringing or cultural beliefs? Did she grow up hearing that, quote, "Good women weren't supposed to enjoy sex"? Has she spent years putting someone else's needs ahead of her own? Is she carrying shame about her body or about wanting sex in the first place? Our beliefs about sexuality often begin long before our first sexual experience, and they don't simply disappear in adulthood They can quietly influence how we think, how we feel, and even whether we give ourselves permission to experience pleasure. Another thing I pay close attention to is whether she's describing low desire or whether she's describing emotional exhaustion. Sometimes women tell me they have no libido, but as we continue talking, it becomes clear that what they've really lost is time for themselves, a sense of identity outside of caregiving, or the emotional capacity to think about one more person's needs. That's a very different problem than a true disorder of sexual desire. This is also where I keep one question in my back pocket. I don't ask it in every visit, but when I'm trying to understand what low desire really means to someone, it can be incredibly revealing. I ask, "If I could magically give you back your libido tomorrow, what would you want to do with it?" I love this question because there isn't a right or wrong answer. Some women say they'd want to reconnect with their partner, while others say that they might feel more like themselves again. Sometimes they just admit that they're not really sure, and that answer is just as important as all the others. What I'm really trying to understand isn't whether she has low libido. I'm trying to understand what her sexuality means to her. What does she miss? What does she hope will change? And whose expectations are driving the distress? Once we understand that, we can begin to build a treatment plan that reflects her goals, not society's or not her partner's expectations, but hers. Before we can help someone rediscover desire, we first have to understand whether the desire that they're searching for truly is their own. So once we've talked about the body and we've explored whether she truly wants to rediscover her desire, the next place I turn to is the relationship itself. This is where we begin to ask questions like, "Do you feel safe with your partner? Do you feel respected? Do you feel heard? Do you enjoy being around them? Do you feel emotionally connected?" While those questions may sound like they're not about sex, they really are. For many women, emotional intimacy and sexual intimacy are closely connected. That doesn't mean that every disagreement causes low libido, and it certainly doesn't mean that every relationship problem results in sexual difficulties. But when someone consistently feels dismissed, criticized, taken for granted, or emotionally alone, it's difficult for desire to flourish. One of the things I often hear is, "My partner is a really good guy. He doesn't cheat. He works hard. He loves our family. I don't know why I don't want sex." Sometimes, though, as we continue talking, another story may begin to emerge. It may be that she doesn't feel listened to or that she's carrying the weight of the household. She may feel more like a roommate, a co-parent, or even a project manager than a romantic partner. It could be that she can't remember the last time that they had a meaningful conversation that wasn't about kids, work, or bills. She may express that she's exhausted from asking for help, explaining her needs, or trying to keep someone else happy. None of those things may seem directly related to low libido, but together they can slowly erode emotional connection. And when emotional connection fades, sexual desire often follows. Many times what I hear from women is that they feel unseen. Not necessarily unloved, but unseen, which is very different. Feeling unseen isn't necessarily about grand romantic gestures. It's about feeling known or appreciated. It's feeling like your thoughts, your efforts, your emotions, and your needs matter to the person that you share your life with. When someone feels invisible day after day, resentment often begins to grow. Resentment is one of the most powerful brakes on sexual desire that I see in clinical practice. It's difficult to feel open, playful, and vulnerable With someone that you're quietly angry with. It's difficult to crave intimacy when you've spent years feeling unheard or emotionally disconnected. That doesn't mean that every couple struggling with desire has a troubled relationship. Some have wonderful relationships and still experience low libido for medical or hormonal reasons. Others deeply love one another but have simply become disconnected over time as careers, children, caregiving, and everyday responsibilities have gradually crowded out the parts of their relationship that once felt fun, affectionate, and intimate. The encouraging part is that relationships are dynamic. They can change. Sometimes the work isn't about increasing libido at all. Sometimes it's about rebuilding friendship, improving communication, expressing appreciation more, repairing old hurts, or making space to enjoy each other's company again. Desire grows much more easily in an environment where people feel emotionally safe, valued, and connected than in one where they feel lonely, resentful, or unseen Of course, even in the healthiest relationships, there's another question that has to be asked. Is the sex itself something worth wanting again? This is simply dopamine 101. If something isn't pleasurable, the feel-good chemicals in the brain aren't going to associate it with something that the person craves or desires. Sometimes we become so focused on why someone doesn't want sex that we never stop to ask what happens when they actually do have it. Was it enjoyable? Did she feel emotionally connected? Did she have adequate stimulation? Did she experience pain? Did she have an orgasm? And if not, was that because she wasn't adequately aroused or because orgasm wasn't really part of the experience in the first place? When women answer these questions honestly, it often changes the direction of the conversation. Think about it this way. If every time you went to your favorite restaurant, the food was disappointing, the service was rushed, and you left feeling unsatisfied, you probably wouldn't find yourself looking forward to going back. It wouldn't be because there was something wrong with your appetite. You simply wouldn't be motivated to repeat an experience that wasn't particularly rewarding. Sexual desire isn't just influenced by hormones. It's also shaped by learning, experience, anticipation, and reward. When sex consistently feels pleasurable, emotionally fulfilling and enjoyable, the brain begins to associate intimacy with something positive. But when sex is painful, rushed, disconnected, predictable, or centered entirely on one person's experience, it's understandable that desire begins to fade. Unfortunately, many women have spent years believing that intercourse alone is supposed to be enough. They assume that if they aren't enjoying sex, the problem must be them. The reality is that most women require direct clitoral stimulation to reach orgasm, and many need time for their bodies to become fully aroused before intercourse is comfortable and pleasurable. If arousal is rushed or if pleasure isn't prioritized, sex can begin to feel like another task to complete rather than an experience to anticipate. As we mentioned in the first section, pain is an important issue that deserves attention. Whether it's vaginal dryness related to menopause, pelvic floor dysfunction, vulvodynia, endometriosis, or another medical condition, painful sex should never be dismissed as something that women simply have to live with. Pain changes the way the brain responds to intimacy. If your body has learned that sex is likely going to hurt, it's doing exactly what it was designed to do when desire begins to disappear, and that's trying to protect you. I also encourage couples to think about whether they've fallen into a routine that no longer creates excitement or connection. Many long-term relationships can become incredibly predictable. The same time, same place, same sequence of events with very little curiosity or novelty. While routine can create comfort, it doesn't always create anticipation. One of the questions I sometimes ask is, "When you think about your last sexual experience, did it leave you thinking, 'I can't wait to do that again,' or did you leave being relieved that it was actually over?" And that question isn't meant to create guilt or shame. It's meant to help us understand whether the experience itself is reinforcing desire or if it's quietly extinguishing it. If sex isn't physically pleasurable, emotionally satisfying, or mutually enjoyable, it makes perfect sense that desire would begin to decline. Rather than wondering how to make someone want to have sex more often, a better question is, how do we make sex an experience that's actually worth wanting again? The final area I explore is context because sometimes the biggest barrier to desire isn't found in the body, the relationship, or even the sexual experience itself. Sometimes it's everything that's happening around it. One of the questions I might ask is, "When you're relaxed, unhurried, and free from pressure, does desire ever show up?" For many women, the answer is yes. Maybe not every day or even every week, but there are moments. Possibly it's during a vacation or after a long weekend together, on a date night where they actually felt connected, or one of those rare evenings where there wasn't a never-ending list of things to do waiting for them. That tells me that desire isn't necessarily gone. It may simply need the right conditions to emerge This is where I like to introduce the concept of responsive desire, because it's a pattern of desire that is incredibly common, especially for women. Yet so many people have never heard of it. We've been taught to think that desire is supposed to work like it often does in the beginning of a new relationship. You're sitting on the couch, you suddenly feel turned on, you initiate sex, and everything just unfolds from there. That's what we call spontaneous desire. And while some women experience it regularly, many don't. Responsive desire works differently. Instead of desire showing up first, it develops in response to something pleasurable. It may begin with affectionate touch, flirting, kissing, emotional closeness, feeling desired by your partner, reading something erotic, or simply having enough time and mental space for your brain to shift out of doing mode. In other words, arousal often comes before desire, not the other way around. When women hear this, many tell me that they've spent years thinking that something was wrong with them because they weren't randomly craving sex. In reality, they weren't broken. They were expecting themselves to experience desire according to a model that doesn't reflect how desire often shows up for women. This also brings me to another of my favorite concepts from sex educator and researcher Emily Nagoski, and that's accelerators and brakes. She describes our sexual response system as having both an accelerator and a brake. Accelerators are the things that turn us toward desire, so things like feeling emotionally connected, flirting throughout the day, laughter, feeling appreciated, physical affection, novelty, privacy, feeling attractive, feeling safe. Brakes are the things that suppress desire, such as stress, anxiety, fatigue, pain, conflict, shame, feeling rushed, worrying that the kids might walk in, feeling disconnected from your partner, or simply having a mind that's still running through tomorrow's grocery list. The mistake many couples make is focusing only on pressing harder on the accelerator. They want to know how to increase desire, but sometimes the better question is, "What's keeping your foot on the brake?" Someone can have the most powerful accelerator in the world, but if the brakes are fully engaged, they're not going anywhere. One of the biggest brakes I see every day is mental load. Mental load isn't just being busy. It's carrying the invisible responsibility of remembering everything that keeps a household running. It's knowing when the kids have dentist appointments, realizing someone is almost out of laundry detergent, remembering birthdays, planning meals, coordinating schedules, managing school forms, and constantly thinking three steps ahead. Even when a woman finally sits down at the end of the day, her brain often hasn't stopped working at all. It's still organizing or planning or problem-solving, and that makes it incredibly difficult to transition into a state that's open to intimacy. Most of us need a little time to shift gears, to get out of our mind and into our body. And then there's resentment. Resentment deserves its own conversation because it's such a powerful brake on desire. When someone feels unseen, unappreciated, or emotionally alone, it's very difficult for the nervous system to relax enough for desire to emerge. Desire isn't just about blood flow and hormones. It's also about emotional safety. When women tell me they don't feel like having sex, I often wonder whether their body is actually saying something much deeper. Something like, "I'm exhausted," or, "I haven't had a moment to myself all day." Maybe it's saying, "I need to feel seen before I can feel sexual." Once we begin to understand the context surrounding her desire, we stop looking for one magic solution and start creating a treatment plan that actually fits her life. When we remove the barriers, reduce the brakes, and create the conditions where desire has room to grow, we can often discover that it was never completely gone in the first place. So as we can see, there's no single answer to low libido. Some women absolutely benefit from hormone therapy or other medical treatments, and when those therapies are appropriate, they can make a tremendous difference. But if we've learned anything from today's conversation, it's that female desire is far too complex to be reduced to a hormone level or a prescription. one of the most common pieces of advice women receive when they're struggling with low desire is just to have more sex. I understand where that advice comes from. We know that intimacy often fosters connection, and for some couples, intentionally prioritizing time together can be incredibly helpful. But if sex has become painful, emotionally disconnected, pressured, or simply unrewarding, telling someone to just have more sex is a little like telling someone who dreads going to the gym to simply work out more without ever asking why they dread it in the first place. If the experience itself hasn't been positive, increasing the frequency rarely addresses the underlying problem. Instead, I think we should become more curious. Is there a medical issue that needs to be treated? Is she grieving the loss of a part of herself, or does she mostly feel pressured to want sex? Does she feel emotionally safe and connected in her relationship? Is the sex she's having pleasurable enough to make her want to come back for more? Or is the context of her everyday life, stress, caregiving, mental overload, exhaustion, resentment, or lack of privacy, are those things keeping her nervous system in survival mode instead of allowing space for intimacy? Those are all very different questions, and they're much more likely to lead us towards meaningful solutions. So that's why I come back to that same framework every time. Body, want, relationship, sex, context. Not because I expect every woman to struggle in all five areas, but because I never want to assume that I already know the answer before I've heard her story. If there's one thing that I hope you take away from today's episode, it's this. Low desire is a symptom, not a diagnosis. It's your mind and body communicating that something deserves attention. Sometimes that something is hormonal. Sometimes it's physical. Sometimes it's relational. Sometimes it's emotional. And often, it's a combination of several different factors. The goal isn't simply to increase libido, but to understand what has been standing in the way of desire so that we can address the real issue instead of chasing a quick fix. So if you've been listening today because you've wondered whether something's wrong with you, I hope you'll leave with a different perspective. Female sexual function is complex and multifaceted. It may not be that your libido is gone. It may be that your body is responding exactly the way a healthy nervous system responds to pain, pressure, exhaustion, disconnection, or unmet needs. And maybe the question isn't: how do I force myself to want sex again? Maybe the better question is: what would make me feel safe, healthy, connected, and open enough for desire to return? When we start asking better questions, we usually find better answers. Thank you so much for spending this time with me today. If this episode resonated with you, I encourage you to share it with someone who may be feeling the same way. And use this as a reminder that sometimes the missing piece isn't a problem to be fixed. It's understanding, education, and the opportunity to see the full picture That's it for today's episode. Thanks for listening, and be sure to rate and review the podcast on whatever platform you're listening from, and share it with your friends. That's a great way to help reach new listeners and make this a more sex-positive world. Until next time, stay curious, stay empowered, and stay you.