Having PCOS is like being dealt a hand of genetic cards. You can play those cards so that you feel your best, sexually and in terms of your energy and mood. Your lifestyle, your diet, and hormonal management are all important pieces to manage the hand you have been dealt.
First thing to know is that you are not alone: one in ten women has a similar set of playing cards. PCOS (Polycystic Ovarian Syndrome) is a common genetic hormonal pattern in which your DHEA (an adrenal hormone) and your testosterone are robustly influential in relation to your ‘female’ hormones (estrogen and progesterone). Even though testosterone is widely accepted as the hormone of desire, if you have too much, you will not necessarily have a high libido. You may still have similar desire problems, or arousal and orgasm problems, as women without PCOS, though not for the same reasons.
Twenty percent of the women I see in my practice have this hormonal pattern and I have found multiple things that work to balance you emotionally and physically, as well as improve your sexual experience. Let’s start with the basics, your period, and then go on to hear how PCOS interacts with your sex life, and what you can do about it.
With this hormone pattern women often experience problems with their periods—skipped periods, frequent periods, heavy bleeding, extra long periods, severe cramps, or no periods at all. Sometimes providers prescribe oral contraceptives to manage the pain and the bleeding, and to make the cycles regular. Women who have heavy and/or long periods can bleed so much that they become anemic. If you have anemia you can become so tired from an iron deficiency that you don’t have the oomph to be interested in sex. On top of that, it can seem to your partner that you are always on your period, and never available for sex. Misunderstanding around this can lead to distance and resentment in your relationship.
Even if periods are regular, with the extra androgen influence, women with PCOS are more likely to have cycles without releasing an egg. Without that mid-cycle hormone spike, you are less likely to experience the surges of desire, the ‘horniness’, mid cycle. Also, when you don’t ovulate you don’t produce much progesterone. Progesterone is the relaxing hormone in your chemical mix. You have estrogen and testosterone in that mix and those are both activating; progesterone balances that activation with relaxation. You have receptor sites in your brain for progesterone and when it lands there, you can feel mild sedation and calmness. When your progesterone level is low your sleep can be restless, you toss and turn, you can get sweaty, and you don’t wake up feeling restored.
Women with this hormonal pattern of PCOS report to me having night sweats, itchy or hypersensitive skin, and greater anxiety and irritability—sometimes too irritable to want to be touched. They also are, according to research, more likely to be depressed.
Also, If you have PCOS you are more likely to struggle with weight, and be at a higher risk of diabetes. The increase in testosterone increases the size of your muscles. Sometimes this works for you, and sometimes your muscles bulk up more than you want. This bulking up increases your weight and excess body weight can contribute to a lack of desire for sex. Many women who gain weight become self-conscious about their weight. It inhibits them from wanting to be seen naked, and so they refrain from initiating sexual contact.
Not all women with PCOS have or are going to have all of these symptoms. Many women with PCOS have no sexual problems, none at all. There is a large variation in how women with PCOS are affected. One third of women with PCOS will struggle with decreased fertility, and having sex will be linked with using ovulatory kits, and jumping in bed when the timing is ‘right’. Some women will have extensive medical workups for this and be on medications that influence their mood and desire. PCOS is not one thing — the underlying hormonal pattern of PCOS is there, but the expression is different. With genetic studies, we are still learning why this expression is so varied and how we can intervene.
Besides low sexual arousal and desire, women with excess androgen hormones can complain of vaginal symptoms including burning, dryness, or irritation. Some women report their own lubrication does not last long enough for them to finish sex without needing to add a lubricant. Sometimes there is ongoing itching and burning of the vagina that gets worse at certain times of the month.
Ann had this PCOS hormonal pattern. It was her anxiety and irritability that brought her in for a hormone evaluation. Specifically, it was the flush of embarrassment on her twelve-year-old daughter’s face when she, Ann, angrily demanded that the man in the ice cream truck turn down his annoying music. She recognized that her reaction was over the top and she was tired of being on the edge. On her intake form, Ann marked her symptoms— anxiety, irritability, vaginal dryness, specifically vaginal burning after intercourse, low libido, restless sleep, and worsening PMS. She had felt on edge for a few years and the number of days she felt moody was on the increase. Her sexual desire had been low for years. Vaginal dryness had started after the birth of her second child and was getting worse. Lubricants helped intercourse feel comfortable, but she was not that excited about having intercourse at all. She had sex because she knew it was important to her marriage, and she did like the closeness she and her husband shared after sex.
The vaginal dryness and burning that is sometimes found in women with PCOS is easily treated. Ann found this to be true. Eight weeks after she began treatment, her vagina felt back to the way it was before she had her second child. She no longer had dryness, and she no longer burned for a few days after being sexual. These vaginal symptoms responded quickly to the same estrogen treatment used for menopausal vaginal dryness : a topical low dose estradiol cream, or suppository used once a week.
Ann received a prescription of micronized progesterone, and with it she felt more relaxed and was able to sleep longer and deeper. She no longer experienced on the edge, moody feelings. She still felt anxious at times, but the feeling was slight in comparison. Her husband could approach her without her snapping at him. His touch, which had become annoying, felt good again. Intercourse was distress free, and she felt stronger levels of arousal than she had in years.
Ann did not have the anemia, but if she did she would have been given an over the counter iron pill to take daily and advised to increase the iron rich foods in her diet. About one third of women with PCOS have heavy periods. Heavy bleeding is defined, in medicine, as a need to change your pad or tampon every one to two hours. Long periods are defined as ones that last longer than seven days. Treat the low iron until your hemoglobin and hematocrit are in the normal ranges. Sometimes prescription iron is recommended. Also, if your provider doesn’t test your ferritin level (a measurement of stored iron), ask for it. Clinically, I notice women with ferritin levels greater than 50 report a stronger sense of wellbeing and are more likely to have some energy left for sex when they get into bed at night, than women with ferritin levels below 50.
Also, your health care provider can help you look at several treatment options to help you modify the heavy bleeding. Some of your options are friendlier to your arousal and libido than others. When your hormones are managed well, you will have more regular cycles, and probably lighter periods. You will discover you have more choices around which days to be sexual, and more energy with which to have it.
Remember, there is nothing ‘wrong’ with you and you are not alone. One in ten women are managing this too, and more genetic studies are underway to increase understanding and optimize health.
Symptoms of Too Much Testosterone in Females
- Restless sleep/Insomnia
- Short fuse/Anger/Rage
- Worse PMS
- Menstrual Cramps
- Weight gain/Bulking up
- Irregular periods/No periods/Heavy periods
- Increase in chin and lip hair and hair elsewhere on body and a thinning of hair on top of the head
- Vaginal irritation and/or dryness
This is an edited excerpt from Fanning the Female Flame-How to Increase Sexual Desire (without Changing Parters).