Low Libido in Women: A Gynaecologist's View

In my practice, low libido is one of the most common concerns I hear — yet it remains one of the least discussed. Many women suffer in silence, assuming that a declining sex drive is simply something they must accept: a natural consequence of ageing, motherhood, or the demands of modern life. In reality, low libido is a medical issue with identifiable causes and, in the majority of cases, effective treatments. As a gynaecologist trained in France and now practising in London, I have seen how profoundly this issue can affect quality of life, self-esteem, and intimate relationships. I want to reassure you that there is no reason to suffer alone.

You are not alone

Studies suggest that up to one in three women experience low sexual desire at some point in their lives. It can affect women of any age, though it becomes significantly more prevalent during and after the menopause transition. Despite being so widespread, it is rarely volunteered during medical consultations, and even more rarely asked about by healthcare professionals. This silence can leave women feeling isolated, frustrated, or convinced that something is fundamentally wrong with them.

It is not. A change in desire is a medical symptom like any other, and it deserves proper attention. What I find most helpful is to start the conversation openly, without judgement. When I raise the subject proactively during consultations, patients often tell me they are relieved that someone finally asked. That first step — simply acknowledging the problem — can itself be therapeutic.

The menopause and perimenopause connection

In my menopause clinic, the link between declining hormones and reduced libido is something I discuss almost daily. The perimenopause — the years leading up to a woman's final period — often begins in the early to mid-40s and brings fluctuations in oestrogen and progesterone that can affect mood, sleep, energy, and desire long before periods actually stop.

What many of my patients do not realise is that testosterone levels also decline steadily from the late 20s onwards, and this decline accelerates during the menopausal transition. By the time a woman reaches her mid-50s, circulating testosterone may be half of what it was in her 20s. Because testosterone is a key driver of sexual desire and arousal in women, this hormonal shift often explains why libido seems to evaporate around menopause.

The psychological burden of menopause compounds the problem. Mood changes, anxiety, and low confidence are extremely common during perimenopause and can erode sexual interest from a completely different angle. Sleep deprivation from night sweats further drains the energy and motivation needed for intimacy. I always tell my patients that these issues are interconnected: addressing the hormonal component often improves mood, sleep, and desire simultaneously.

Hormonal causes

Hormones play a central role in female sexual desire. The most significant hormonal contributors to low libido include:

• Declining testosterone: Although widely thought of as a male hormone, testosterone is essential for sexual desire in women. Levels decline steadily from the late 20s onwards and drop more sharply during perimenopause and menopause. Even relatively small changes can have a noticeable impact on arousal and desire.
• Falling oestrogen: Particularly around the menopause, reduced oestrogen can lead to vaginal dryness, discomfort during sex, and a consequent loss of interest in intimacy. HRT can help restore oestrogen levels and improve these symptoms considerably.
• Hormonal contraception: The combined oral contraceptive pill and other hormonal methods can suppress testosterone levels and increase sex hormone-binding globulin (SHBG), which binds free testosterone and reduces its availability. In my experience, some women notice a marked improvement in desire when switching to a non-hormonal method or a different formulation.
• The postpartum period: A combination of hormonal shifts, breastfeeding (which raises prolactin and suppresses oestrogen), sleep deprivation, and the physical recovery from childbirth can significantly impact desire. I reassure new mothers that this is temporary, though it may take longer than expected to resolve.
• Thyroid disorders: Both hypothyroidism and hyperthyroidism can affect libido. An underactive thyroid is particularly common in women and frequently goes undiagnosed, causing fatigue, weight gain, and low mood alongside reduced desire.

Physical causes

Several physical factors can contribute to a reduced sex drive, either directly or by making sexual activity uncomfortable:

• Vaginal dryness and pain during sex: If intercourse is painful, it is entirely natural that the desire for it diminishes. This is particularly common after the menopause but can occur at any age. The medical term for this is genitourinary syndrome of menopause (GSM), and it is far more treatable than many women realise.
• Pelvic floor dysfunction: Weakness or tension in the pelvic floor muscles can cause pain during intercourse, urinary symptoms, or a sense of heaviness, all of which can inhibit desire. A specialist pelvic floor physiotherapist can make a significant difference.
• Chronic illness and fatigue: Conditions such as thyroid disorders, diabetes, autoimmune disease, and chronic pain syndromes can all reduce energy and interest in sex.
• Medications: Certain commonly prescribed drugs, including some antidepressants (particularly SSRIs and SNRIs), beta-blockers, blood pressure medications, and antihistamines, are known to affect sexual desire as a side effect. I always review a patient's medication list carefully, as sometimes a simple switch can make a meaningful difference.

Psychological and relational factors

Desire does not exist in a vacuum. Emotional wellbeing and the quality of a relationship are intimately connected to sexual interest. I always start by asking about stress, mood, sleep, and the broader context of a woman's life, because addressing these factors can be just as important as addressing the hormonal ones:

• Stress and mental health: Anxiety, depression, and chronic stress are among the most common causes of reduced libido. The mental load of work, caregiving, and domestic responsibilities — which falls disproportionately on women — leaves many feeling that intimacy is simply one more demand on their energy.
• Body image: Feeling uncomfortable or unhappy with your body can make it difficult to feel desirable or to enjoy physical intimacy. Changes related to pregnancy, weight fluctuation, or ageing can all contribute.
• Relationship dynamics: Unresolved conflict, lack of emotional connection, or mismatched expectations around sex can all erode desire over time. In my experience, couples who struggle to communicate about their needs often find that desire fades on both sides.
• History of trauma: Past experiences of sexual trauma or abuse can have a lasting and complex impact on a woman's relationship with intimacy and desire. This requires sensitive, specialist support, and I always take care to ask about it in a safe and non-judgemental way.

The diagnostic workup: what I look for

When a woman comes to see me about low libido, I always start by asking about the timeline and context of the change. Has it been a lifelong pattern, or did it develop at a particular point? Is it situation-specific, or does it affect all forms of desire? Understanding the nuance of the problem helps me identify the most likely contributing factors.

I then take a thorough medical and medication history, ask about menstrual patterns, contraception, sleep, mood, stress levels, and the quality of the intimate relationship. This conversation is never rushed — it is the foundation of everything that follows.

Blood tests are an important part of the assessment. I routinely check:

• Total and free testosterone: Low levels, particularly when accompanied by symptoms, may support the use of testosterone therapy.
• Sex hormone-binding globulin (SHBG): Elevated SHBG reduces the amount of free, biologically active testosterone. This is commonly raised by the oral contraceptive pill and can persist even after stopping it.
• Oestradiol: To assess menopausal status and the degree of oestrogen deficiency.
• FSH (follicle-stimulating hormone): Helps confirm whether a woman is approaching or has reached menopause.
• Thyroid function (TSH and free T4): To rule out thyroid disease, which is a common and easily treatable cause of fatigue and low desire.
• Prolactin: Elevated prolactin can suppress libido and may indicate an underlying issue requiring investigation.
• Full blood count, ferritin, and vitamin D: Anaemia, iron deficiency, and low vitamin D are remarkably common in women and contribute to fatigue that undermines desire.

If pain during sex is a factor, I may recommend a gentle examination to identify underlying causes such as vaginal atrophy, vulval skin conditions, infection, or pelvic floor tension. Our sexual health service can also help rule out infections that may be contributing to discomfort.

Treatment options: a tailored approach

Treatment depends entirely on the underlying cause and is always tailored to the individual. What I find most helpful is to combine medical and psychological strategies, because libido is rarely a single-cause problem. Here are the main approaches I consider:

Testosterone therapy

The evidence for testosterone supplementation in women with low libido is now well established, particularly for postmenopausal women. The International Society for the Study of Women's Sexual Health (ISSWSH) and the British Menopause Society both support its use when hypoactive sexual desire disorder (HSDD) is diagnosed. I typically prescribe testosterone as a transdermal cream or gel, applied daily at a low dose appropriate for women — usually one-tenth of the male dose. Most patients notice an improvement in desire and arousal within three to six months. I monitor levels at six weeks, three months, and then six-monthly thereafter to ensure the dose remains appropriate and to check for any side effects such as acne or excess hair growth, which are uncommon at the correct dose.

Oestrogen replacement

For women experiencing vaginal dryness, discomfort during sex, or urinary symptoms, restoring oestrogen is often transformative. I may prescribe systemic HRT if there are also vasomotor symptoms (hot flushes, night sweats), or topical vaginal oestrogen (pessaries, cream, or the oestradiol ring) if the symptoms are predominantly local. Many women find that once intercourse is comfortable again, desire returns naturally. Vaginal oestrogen is safe for the vast majority of women, including many with a history of breast cancer, and can be used long-term.

Psychosexual therapy

Working with a trained psychosexual therapist can be invaluable, particularly when psychological or relational factors are prominent. Cognitive behavioural therapy (CBT) approaches, mindfulness-based techniques, and couples therapy can all help. I frequently refer patients to specialist psychosexual therapists and find that the combination of medical treatment and psychological support delivers the best outcomes. This is not about assigning blame — it is about understanding the complex interplay between mind, body, and relationship.

Medication review

If an SSRI or another medication is contributing to the problem, I work with the patient and their GP or psychiatrist to explore alternatives. Switching to bupropion or mirtazapine, for example, may preserve mental health benefits while reducing the impact on libido. This must always be done carefully and collaboratively.

When to refer

In some cases, I refer to other specialists: an endocrinologist if there is a complex hormonal picture, a pelvic floor physiotherapist if musculoskeletal factors are involved, or a psychiatrist if there is significant untreated mental health illness. Addressing low libido effectively often requires a multidisciplinary approach, and I am always honest with my patients about who else might be able to help.

Taking the first step

A change in your desire for intimacy is not something you should simply accept. The British Menopause Society provides helpful resources on sexual health and libido changes during the menopausal transition. If it is affecting your quality of life or your relationship, help is available. I encourage every woman experiencing this to seek a proper assessment. You deserve to feel like yourself again.