Hormones and Low Libido: When to See a Doctor vs. a Sex Therapist

Hormones and Low Libido: When to See a Doctor vs. a Sex Therapist

You have noticed that your interest in sex has dropped. Maybe it happened gradually, over months or years. Maybe it seemed to shift after a major life event, a health change, or a new medication. Maybe you cannot point to anything specific at all, only the quiet awareness that something that used to feel natural now feels distant or absent.

The first question most people ask is some version of: is this a physical thing or a mental thing? Is something wrong with my body, or is something going on in my head? And the honest answer, supported by a large and growing body of research, is that it is almost always both to some degree, and that separating the two cleanly is often neither possible nor particularly useful.

That said, understanding where the primary driver seems to be is a genuinely helpful starting point. It shapes where you go first, what questions to ask, and what kind of support is most likely to make a real difference.

The Role Hormones Actually Play in Sexual Desire

Hormones do matter for libido. That much is well established. Testosterone, in particular, plays a meaningful role in sexual desire for people of all genders, not just men. Estrogen, progesterone, thyroid hormones, prolactin, and cortisol all have documented effects on the sexual response system as well.

For men, the evidence is fairly direct. A 2022 narrative review found a significant correlation between testosterone levels and libido in men, with desire declining in a dose-dependent manner as testosterone dropped. For men with confirmed low testosterone, hormone therapy consistently showed improvements in sexual desire across multiple meta-analyses.

For women, the hormonal picture is more nuanced and has historically been underresearched. Testosterone plays a role in female desire too, though the relationship is not as straightforward. A 2019 review examining testosterone and low female sexual desire found that nine out of ten studies failed to identify a significant correlation between total testosterone levels and sexual desire in women, underscoring that hormones are one piece of a more complex picture. That said, testosterone therapy has shown meaningful benefits in specific populations. A 2022 article on testosterone replacement therapy in postmenopausal women with HSDD found consistent improvements in sexual desire and satisfying sexual activity, particularly when testosterone was used alone or alongside estrogen in surgically or naturally menopausal women.

Recommendations from the 5th International Consultation on Sexual Medicine (ICSM 2024) reviewed the broadest available evidence base and confirmed that testosterone therapy has demonstrated short-term efficacy for postmenopausal women with HSDD, supported by a meta-analysis of 36 randomized controlled trials and over 8,000 participants. The evidence for premenopausal women remains insufficient for a routine recommendation, and systemic estrogen alone has not been shown to significantly improve sexual desire independent of its role in managing menopausal symptoms.

What this means practically is that hormones can be a real, treatable driver of low libido, but hormonal status alone rarely tells the full story, and particularly not for women. Even when a hormonal factor is present, psychological and relational variables frequently amplify or maintain the problem long after any physical cause has been addressed.

When the Cause Is More Psychological Than Hormonal

Sexual desire is generated in the brain before it is expressed in the body, and the brain is extraordinarily sensitive to psychological and emotional states. Research suggests using a biopsychosocial approach supports women’s sexual function at midlife, confirming that biological factors, psychological variables, relationship quality, and sociocultural context all interact dynamically to shape sexual desire over time. No single factor operates in isolation.

Some of the most common psychological and relational drivers of low libido include:

•  Depression. Research consistently finds that low libido is among the most common symptoms of depression. The relationship runs in both directions: depression suppresses desire, and persistent low libido can deepen depression, particularly when it affects relationships or self-image.

•  Anxiety and chronic stress. The sympathetic nervous system response that governs the stress reaction is physiologically incompatible with sexual arousal. When the body is in a sustained state of threat or overwhelm, desire is among the first things to go offline.

•  Relationship distress. Unresolved conflict, emotional distance, resentment, or a breach of trust can suppress desire in ways that no hormone panel will detect. Desire does not exist in a relational vacuum.

•  Body image and shame. Negative feelings about one’s body, internalized sexual shame, or past trauma can create a chronic internal environment that is incompatible with felt desire, regardless of hormone levels.

•  Medication side effects. SSRIs and other antidepressants, hormonal contraceptives, antihypertensives, and several other common medications are documented contributors to reduced libido. This is a medical variable, but one that often requires both medical management and psychological support.

When to See a Doctor First

There are specific circumstances where a medical evaluation should be your first stop, before or alongside any psychological support:

•  The change was sudden and unexplained. A sharp drop in libido with no clear psychological trigger, particularly if accompanied by other physical symptoms such as fatigue, weight changes, mood shifts, or irregular cycles, warrants a medical workup.

•  You are in a known hormonal transition. Perimenopause, menopause, postpartum recovery, thyroid disease, or a history of conditions affecting hormone production all make a medical evaluation a logical first step.

•  You have not had a recent physical. Low libido can be an early signal of thyroid dysfunction, diabetes, cardiovascular disease, or other conditions worth ruling out before assuming a psychological cause.

•  You are on medications with known sexual side effects. If your libido declined after starting a new medication, talking to the prescribing provider is the most direct next step. Dose adjustments or medication changes can sometimes resolve the issue without further intervention.

If you are seeing a physician for low libido, ask specifically about hormone panels including testosterone (total and free), estrogen, thyroid function, and prolactin levels. General practitioners do not always run these tests routinely, and having a clear picture of your hormonal baseline is useful regardless of what the results show.

When to See a Sex Therapist First (or Simultaneously)

A sex therapist is the appropriate first or parallel stop when any of the following apply:

•  The change is clearly tied to a life event. A shift in desire that followed a stressful period, a relationship rupture, a major loss, or a change in life circumstances is more likely to have a significant psychological component from the outset.

•  You have been cleared medically but nothing has changed. If you have had a full workup, your labs are within normal range, and your libido is still low, the primary drivers are almost certainly psychological, relational, or contextual.

•  You and your partner have very different levels of desire. Desire discrepancy is one of the most common presenting concerns in couples therapy. It is rarely resolved by medical treatment alone and almost always has relational and psychological dimensions that benefit from therapeutic work.

•  You feel shame, anxiety, or dread around sex. These emotional experiences are clinical presentations in their own right. They will not resolve with hormone treatment, and they respond well to evidence-based psychological intervention.

•  Your desire functions differently in different contexts. Situational patterns, such as desire disappearing with a partner but present during solo activity, or fluctuating with stress levels, are strong indicators of psychological rather than purely hormonal drivers.

Why the Best Outcomes Come from Both

The field of sexual medicine has moved decisively toward what researchers call a biopsychosocial model: the recognition that biology, psychology, relationships, and culture all shape sexual function simultaneously. A 2025 review on the biopsychosocial model in sexual medicine reports addressing only the biological dimension of sexual dysfunction, while ignoring psychological and relational factors, consistently produces weaker and less durable outcomes.

The ICSM 2024 consensus on HSDD explicitly recommends that all available therapies for low sexual desire, hormonal and non-hormonal, medical and psychological, be used through a biopsychosocial framework. Psychological treatment, including cognitive behavioral therapy and mindfulness-based approaches, has its own strong evidence base for improving sexual desire, independent of any medical intervention.

In practice, this often means working with a physician and a sex therapist in parallel rather than sequentially. Both providers contribute something the other cannot fully replace, and clients who access both tend to see more complete and more lasting results.

Where to Start If You Are Not Sure

If you are uncertain which door to walk through first, a sex therapist is a reasonable starting point for most people. A clinician trained in sexual health can conduct a thorough assessment that helps clarify whether your situation warrants a medical referral, a psychological approach, or both. That assessment alone can save significant time, reduce confusion, and help you feel like someone finally understands the full picture of what you are experiencing.

At Embrace Sexual Wellness, our Chicago-based sex therapists are experienced in assessing and treating low libido across its full range of causes. We take a biopsychosocial approach that considers your hormonal context, your mental health, your relationship dynamics, and your personal history. We also collaborate with medical providers when appropriate, so that your care is connected rather than siloed.

If you are ready to understand what is driving your low libido and explore your options, we invite you to schedule a free 10-minute phone consultation. You do not need to have it figured out before you call.

Perimenopause, Libido, and Your Sex Life: What’s Normal and When to Seek Help

Perimenopause, Libido, and Your Sex Life: What’s Normal and When to Seek Help

If you’ve noticed that your desire for sex has shifted, that it takes longer to feel aroused, that intimacy feels more like an obligation than something you actually want, or that your body just doesn’t respond the way it used to, you’re not imagining things. And you’re not alone.

For many women in their late 30s, 40s, and early 50s, changes in sexual desire are one of the first signs that perimenopause has begun. Yet it’s a topic that rarely comes up at annual checkups, and it’s almost never talked about openly among friends. This means millions of women are quietly wondering whether something is wrong with them.

Nothing is wrong with you. But there is a lot worth understanding.

What Is Perimenopause?

Perimenopause is the transitional phase leading up to menopause, typically beginning anywhere between ages 35 and 50, when the ovaries gradually produce less estrogen and progesterone. This phase can last anywhere from one year to a decade, and it’s marked by hormonal fluctuations that affect nearly every system in the body.

The symptoms most people associate with menopause such as hot flashes, irregular periods, sleep disturbances, and mood changes often begin during perimenopause. What gets less airtime is how profoundly these hormonal shifts can affect a woman’s relationship with her own sexuality.

How Perimenopause Affects Sexual Desire and Intimacy

Research consistently shows that sexual function changes during the menopausal transition. A study published in the Seattle Midlife Women’s Health Study found that hot flashes, fatigue, depressed mood, anxiety, and sleep problems were all associated with reduced levels of sexual desire in perimenopausal women. Declining estrogen levels are a central driver, contributing to a range of physical and psychological changes that impact sex and intimacy.

These changes can include:

•  Decreased libido. Estrogen and testosterone play a key role in maintaining sexual desire. As levels drop, many women notice their interest in sex fading, not because of their relationship or their partner, but because of what’s happening hormonally.

•  Vaginal dryness and discomfort. Lower estrogen can cause vaginal tissue to become thinner and less lubricated, making sex physically uncomfortable or even painful. This condition, known as genitourinary syndrome of menopause (GSM) affects between 27% and 84% of postmenopausal women according to the North American Menopause Society, yet many women suffer through it without knowing that effective treatment exists.

•  Longer arousal times. Hormonal changes can slow the body’s natural arousal response, meaning more time and stimulation may be needed to feel ready for sex. This is common, though it can feel disconcerting if you don’t know why it’s happening.

•  Mood shifts and emotional distance. Anxiety, irritability, and low mood, all common during perimenopause, can significantly dampen desire and make emotional intimacy harder to access.

•  Body image changes. Weight shifts, skin changes, and other physical transitions can affect how a woman feels in her body and, by extension, how comfortable she feels being intimate.

So What’s “Normal”?

Here’s the honest answer: there is a wide range of “normal” when it comes to perimenopause and sexuality. Some women notice only minor shifts. Others experience a more dramatic change in desire. Some find that sex actually improves during this time, freed from concerns about pregnancy or the pressures of younger years.

What matters most is not how your experience compares to a chart or a statistic. It’s how you feel about it. If your changing libido is causing distress, affecting your sense of self, or creating tension in your relationship, that’s worth paying attention to. You don’t have to accept diminished desire as simply “part of getting older.”

The Emotional Side That Often Gets Overlooked

The physical changes of perimenopause are real and significant. But they rarely happen in isolation. For many women, this life stage arrives alongside other major transitions such as shifting family dynamics, career changes, aging parents, and evolving relationships. The stress of it all can compound hormonal changes in ways that make desire feel even more elusive.

A 2024 meta-synthesis published in PMC highlighted that understanding women’s sexual experiences during menopause requires situating female sexuality within a broader framework of sexual health, relational health, and overall well-being rather than treating changes in desire as inherently problematic. In other words, what you’re feeling has context, and that context matters.

There’s also a grief process that doesn’t get named often enough: a quiet mourning of the body you used to have, the spontaneous desire you used to feel, or the version of yourself that felt effortlessly sexual. This emotional layer is just as real as the hormonal one and just as deserving of support.

When It Might Be Time to Seek Support

You don’t have to be in crisis to benefit from professional support. Consider reaching out to a sex therapist or mental health professional if:

•  Your low libido is causing you significant personal distress, regardless of whether you’re in a relationship.

•  There is a significant mismatch in desire between you and your partner, and it’s creating tension, distance, or resentment.

•  Sex has become painful and you’ve begun avoiding intimacy altogether.

•  You’re experiencing anxiety, depression, or shame around your sexuality that feels hard to shake.

•  You feel disconnected from your body or your sense of yourself as a sexual person.

Sex therapy during perimenopause isn’t about “fixing” you. It’s about helping you understand what’s happening in your body, navigate the emotional terrain of this transition, and reconnect with your desire on your own terms.

What Treatment and Support Can Look Like

The good news is that there are many effective, evidence-based options for supporting sexual wellness during perimenopause. A comprehensive approach might include:

•  Sex therapy and mindfulness-based interventions to manage performance anxiety and distractions. A 2024 meta-analysis in the International Journal of Sexual Health found that mindfulness-based cognitive therapies significantly improved sexual function, reduced sexual distress, and lowered depression in women. These approaches address the psychological, relational, and emotional dimensions of changing desire.

•  Couples therapy to navigate desire discrepancy and maintain connection and intimacy as a team.

•  Medical consultation with a gynecologist or menopause specialist to explore hormonal and non-hormonal treatment options. A systematic review and meta-analysis published in PMC found that estrogen therapy and related hormonal treatments may offer modest improvements in sexual function, and these options are worth discussing with your provider.

•  Somatic and body-based practices that help you reconnect with your body and cultivate presence during intimacy, often used alongside therapy for deeper and more lasting results.

These approaches work best in combination and ideally with providers who communicate with one another and see you as a whole person.

You Deserve Support Through This Transition

Perimenopause is a natural part of life, but navigating its effects on your sexuality alone doesn’t have to be. Whether you’re looking for information, guidance, or a space to process what’s shifting, you deserve care that meets you where you are.

At Embrace Sexual Wellness, our Chicago-based sex therapists specialize in helping women reconnect with their desire, navigate life transitions, and build intimacy that feels authentic and fulfilling. We offer individual therapy, couples therapy, and a warm, nonjudgmental space to explore whatever is coming up for you.

If any of this resonates, we’d love to connect. Schedule a free 10-minute phone consultation today and take the first step toward feeling at home in your body again.

Is Sexual Fantasy Healthy? How to Use Fantasies to Boost Desire and Intimacy

As a Chicago sex therapist, one of the most common questions I hear is: “Is it okay to fantasize?” This question often comes with a mix of curiosity, shame, and worry. For some people, fantasies come easily. For others, fantasizing feels foreign, awkward, or even off-limits.

The reality is that sexual fantasy is a completely normal and healthy part of sexuality. Whether you’re single, in a long-term relationship, or exploring intimacy after a change in life stage, fantasy can play an important role in reconnecting with desire and pleasure.

In this article, we’ll explore why sexual fantasies matter, how they can benefit your intimacy, and practical ways to start fantasizing if it doesn’t come naturally to you.

What Is a Sexual Fantasy?

A sexual fantasy is simply a thought, image, or scenario that creates erotic excitement. Fantasies can range from imagining a romantic, sensual moment with a partner to envisioning scenarios that you would never act out in real life.

Importantly, fantasies are not the same as real-life desires. Many people fantasize about situations they would never want to pursue outside of their imagination. This is one reason why fantasies can be so freeing: they’re a mental space to play, without consequences.

Why Do People Fantasize?

Research shows that nearly everyone has sexual fantasies, regardless of gender, age, or relationship status. Fantasies serve many purposes, including:

• Stimulating arousal: Fantasies can help the body respond when desire feels low.

• Reducing anxiety: Focusing on an erotic image or story can quiet distracting thoughts that interfere with sexual pleasure.

• Exploring identity: Fantasies allow people to try on different roles or explore aspects of themselves in a safe way.

• Enhancing partnered intimacy: When shared (with consent and comfort), fantasies can spark new conversations and closeness in relationships.

The Benefits of Fantasy for Your Sexual Health

For many of our clients, fantasy becomes a tool for healing and growth. Here are some of the benefits we often explore in sex therapy:

Reducing Performance Pressure

If you struggle with anxiety during sex, fantasies can help you shift focus away from “Am I doing this right?” toward erotic imagery that feels exciting. This mental shift can make it easier to stay present and experience pleasure.

Boosting Sexual Desire

Fantasies can reignite interest when desire feels flat. They work like a spark for your erotic imagination, offering new ideas and sensations that the body can respond to. This can be especially helpful for couples navigating loss of intimacy or low libido.

Enhancing Partner Connection

While not all fantasies need to be shared, some couples find that talking about them creates intimacy and trust. Even if you never act out the fantasy, sharing it can help you and your partner better understand each other’s inner worlds.

Healing from Shame and Dysfunction

For those dealing with sexual dysfunction, trauma, or shame, fantasy can be a safe entry point into sexual exploration. Imagining a pleasurable scenario provides a sense of control that real-life intimacy sometimes lacks.

How to Start Fantasizing

Not everyone finds fantasizing easy. Some people worry they “don’t have an imagination,” while others feel blocked by shame or religious or cultural beliefs. If that’s you, here are some steps to begin experimenting with fantasy:

1. Start with Memory

Think back to a time when you felt desired, attractive, or deeply connected. Replay that memory in your mind and allow it to expand into a new imagined scenario.

2. Use Your Senses

Fantasies don’t need to be cinematic. Start by imagining touch, sound, or smell that excites you. For example, the warmth of skin, the sound of breath, or the scent of your partner’s cologne.

3. Try Erotic Media

Erotic short stories, romance novels, or audio erotica can help spark ideas when your own imagination feels blank. Reading or listening can lower the pressure of “making up” something yourself.

4. Focus on Themes, Not Scripts

Instead of creating a detailed storyline, think about a theme that excites you, like adventure, seduction, or tenderness. Let the details fill themselves in naturally.

5. Release Judgment

Fantasies often don’t align with real-life desires, values, or behaviors. That doesn’t make them wrong. Your imagination is a safe place to explore, with no rules.

Common Questions About Fantasy

Is it normal to fantasize about things I don’t want in real life?

Yes. Most people fantasize about scenarios they wouldn’t act on. Fantasy is symbolic and exploratory, not a blueprint for your actual choices.

What if I can’t fantasize at all?

This is more common than you think. Sometimes, anxiety, depression, or trauma makes fantasizing difficult. Working with a sex therapist can help you explore these blocks in a supportive way.

Will sharing fantasies with my partner hurt our relationship?

It depends on how you share them. Approach the conversation with curiosity, not pressure. If your partner isn’t interested in hearing or acting on a fantasy, that’s okay. Talking about fantasies is about connection, not performance.

When to Seek Support

If fantasizing brings up guilt, shame, or confusion, or if you find yourself unable to access fantasies at all, therapy may be a helpful step. At Embrace Sexual Wellness, we help individuals and couples explore fantasies, reconnect with intimacy, and work through concerns like low libido, sexual dysfunction, and loss of desire. You can read more about our work with erectile dysfunction and loss of intimacy, both of which can benefit from integrating fantasy as part of treatment.

TLDR

Sexual fantasy is a natural, healthy part of human sexuality. It can reduce anxiety, boost desire, and bring new energy into your intimate life. Whether you’re imagining something tender or something bold, fantasies offer a private, safe space for pleasure and exploration.

If you’re ready to explore your erotic imagination but aren’t sure where to begin, remember: fantasy is a skill you can practice. And if you need support along the way, our team of Chicago sex therapists at Embrace Sexual Wellness is here to help and are licensed to practice in Illinois, Indiana, Kansas, Idaho and Louisiana.