Maggie McKay (Host): Welcome to Conversations Like No Other: presented by Valley Health System in Paramus, New Jersey. Our podcast goes beyond broad everyday health topics to discuss very real and very specific subjects impacting men, women, and children. We think you'll enjoy our fresh take. Thanks for listening. I'm your host, Maggie McKay.

Today, we have with us Cristina Giambalvo, Director of the Midwife Program at Valley Health System and Certified Nurse Midwife, to discuss how age impacts libido and solutions for women. Thank you so much for being here.

Cristina Giambalvo, DNP: Well, thank you so much for having me. I'm really glad we're talking about this. This is a really important topic that doesn't get talked about enough.

Host: Absolutely. So, let's just start with the basics. What is libido and what affects libido as people age?

Cristina Giambalvo, DNP: So, simply put, libido is your sexual drive or desire, that sort of internal energy or interest in sexual activity. It's influenced by not just hormones, but also by emotional connection, mental wellbeing, physical health, and even lifestyle factors like stress or sleep and nutrition. It's really not a fixed thing. It ebbs and flows naturally throughout life, and that's completely normal.

There's a number of factors that affect libido: their biological, psychological, social factors; things like hormones, which I think most women attribute most of the decrease in their libido to. But there's so many other factors that come into play, things like health conditions, diabetes, thyroid issues, heart disease, medications, sleep and fatigue, alcohol and drugs. I think when we're talking about psychological factors, stress and anxiety is a huge killer of libido. And I think body image issues as women gain weight over the course of their lifespan, which is common, that can affect body image. Anxiety and depression.

And then, I think what people don't think enough about are the social and relationship factors, right? What's the quality of your relationship? Women are very turned on by intimacy and connection. Men are sort of turned on by-- they're very visually inclined. So, I think understanding the relationship factors. And then, also understanding that in a long-term relationship, sometimes intimacy can dull or the novelty can dull a little bit and, you know, you can have decreased excitement.

Host: And with all those changes that come with age, how do you know if your libido is normal?

Cristina Giambalvo, DNP: Yeah, that's such a great question. So, there's really no single normal level of libido that I think fits everyone. So, sexual desire naturally varies a lot from person to person or even within the same person at different times of life. But that said, there's some ways that you can tell if your libido is sort of within a healthy range for you.

I think if you have an interest in sex or intimacy, sometimes, even if it's not constantly, that is normal. If your level of desire feels comfortable and natural and it's not really distressing; if your libido matches your circumstances, so for example, it's normal for it to dip when you're stressed or tired or ill. And then, I think also if you and your partner, if you have one, are satisfied with your sexual connection or, you know, if you can talk openly about the differences in desire.

Host: What medical conditions can cause decreased libido? Is low desire because it just "isn't worth it"?

Cristina Giambalvo, DNP: There's a number of medical conditions that can contribute to low libido. One of the first I would say is hormonal or endocrine issues. Low testosterone in both men and women can play a role in having low levels that reduce desire or arousal. Certainly, thyroid disorders, both hypothyroidism, which is underactive thyroid and hyperthyroidism, which is overactive thyroid. Both of those can lower libido. I think the most common in women is perimenopause or menopause, which results in falling estrogen levels, which can lead to some physical symptoms like vaginal dryness and discomfort, which makes sex less appealing.

And I think that with postpartum and breastfeeding, your hormone levels change. There's high levels of prolactin, and those hormonal changes can temporarily reduce your libido And then, really getting into something like adrenal fatigue or Cushing's disease that can affect hormone balance and energy levels. In addition to that, there's chronic illness, diabetes, heart disease, blood pressure, chronic kidney disease, cancer, chronic pain. And then, medications, right? Certain medications are well-known for reducing libido, antidepressants, anti-hypertensive, birth control pills, mood stabilizers. And then, mental health conditions-- anxiety, depression, trauma, PTSD-- right? Especially if it's related to past sexual experiences.

And then, I think, finally, lifestyle and physical factors. Sleep disorders is a big reason why people have lower desire; obesity. And then, of course, substance use, alcohol, nicotine, certain drugs will reduce sexual response.

Host: Is there a mental health component? What medications can cause decreased libido?

Cristina Giambalvo, DNP: So, there are certain drugs that are well-known for reducing libido, certain antidepressants that fall within the classification of SSRIs or SNRIs, some of those medications are Prozac, Zoloft. There's a number of medications within those two classifications that can, you know, sort of reduce your desire for sexual activity. Anti-hypertensives, especially beta blockers, certainly birth control pills. I kind of joke with patients sometimes when they come in and they are on birth control pills and they say, "I really just feel like I don't have any desire for sex," and I kind of joke with them and say that's part of the reason why they work so well.

But they do, we know that birth control pills, you know, lower testosterone levels, and that can lead to decreased desire. Any of the mood stabilizing medications or antipsychotics, any of the opioids or even certain antihistamines, which can cause dryness, like sort of a sedation type of an effect, which can impact your libido.

Host: You mentioned sleep. Does poor sleep cause low levels of interest in sexual desire? What effect does weight gain have also?

Cristina Giambalvo, DNP: So as far as sleep, absolutely. And most people don't realize just how big a role sleep plays in sexual health. If you think of sleep as your body's nightly tuneup, you know, when you're not getting enough, everything from your hormones to mood, to energy gets thrown off. And libido is one of the first things to take a hit.

So if we break that down, right, and we are talking about how poor sleep affects libido, when we don't sleep well, our levels of testosterone and estrogen, which are two key hormones for women, for sexual desire, they start to drop. There's also a mental piece, right? Poor sleep increases stress hormones like cortisol, which interfere with arousal and make it harder to relax into intimacy. You're just simply too tired, too anxious, and too foggy to feel desire. And if we're being honest, when you're running on four hours of sleep, romance usually takes a backseat because you're just trying to make it throughout the day. And this is probably one of the things that so many women in my practice talk about. They're just burning the candle at both ends. And the last thing they feel like they want to do is be touched by the end of the day.

Host: Right. What about weight gain?

Cristina Giambalvo, DNP: So, it makes sense, right? What about weight gain? A lot of people notice changes in their bodies during pregnancy, trying to get their body back to what it looked like before pregnancy. And then, in their 40s and their 50s and post-menopause, our bodies change a lot. So yes, that affects libido in a few different ways. Physically carrying around the extra weight can affect blood circulation and lower energy levels. Hormonally, fat produces more estrogen, both in men and women, which can throw off hormonal balance. And then, there's the emotional impact. When you don't feel comfortable in your own body, it's really, really hard to feel sexual. So, a lot of women pull back from intimacy because of self-consciousness, not because the desire isn't there. They're just not comfortable in their own skin.

Host: And stress has got to be a big factor. Is that right?

Cristina Giambalvo, DNP: Absolutely. In fact, I'd say that stress is probably one of the top reasons why women over 40 experience a drop in libido. It's really not just in your head. There's a very real biological link between stress and sexual desire. When we're under stress, our bodies release cortisol. The main stress hormone. Cortisol is great for short-term survival. It's like that fight or flight response that we get. It helps you stay alert and ready to respond to danger. But when it stays elevated over a long period of time, it suppresses other hormones, especially the ones that drive desire, estrogen, progesterone, and testosterone. So in simple terms, when your body thinks it's fighting for survival, it's definitely not prioritizing reproduction or pleasure. Your body literally says, you know, "Now's not the time for intimacy."

Host: Are there any lifestyle changes that can keep sexual desire active?

Cristina Giambalvo, DNP: Absolutely. Keeping your libido alive isn't really about chasing youth, which I think is what most women think. It's really about nurturing connection and vitality and confidence. The truth is sexual desire doesn't have to fade with age. It really just needs a little support from the rest of your lifestyle. So, how do we do that? What do we do to make that difference? So, let's just walk through them.

I think as far as nutrition, what's good for your heart is good for your sex life. So, a diet that's rich in whole foods; thinking, fruits, vegetables, whole grains, lean proteins. I try to talk to patients about a Mediterranean diet. That improves circulation and supports hormone balance.

You want to stay physically active. Movement is like magic for libido. Exercise improves blood flow. It strengthens muscles. It reduces stress. And it increases endorphins. Your body's natural feel-good chemicals, and it doesn't have to be like running marathons at all. Walking, swimming, dancing, anything that gets your body moving.

And here's the bonus, regular exercise also boosts self-confidence and body image, which are major drivers of sexual interest. And then, prioritizing sleep. You know, we talked about it earlier, but I think it's worth repeating. Good sleep is foundational. Sleep is when your body restores hormone levels, repairs tissue, and resets your brain chemistry.

Host: And so, do you have any suggestions for physical conditions that can challenge intimacy?

Cristina Giambalvo, DNP: It's a really wonderful question, and I think it's really necessary. I think that many women over the age of 50 especially experience some physical conditions that can make intimacy challenging. But here's the hopeful part. With some understanding and communication and the right medical support, most of these challenges can be improved and worked around.

So, let's go over, I think, some of the most common, the first and probably the most prevalent for women is-- as we age anyway-- is vaginal dryness, vaginal discomfort. So after menopause, estrogen levels drop. And that can cause vaginal tissues to become thinner and less lubricated. And the result is discomfort or even pain during intercourse, something that can understandably lower desire. But the fix there often starts with communication and comfort. There are over-the-counter lubricants and moisturizers that can help tremendously. And there's also prescription treatments like vaginal estrogen creams, or even some non-hormonal options that would be recommended by your healthcare provider that help to restore moisture and elasticity.

The key message, I think, is if sex has become painful, that's not something that you have to just live with. There are safe and effective ways to make it comfortable again. Then, there's, I think, issues of chronic pain and arthritis, joint stiffness, mobility issues, then we have to just adapt, right? A little creativity, using pillows for support, exploring different positions, focusing more on touch and sensuality rather than penetration can oftentimes make intimacy enjoyable again. Working sometimes with a physical therapist can help. I think you learn safer, more comfortable ways to move and connect. And then, thinking about something like heart disease or diabetes because so much of the population suffers from both of those conditions, they can affect blood flow and energy and nerve sensitivity, all which play a big role in sexual response. So, I think the best approach here is kind of twofold: managing the condition itself and then talking openly with your healthcare provider about how it's affecting your sex life.

Host: You mentioned a few medications. We know about Viagra for men, but what about medications for women? I know you mentioned a few, but I think it's worth going over again.

Cristina Giambalvo, DNP: Yeah, absolutely. There are certainly some prescription medications that are, I would say, not as popular. There's supplements, and then there's medications. So, let's talk about some of the medications that are available for low sexual desire. One of them is called Addyi, A-D-D-Y-I, which is a daily pill only, recommended for premenopausal women with low sexual desire. It is not recommended for women who are menopausal. It works on brain chemicals, dopamine and serotonin. It's not a female Viagra, but I think patients think of it that way. It increases desire, it does not increase arousal or lubrication. I think the downside with Addyi is that you do have to avoid any alcohol while you're taking it because it can significantly reduce your blood pressure.

And then, there's another medication called Vyleesi, V-Y-L-E-E-S-I, which is injection form. It's taken as needed about 45 minutes before sex. It works on your brain pathways that influence sexual desire. I think one of the downsides of that medication is that it can cause temporary nausea or flushing, like hot flashes. And I think one of the biggest downsides to both medications is that oftentimes they are not covered by insurance. So, there's a cost factor when it comes to women's health and what will be covered. There's also vaginal dryness we talked about earlier. We talked about local estrogen therapies, non-hormonal options like vaginal moisturizers or lubricants.

Host: Are there any other forms of therapeutic treatment for low libido?

Cristina Giambalvo, DNP: Yeah. For women, treatment definitely depends on the main issue. What is the main issue? Is it low desire? Is it pain? Is it dryness? Is it hormonal changes? Right now, all the rage for women is testosterone. It's everywhere on social media. Should I be taking testosterone? Can I take testosterone?

And I think that it's important to realize, at least when we're talking about testosterone, do we look at testosterone as if it's going to fix a bad relationship. It's not. So, I think we have to know that it has its place, but it's not definitely this be-all, end-all in terms of treatment. And it's not actually FDA approved for use in women. It's used sort of off-label.

So, what are some of the other things that you know can help libido? And we're really now getting into the relational aspect of it. Sex therapy, which is essentially psychosocial counseling, a specialized form of counseling with a certified sex therapist that helps couples to understand the emotional and psychological or relational factors that are affecting sexual desire.

 Then, you step into couples therapy, looking at relational issues within the actual relationship. And then, I think when we're talking about issues with self-esteem or body image issues. We look at cognitive behavioral therapy, which is a form of talk therapy. It sort of identifies and reframes negative thoughts about sex and body image and self-worth. And then, hormone therapy, sort of going back to what I said earlier about testosterone, I think for women, low-dose estrogen or low-dose testosterone in some cases can certainly help to improve desire and comfort.

Host: And talking about sex seems to still be taboo among many older people. So, what advice do you have for your patients about talking to their doctor about it or talking to their doctor about experiencing changes in their libido?

Cristina Giambalvo, DNP: Yeah. All right. So, I think we just need to sort of get real for a minute, I'm going to say it like you're going into your doctor's office and you're going to talk about sex. And so, I think if you just reach for the volume knob to turn it down so nobody hears what you're talking about, you're not alone.

For a lot of people, especially for those of us, and I am in that same group who didn't grow up with TikTok or oversharing every detail of your life, sex is still somewhat of a taboo topic. But here's the thing, sexual health is part of overall health. And I try to talk to my patients about this as much as I can. It's just as important as your blood pressure or your cholesterol, although admittedly, you know, it's a lot more fun to talk about things when they're going well. So when there's changes in libido that are so common as we get older, we have to just find the space to introduce the conversation. Hormones shift, medications can interfere, and sometimes the body just doesn't cooperate like it used to. But that doesn't mean that you just shrug it all off and say, "Well, I guess that ship has sailed." You know, there's treatments and therapies and solutions that can make a big difference if you tell your healthcare provider what's going on. I just think that we have to try easing into the conversation. So, what does that look like?

A lot of my patients, because I've known them for many, many years, come in and they just spill it all out and they give it to me and they tell me, "I used to really, really want to have sex and now I'm exhausted. I can't do it. I can't find the time," or "I love my husband, but what is wrong with my body?" So, what about maybe saying to your healthcare provider, "Could my medication be making me feel less interested in intimacy or can I talk about some vaginal dryness or performance? Do you have any advice for me?" I think that's a really easy way to sort of introduce that topic. There's no fancy words. Just be honest. Remember, everything that you share stays between you and your provider. And if you get the deer in headlights look from your provider, don't take that personally. You know, you just need to find another provider who's comfortable having the conversation.

Host: How does low libido affect your relationship with your partner, and how do you bring up the topic without offending him or her?

Cristina Giambalvo, DNP: Yeah, This is huge. And nobody feels comfortable having this conversation, right? So, it can make even the most confident couple, I think, squirm when one person feels like their sex drive has changed. You know, maybe you've noticed you're just not as interested in sex as you used to be, or maybe your partner's the one that's pulling away. But either way, it kind of leaves you both wondering, "Is it me? Is it them? Is this my new normal?

I think first you just need to take a deep breath and understand that changes in libido are completely normal for both sexes as we age. We already talked about the hormone shift. We talked about medications kick in, stress creeps up, raising children and sometimes caring for elderly parents. You know, sometimes that all kicks in, and we don't want to, or sometimes the spark just flickers. When you're with somebody for a very, very long time, I always sort of joke about Tom Brady and Giselle Bunsen, probably two of the most beautiful people on the planet, and at some point, they probably looked at each other and thought, "Yeah, I don't know. You're not doing it for me right now." The spark sometimes just falls a little bit. It doesn't mean that you've fallen out of love or lost your attraction. It just means your body and brain are doing what they do, which is changing. So, how do you talk about it? Nobody wants to hear, "I'm just not into it." That can sting. So, bringing it up in a very sort of confrontational way, where you're talking about how it affects you and not what they've done wrong.

How about, I've "I've noticed my desires changed a little bit and I miss our closeness. Like, can we talk about that?" Or like, "I love being with you, but my body seems to be reacting differently. Maybe we can figure this out together." You know, you see the difference in the way that lands as opposed to "You're not doing something right and I don't want to have sex with you anymore," right? You just want to be able--

Host: Never works.

Cristina Giambalvo, DNP: That never works. And like sometimes even a little humor, you know, "My hormones have gone on vacation. I just wish they left a forwarding address. I wish I could get them back." I think it's really keeping it light, opening the door to sort of a deeper, more honest conversation.  

Host: Well, this has been so informative and educational. We really appreciate your time. Thank you for sharing your expertise. Because, as you said in the beginning, this is such an important topic.

Cristina Giambalvo, DNP: Well, thank you so much. I appreciate you taking the time.

Host: Again, that's Cristina Giambalvo. For more information about women's services at Valley, please visit valleyhealth.com/women. Thanks for listening to Conversations Like No Other: presented by Valley Health System in Paramus, New Jersey. For more information on today's topic or to be connected with today's guest, please call 201-746-9385 or email valleypodcast@valleyhealth.com.