Susan is 47 and thinks she must be menopausal because she has lost her libido. Crying, she says she has got too many other things to worry about, and is only seeing you to please her partner
There are several strands to this consultation, but one of the most important is to assess whether Susan is depressed, and if so how badly?
Her poor libido may reflect a more general loss of interest. Poor motivation, concentration and lack of pleasure in things that she would normally enjoy are typical of depression, as are biological symptoms, low mood, sleep disturbance and irritability or weepiness. It's vital to ask about suicidal ideation, and to inquire about other possible problems.
Even if she is not depressed and however good your consultation skills are, you are unlikely to sort this out in 10 minutes it may be more appropriate to suggest she books another appointment 'to give this the time it deserves'. You could, however, ask some screening questions to see whether it would be useful to arrange relevant investigations in the meantime.
Not all of us are, and this may vary with the age and sex of the person we are talking to (patients often take the same view of us). We may sometimes be shocked by what patients tell us, and you may want to discuss things with your trainer. If our personal beliefs or adverse experiences could affect our patient care we have a duty to avoid this.
A non-judgmental suggestion that the patient sees another practice doctor with more expertise, or is referred to specialist services, may be appropriate.
The most common cause is probably tiredness. Women juggling work and home often complain that sex gets left until bedtime, by which time they'd rather get some sleep!
A new baby can be particularly exhausting; bodily changes and breast-feeding can also affect new mothers' libido. Some women suffer from hypothyroidism, anaemia or depression in the postnatal period.
Gynaecological problems can put women off sex, particularly those that can cause dyspareunia, including fibroids, ovarian cysts, endometriosis, pelvic infection and vulval conditions. Leaking urine during intercourse or orgasm is not uncommon, but women may not mention this unless asked.
Pelvic floor weakness can affect sensation for both partners and even drives some women to seek a 'designer vagina'.
Systemic illness such as diabetes and hypothyroidism, or an excessive alcohol intake, can lower libido, as can diseases that result in physical difficulties during sex, such as arthritic hips, angina, dyspnoea, muscle spasms/stiffness or morbid obesity.
For some perimenopausal women, losing their libido is a simple hormonal problem, often linked to hot sweats, vaginal dryness and reduced breast/genital sensitivity. These can usually be rectified with HRT, but women who cannot or do not want to take HRT often find their libido can be improved by spending more time on foreplay and/or using a lubricant such as KY Jelly, Senselle or Replens (from the pharmacy) to improve vaginal dryness.
Prescribed drugs can also reduce sexual desire, including antidepressants, tranquillisers and tamoxifen. In someone taking the contraceptive pill who is not depressed, a more progestagen-dominant pill may help (but adversely affect lipids); if there is associated depression a more oestrogen-dominant pill may help (but may increase VTE risk).
But the problem may be practical rather than physical for example unreliable or unsatisfactory contraception. Privacy for sex can also be difficult to achieve, even for adult couples. Living apart, or sharing a house with toddlers, teenagers or parents can mean sex has to be timetabled around other people's schedules.
Worry and stress, even in the absence of depression, can reduce female libido; stress-busting techniques such as exercise, relaxation techniques or time out may help.
Relationship problems are often to blame; these include infidelity, frequent arguments, a partner immersed in work or hobbies leading to separate lives, poor communication, emotional/physical abuse, or simple boredom. Is Susan worried that she or her partner may have a sexually transmitted infection, or has treatment for an STI affected her libido?
The disapproval of friends or family may be a factor, eg if the partner is of the same gender, already married or seen as 'different'.
Some women feel less attractive once they reach the menopause, especially if their partner is also critical of their looks. (Younger women may also avoid sex because they do not want their partners to see their bodies). Some women mourn the loss of their fertility and feel sex is pointless without the possibility of conception.
Occasionally a woman will complain of reduced libido when the real problem is vaginismus or anorgasmia. Also, sexual abuse in childhood or adult life may have a lasting or delayed effect on the victim's sexual functioning. Referral to a specialist counsellor or psychosexual clinic may be indicated.
Susan's lack of libido may be the presenting complaint for erectile dysfunction or other sexual problems in her partner. He may be persuaded to attend if she can pass on the message that effective treatment is available.
Melanie Wynne-Jones is a GP in Marple, Cheshire