Making Love | "Not Tonight, I Have A Headache"

"40% of all women complain of low libido at some time in their lives"

-- Dr. Kevin Kiley , chairman of obstetrics and gynecology at Albany Medical Center

Worried that your sex drive isn't what it used to be? You're not the only one! Although you'd never know it from reading postings on men's forums, most couples aren't actually having sex twice a day -- or even twice a week. Between work, the kids, the dog and the broken furnace, some couples consider it an accomplishment if they can get together once a month.

"I think that we have a social mythology about the frequency of sex," says Arlene Istar Lev, clinical social worker at Choices Counseling and Consulting in Albany. "Everybody thinks everybody else is having more sex than they are. There are lots of couples who have relatively infrequent sex, once or twice a year. I also think it is 'normal' for many couples to have less frequent sex over the long life of a relationship. We're looking at a 30-year marriage (so) it doesn't surprise me there is less passion over time."

Not everyone sees this as a big problem, but if one person craves more sexual contact than her partner, it can become one. "There is going to be a difference between partner A and partner B's libido," Lev says. "The question becomes, how does a couple negotiate those differences? Often the person who has a lower sex drive ends up 'controlling' the frequency of sexuality -- and that's often a source of tension in the relationship."

Why You Can't Keep It Up

"Forty percent of all women complain of low libido at some time in their lives," says Dr. Kevin Kiley, chairman of obstetrics and gynecology at Albany Medical Center . The problem isn't unique to women, however. Dr. Roland Nathan , a clinical psychologist in Albany who limits his practice to men, estimates that about 10 percent of his clients also complain about decreased sexual desire or activity.

"I've seen a number of rather young men in their early 20s who are having erectile problems because of the demands on their performance by young women," says Nathan. "Unfortunately, performance anxiety interferes with intimacy."

It doesn't help that the honeymoon phase of most relationships sets the bar high, flooding the brain with so much adrenaline, oxytocin (the "cuddle hormone" released after an orgasm), dopamine, and testosterone that everyone feels like Superman and Wonder Woman -- at least for the first six months.

After the initial rush, sexual desire slows to a simmer and other aspects of the relationship take the front burner. Clinical Sexologist Tammy Nelson , author of Getting the Sex You Want , describes the next stage of intimacy as "maintenance sex" or "the sweatpants phase."

"It's usually good, and you know how to push all the right buttons," she says, "but people think if it's not the same as it was in the beginning, there must be something wrong."

If your sex life takes a sudden or dramatic downturn, however, that "something" could be a medical problem.

Feeling the Chemistry

Although everyone experiences occasional dry spells, a prolonged drought could be a sign of serious illness. Kidney disease, neurological diseases, coronary artery disease, anemia, arthritis, anorexia, obesity and diabetes can all lower the libido.

In some cases, it's the treatment for a disease that's the problem. Chemotherapy, prescription drugs such as blood pressure medication or steroids and even over-the-counter antihistamines and alcohol can all stall sex drive.

People suffering from depression are in a double bind. A lack of interest in sex is a symptom of depression, but antidepressants such as Prozac and Zoloft often decrease a person's desire. Ironically, birth control pills can have this effect too, because they lower testosterone, which powers the sex drive in both men and women.

Hormonal changes have a direct affect on the libido. As men age, testosterone levels drop, which decreases sexual urges and sometimes causes erectile dysfunction. In women, testosterone peaks during ovulation to encourage breeding but hormone levels begin to decrease as a woman approaches menopause.

The loss of estrogen during "the change" can curtail a woman's lustier instincts and cause vaginal dryness, making sex painful without additional lubrication. Levels of the hormone dehydroepiandrosterone, which strengthens the vaginal wall, start to drop. "Women will often talk about their discomfort with their bodies," says Donna Lochner , a therapist and couples' counselor in Albany. "(They'll say) 'I feel fat, I'm bloated, I gained 10 pounds. I don't feel sexual.' And quite frequently, their partners are saying, 'Hey, I love your body!' "

But not all women want to feel the love. "Believe it or not, many women don't want to have sex because it hurts," says Dr. Helen Vu , an OB-GYN in Albany. "Once it becomes painful, you prepare for the pain so your pelvis contracts to avoid the pain." Tensing up, of course, only exacerbates the problem, but for some women, vaginal pain is a chronic condition that seems to have only one solution. "If something hurts," says Kiley, "you stop."

Getting Over the Hump

Medical problems may explain why some couples aren't hot to trot but, as Nathan notes, "the most important sexual organ is the mind." Need proof? Libido-lifters such as Viagra work for men but similar products intended for women rarely have the desired effect. Even though women showed physical signs of arousal in clinical trials for a female Viagra, they still told researchers they weren't in the mood.

Sex therapists weren't surprised. When men get an erection, they want to use it, but there's a pre-arousal stage with women -- they have to be willing to allow their bodies to be touched by a specific partner. For both men and women, however, stress throws a big bucket of ice water on the bed.

"Sometimes intimacy just takes a back seat, and if you don't use it, you tend to lose it," says Lochner. "Anything we get out of the habit of doing, we are reluctant to do. Sometimes it's all or nothing -- I want to wait until I have the energy and can really do it right."

To counter this, sex therapists suggest scheduling a "date" night -- and they're not talking about dinner and a movie. The idea is to make time to be together. While many people embrace the concept of a family meal or game night, however, most are reluctant to "pencil in" sex.

"I always hear, 'But that's not spontaneous. I don't like it when it's not spontaneous!'" says Lochner. "I don't want to make it sound like a job, but having a little creativity and playfulness can spice things up."

Setting a date empowers both partners to decide when they'll be intimate and takes away the fear of rejection. Just knowing that you're going to meet in the bedroom every Friday at 9 p.m. can prime the pump, too, as long as the goal is intimacy rather than intercourse. "I don't say 'time to have sex,' because that's too much pressure," says Lochner. "Rather than focus on having sex, focus on whatever physical touching or closeness gives you pleasure."

"I think that sometimes our expectations are too high," she adds. "So we used to do it three times a week and now we have the energy once every three weeks -- who says it has to stay the same? It's whatever feels right to the couple."

Deborah DiSesa Hirsch contributed to this story.

ONLINE EXTRA: Raging Hormones -- and how to fight back

An old man visits his doctor and tells him, "I need my sex drive lowered." The doctor says, "You want your sex drive lowered?" To which the old man replies, "It's all in my head. I need it lowered!"

We've all heard the jokes, but low libido is no laughing matter to the men experiencing it -- or their partners. Testosterone is not just responsible for sex drive and erections, says Dr. Andrew McCullough , director of men's health in the division of urology at Albany Medical College , "It's what makes us tick, as men."

After men turn 40, testosterone levels begin to decrease by 1.5 percent a year. Even so, doctors don't test male hormone levels unless they see symptoms, such as vascular disease, decrease in muscle mass, increase in body fat, fatigue, a drop in bone mineral density, and sexual dysfunction, suggesting that testosterone levels are too low. "You used to have sex three times a week, then it's once a month and now all you want to do is sit in front of the TV and watch Everyone Loves Raymond. Yeah, that's a problem," McCullough says.

Fortunately, there's a solution. Synthetic testosterone can be applied topically, injected, or inserted in a pellet under the skin. Men taking the hormone are monitored closely, however, because the supplements sometimes lead to enlargement of the prostate and prostate cancer, and can thicken the blood, leading to heart disease.

Decreases in testosterone after menopause can also lower a woman's libido but while some doctors will prescribe testosterone supplements for women, these are none yet FDA-approved for women, and they may cause unpleasant side-effects such as unwanted hair growth, a deepening of the voice, higher cholesterol levels. Dr. Kathryn Leopold of Women's Care OB-GYN in Saratoga Springs also notes that these supplements don't always work.

A wide range of supplements are available, however, to boost the levels of other hormones that decrease when women hit menopause. Synthetic dehydroepiandrosterone, (DHEA) can be used to strengthen the vaginal wall in post-menopausal women and increase bone mineral density. Estrogen supplements, prescribed to ease dryness and pain, are widely available in the form of lubricants, creams, and a vaginal ring. -- Deborah DiSesa Hirsch

For more on Low Libido check out this month's Ask Emma story, "Low libido: Is it really a problem?"