Episode 3: You Haven't Thought About Sex in Months

You love your partner. Nothing is wrong with your relationship. But somewhere along the way, you stopped thinking about sex — and you might not have even noticed it was gone.

If you're in your late 30s or 40s and your desire has quietly disappeared, there's a reason. It's not you. It's not your relationship. It's your hormones — and it's one of the most common things that happens in perimenopause that nobody warns you about.

In this episode, Crystal and Steven walk through what's actually happening in your body: why estrogen and testosterone both matter for desire, why sex can start to feel different or painful, why orgasms take longer or feel weaker, and why your libido can seem fine one week and gone the next.

You'll also hear about the grandmother theory — an evolutionary explanation for why your body may be wired to lose interest, and why that doesn't mean you have to accept it.

If you've been quietly wondering what happened to that part of you, this one's for you.

www.menopauselouisiana.com

Transcript

SPEAKER_00 0:00

You are listening to Clary Metaplaus Explain. This show is about Clary Metaplaus. Years before Metaplause. When things start changing, often before anyone calls it menopause.

SPEAKER_01 0:11

Each episode is real talk, from real questions to explain what's going on in your body. No hype, no minimizing, just straight answers and honest conversation.

SPEAKER_00 0:20

If something feels off and you haven't gotten clear explanations yet.

SPEAKER_01 0:24

This podcast is for you. Hello, I'm Steven Youngblood. This is Perimenopause Explain. Um, I'm a physician, and this is Crystal Burke.

SPEAKER_00 0:35

Hi, I'm Crystal Burke. I am a nurse practitioner, menopause specialist, and co-founder of the Menopause Clinic.

SPEAKER_01 0:42

Quick reminder we're offering general advice and not actual medical advice. This is just for answering questions and talking about perimenopause and menopause from a broad perspective.

SPEAKER_00 0:55

So today we're going to be talking about libido. What changes, what's actually happening, and what helps?

SPEAKER_01 1:02

There we go. So let's start off with the patient. What do you say, Kristen? Sure. All right. So we have a 41-year-old woman, obviously. Um, her libido is her libido has disappeared. She loves her partner, but feels completely completely uninterested in sex. She goes to her physician, primary care physician or Obi-Gen. They check labs and said everything is normal.

SPEAKER_00 1:26

Yeah.

SPEAKER_01 1:28

Tell me what's really going on with her.

SPEAKER_00 1:31

So libido is low libido is one of the most common things to happen in parametapolis, which is why we're talking about it today. So yeah, we see this very frequently in clinic. So yeah, labs are normal. The thing is, is is first of all, it's important for her to talk about. Women rarely talk about it. A lot of women feel like talking about libido is extra, but it's not. If it's important to you, it's important. And sexual health is health. So in a 41-year-old woman, whether she's pre-periods are still the same, whether that's still the same, or she's had changes to her period, or any of any of those things. You can still have low libido before periods change. But estrogen's still estrogen's still changing. Testosterone starts dropping in your 30s, there's a lot of things that can happen. And so that's low libido is one of the most common things that we see. And that's the right age range.

SPEAKER_01 2:41

So tell me a little more about how I mean we know the hormones are declining at various intervals. And in case of estrogen, maybe going a little bit just haywire in general. But how what are the physical, how does that physically involve change a woman to make sex or decrease lived? Make sex less pleasurable or decrease.

SPEAKER_00 3:04

So so one of the things we talked about last time was sex can become painful. So when estrogen declines, vaginal tissue changes. So it becomes thinner, drier. Sex can be really painful. So it so when that happens, your brain starts to think differently about sex. Sometimes. Sometimes it's just something you wonder about, sometimes it's something you notice. It doesn't happen to everyone, but it is very common for sex to become painful. Um also estrogen has to do with desire. So the the thinking about sex can be less. So at 41, it does make sense that that she would start to feel this because testosterone affects desire also. So one of the things I realized, and uh we, if you remember, we were talking uh to this guy once, and he was I we didn't realize he was a sex therapist, remember? But we were just talking about things, and I realized that I hadn't had a sexual fantasy in a long time. But not even just that. I also realized I hadn't had a fantasy about or a daydream about anything in a long time. I used to have an imagination about everything.

SPEAKER_01 4:29

Right, right.

SPEAKER_00 4:29

And then remember we were having that conversation. I was like, no, I haven't had anything, any daydreams or fantasies in a while. That's actually really common in perimenopause. You're sometimes, sometimes women will realize it. Sometimes it'll be a year after, and they'll realize, you know what? My thinking is different, my thinking has changed. I just don't think about it anymore. Have you heard of the grandmother theory?

SPEAKER_01 4:55

I have not. I'm excited. Tell me about it.

SPEAKER_00 4:59

So it's the evolution that evolution, we've talked about this. The change in evolution that a long time ago, women after the whatever age it was, whatever age they picked, uh when you got closer to not being able to have children, it became beneficial for society for women to not want sex.

SPEAKER_01 5:22

So they could continue to live and raise the children, raise the children, and also be a source of information that gets passed on from generation to generation, right? So and I didn't realize it was called the grandmother theory. So the theory would be that you know a woman in I won't say prehistoric times, but let's say around 500 AD.

SPEAKER_00 5:48

Yeah.

SPEAKER_01 5:49

Um during the the times of the Black Peds, medieval medieval times, right? Yes. She's had her number of children, she's no longer sexually active, she can no longer have children. But she's raising, she's raised those children, but she's now going to raise, likely to some degree, the next generation because childbirth is dangerous. Even in today's society, childbirth is dangerous, right? Back then it was a lot more dangerous. And so it wasn't uncommon for women to die, and then that child gets raised by the grandmother. Plus, then you have a source of information.

SPEAKER_00 6:23

Right.

SPEAKER_01 6:23

You know, mid they become a midwife, they become various other aspects in the community.

SPEAKER_00 6:29

Reproductive age women focus on reproduction and graduate.

SPEAKER_01 6:32

And if you graduate, if you survive. If you survive, you become the the matriarch informational storage for that society.

SPEAKER_00 6:42

Right. And so at that time, not wanting sex was beneficial.

SPEAKER_01 6:46

Right, right. But it's a different time, right?

SPEAKER_00 6:51

It's a different time. We we've outlived that. And and it doesn't, even if that's true, even if that that is a part of how or wire, it doesn't have to be it. There are definitely, definitely ways to treat low libido and to fix things. But yes, low libido is common because because our hormones are changing. Both estrogen and testosterone are important in libido. And with the changes that we know happens, this is a physiological reason. Yeah.

SPEAKER_01 7:18

No, it's a common. It's interesting because the reality of it is our society has changed much faster than humans have changed evolutionary, right? Yeah. Which is why we have issues with hypertension and diabetes, which really didn't happen back then because you didn't have to worry about overeating. There wasn't enough food to overeat, right? You were happy to get one square a day.

SPEAKER_00 7:41

Yeah.

SPEAKER_01 7:41

Right, right. 100%.

SPEAKER_00 7:43

Um but going back to the 41-year-old woman, a lot of times she she wonders, you know, like she starts to feel not everybody, because everyone is so different in how they handle everything. But she's not sure what's happening. Maybe she knows this happens, maybe she does it, maybe she talked to her friends, maybe she hasn't. Maybe she has a great relationship, and that's she has a great relationship. She loves her partner, and it's nothing to do with that. But then after it might go on for a while, and then she starts to think, is it me? Is something wrong with me? Is something wrong with us? Is uh it starts to second guess all these things, but there's there's a reason that she does that because we don't talk about it enough. But if she would only know that there isn't physiological reason and a way to fix it, right, right.

SPEAKER_01 8:31

And you know, and again, we have a tendency, and I know we've talked about this before. There's we have a tendency to blame a lot of these things on raising kids, life, busy. And that does have an effect. And it does have an effect, absolutely. Okay. Um, can we talk a little bit about arousal physiology? Yeah. Yeah. So kind of give us a you know, a 30,000-foot view of that, like so people can kind of understand how it all plays out.

SPEAKER_00 8:55

So the two parts of sex in general, right, are desire, which the thinking, the daydream, and the fantasies, the um the arousal, how the body responds. So in perimenopause and and on to menopause, it can take longer for the body to respond, right? So if you have vaginal dryness, which it just takes longer for the body to respond. Sensation is different. When we lose estrogen, it affects sensation. So it can take longer. And um, some people can't have orgasms anymore, or it can take longer, or they're just weaker. Um, I mean, it it affects everything. But the body arousal definitely changes as a part of genital urinary syndrome of menopause.

SPEAKER_01 9:45

Right. That was crazy.

SPEAKER_00 9:45

It's a big long name, but that can absolutely affect arousal. And it can be hard for a woman who doesn't know that this is going to happen because she blames herself, but that's her body responding to decreasing estrogen.

SPEAKER_01 10:00

So a little bit about the genoturinary syndrome. Genitalurinary syndrome. Um, I know there's one of the key elements is the pH of the vagina changes, right? So if we replace estrogen, does that pH, does that does, for lack of a better term, vaginal health come back around?

SPEAKER_00 10:23

So yes, yes, because this all these things happen because we're losing estrogen, but the pH of the vagina changes. So some people will get UTIs more frequently, especially after sex. So that's one thing. Um, but it changes losing estrogen changes the whole structure of the vagina. The vagina changes. So all of that replacing estrogen with vaginal estrogen, yes, all of that can can go back. It can reverse all of those changes, but it has to, you have to keep doing it. Once you stop using that vaginal estrogen, it happens again for most women. And one of the things to know, and a lot of women don't know this, is that if you're on systemic estrogen, so the whole body estrogen, so the patch and the gel, if you're on those, about 60% of women still will need vaginal estrogen.

SPEAKER_01 11:20

60%, more than half.

SPEAKER_00 11:22

More than half.

SPEAKER_01 11:23

More than half.

SPEAKER_00 11:23

And and a part of my that that's what the literature says, that's the research says, and that that's what I've seen really, but not everybody will have symptoms of genital urinary syndrome of menopause. Not everybody, but most will. So I I think it's mostly the ones that have the symptoms that will need the vacual estrogen still. Gotcha.

SPEAKER_01 11:43

Gotcha.

SPEAKER_00 11:44

Yeah.

SPEAKER_01 11:44

So when you're prescribing estrogen for a woman, you know, you could be in following this theory, giving two types of estrogen, right? Yeah, a more systemic and then a local.

SPEAKER_00 11:58

Definitely.

SPEAKER_01 11:59

And so I would imagine that that goes through insurance as easily.

SPEAKER_00 12:07

So insurance usually doesn't have a problem with this. Sometimes pharmacists do. Most of the time they don't, because pharmacologically it's very different. Right.

SPEAKER_01 12:17

Right.

SPEAKER_00 12:17

Estrogen goes through the whole body, vaginal estrogen does not. It stays in the vaginal and urinary system. Very rarely, but recently it has started to happen more where a pharmacist will question if a woman needs both. If, but yes, that they are very different, and many, many women need both.

SPEAKER_01 12:42

You would say, well, why would you do both? That doesn't make sense.

SPEAKER_00 12:46

Yeah.

SPEAKER_01 12:46

But there's a lot of things in medicine that don't always make sense until after the fact.

SPEAKER_00 12:50

Well, uh it just needs an explanation. They it absolutely makes sense. But but just like anything, you have you should know the what the medicine is doing, what it's for, how it works. Yeah.

unknown 13:02

Yeah.

SPEAKER_00 13:03

And one of the questions somebody asked me the other day about vaginal estrogen is do I recommend it to everyone for preventative reasons? And my answer is no. Medical guidelines say, don't say that. But my rec my opinion is yes, everybody should need it.

SPEAKER_01 13:24

Everyone should get it. Everyone should get it. Every woman should get it. Every woman should get it. Every woman should get it. Right, right. Not everyone. Every everyone. Everyone. Absolutely.

SPEAKER_00 13:31

Everyone.

SPEAKER_01 13:31

Um, so let's let's transition a little bit because I think we've kind of talked quite a bit about the physiology. Let's talk about how this presents in the clinic, what we would see. So, you know, you may have. So if we say we take the same, you know, the same woman, she's 41, she comes to the clinic, and you know, I would imagine that first visit with a woman talking about this can get emotional and long.

SPEAKER_00 13:58

Sometimes. Sometimes, not always, but sometimes, uh, because the thing is, is this is all I mean, sex isn't something you've talked to a lot of people about. You might talk to your friends, um, but very rarely are you're gonna talk to some to someone that you've never talked to before.

SPEAKER_01 14:17

Right, right. I I could probably count definitely in two hands, probably one, how many times someone's come into my office and you know, practiced many years before, you know, you know, brown level practice, you know, 15, you know, almost two, 20 years. It doesn't happen very often.

SPEAKER_00 14:38

Yeah. Yeah. And no one has ever, no one has ever asked me about sex. No one.

SPEAKER_01 14:44

But I Well, not not as a primary.

SPEAKER_00 14:47

Yeah, we're talking about like talking about a healthcare provider. No, no healthcare provider has ever asked me about sex.

SPEAKER_01 14:53

Right, right, right, right.

SPEAKER_00 14:55

Right. So I I ask everyone. Oh, like uh uh on a first visit, I ask every patient, is this is this something that bothers you? Is it happening? Does it bother you? Because it could be happening and it might not bother you, and that's okay. But if it's bothering you, we need to treat it. We need to fix it, we need to talk about it and and figure out what to do. Um but yeah, that's it's something that frequently comes up, and there's a I mean, I'm gonna say it's almost it's gotta be more than half of the women I see that yeah, it's happening and it's bothersome.

SPEAKER_01 15:34

Yeah, I'd imagine so. Um okay, so back to the clinic. Woman comes in. So tell me what how what you've seen this, what does it look like? Like walk me through with the thing, the kind of a conversation you would have with a with a 41-year-old woman who's going through this.

SPEAKER_00 15:55

So, first the thing is to think about, you know, what how long has it been happening? Does it are there other factors involved? Because libido, desire, all of that is not just hormones. Hormones can bring you to the table, but it doesn't it doesn't do the whole job. So uh there's the physical, so hormones, desire arousal, uh psychological. Because one of the things is if you've had pain with sex before, even once, it can rewire your brain and it can be difficult. So and there are there's lots of lots of side lots of things in the brain that can happen around sex. Then there's um social like social things. How's your relationship? Is there are you working a full-time job with three kids and and one sick and you have you're taking care of your parents, and you know, there's a lot of things involved in all that. So we go over that, right? Like, like what's all involved in that? And then if we and then we talk about desire and arousal and how hormones affect that, how the body changes, um, things to do about it, right? So estrogen and testosterone both have a lot to do with all that. Um, we talk about why it's happening, like the physical changes to the vagina, the changes to the brain, uh, like we just talked about. We talk about all of that. And most women want to be treated for that. And and it's not always gonna be the first thing, right? Because in parametopause, there's so many things. Sometimes it is the first thing, and that's okay. Um, but a lot of a lot of times it might be let me fix my mood so I can keep my job. But libido is important to me, and I want to get to that next. Whatever it is, it it's if it's important at all, it can be treated.

unknown 17:53

Yeah.

SPEAKER_01 17:54

Okay. So let's let's flip over like what are some of the treatment options for libido? Like, you know, obviously hormone replacement, but anything in addition to that? Like what uh what are the things? Like, is do can we consider pelvic floor therapy?

SPEAKER_00 18:07

Yep.

SPEAKER_01 18:08

Or you know, can you go into a little bit more about that?

SPEAKER_00 18:10

Yep. So uh, so definitely pelvic floor therapy. Pelvic floor therapy has a lot to do with um sensation. Um like the pelvic floor can affect so many things involved in sex that yes, pelvic floor therapy is is really important for a lot of women. Um but I think that the women that do best are gonna do best with hormones, pelvic floor therapy, stress management, um all of the things, making sure relationship is good, all of those things are that's gonna be what's important to make sure it's as good as it can be. Yes.

SPEAKER_01 18:54

Let's go a little bit more into like what are some like from what would be like a standard at a very broad level hormone replacement look like for someone who's going through this? Like maybe the first step.

SPEAKER_00 19:12

So for the mo for the for the most part, not everybody, because everyone is so different. There I have people that sort on testosterone first, I have people that sort of estrogen first. But most women, by the time I see them, if they're having vaginal dryness, that means low estrogen. So I so most women will need estrogen and progesterone if they have a uterus. I mean, this is the thing, is it's so individualized, that's hard to say. But as you we look at what's going on with them, and it's gonna be estrogen andor progesterone and testosterone for the most part, but everyone's so different. So the order can change, the specifics can change.

SPEAKER_01 19:55

Okay. So some additional other questions. Why does orgasms take longer during parameter box? Like what's is there a physiology behind that?

SPEAKER_00 20:07

Yes, yes. Because um bad so the loss of estrogen changes the vaginum tissue, makes it thinner, it affects their nerves, sensation is less. Uh all of those things make a rasal harder.

SPEAKER_01 20:23

Um why do women feel emotionally disconnected during this time period?

SPEAKER_00 20:29

So I had I had one patient that explained it to me this way, and and and in all honesty, I knew what she meant. But I didn't think about it this way. She said, It's like he's touching my arm. Just like this. When she was having sex.

SPEAKER_01 20:51

Okay, so it was it wasn't like a good feeling.

SPEAKER_00 20:54

It it when you have no sensation, it doesn't feel like it used to, it doesn't feel like you think it should. And it doesn't feel it I mean the thing is is if if it doesn't feel like it used to, you wonder what's wrong with you. And so or sh or she was, and and I get that, and and there's nothing wrong with her, but that's that's what happens.

SPEAKER_01 21:18

Um why does sex suddenly hurt?

SPEAKER_00 21:22

Because as we lose estrogen, the vaginal tissues get thinner, and so it's it it's common for that to be painful.

SPEAKER_01 21:31

And why does the libido come and go?

SPEAKER_00 21:35

So in perimenopause, you your estrogen's fluctuating. It's it's all over the place. It's a hormonal roller coaster. So your symptoms will come and go with that. When estrogen's high, you'll feel one way, when estrogen is low, you'll feel another. So that's the point, that's the point of HRT in general, right? Like when we're giving estrogen back in perimenopause, it's to if if say your estrogen is is here, we're Going from here to here, here, the idea is to give estrogen to bring it up so the swings aren't so wide, and you're not having low estrogen.

SPEAKER_01 22:10

Yep. So that swing that can happen within a day. This happens over weeks.

SPEAKER_00 22:14

It can happen within a day. It can happen. But for some people, they'll notice you know what, this week I have this symptom. Next week I don't. Um, but but research shows it it can happen in a day. Yeah.

SPEAKER_01 22:27

Okay. All right. Um, do you have any takeaways you want to bring?

SPEAKER_00 22:33

Just that one of the things to know is that if you're having a libido, it doesn't mean there's anything wrong with you or your relationship. If there is a physiological problem and ways to fix it.

SPEAKER_01 22:52

All right, excellent.

SPEAKER_00 22:53

You are listening to Praymenopause Explain.