Doc, can you give me some pills to pep up my sex life? asked L, 30. She had been married for three years and was still breastfeeding her nine-month-old son.

'My relationship with my husband is good,' she continued. 'We have no major disagreements, but I have lost interest in having sex after the birth of our son and I find it a chore rather than something enjoyable.

'My husband tries his best to make it good for me. We indulge in longer foreplay but this fails to arouse me. In fact, intimacy becomes more painful when the foreplay is too long. I feel very frustrated and apologetic towards my husband. Can something be done?"

L suffers from a common sexual problem called Hypoactive Sexual Desire Disorder (HSDD) which is a lack of desire or interest in sexual activity. It can cause great distress and frustration for a couple and may ruin a marriage simply because it affects their sex life.

HSDD affects about 20 to 35 per cent of women with sexual dysfunction and is more common in menopause.

It can be a primary condition, in which the woman has never had sexual interest, or it may be secondary, as in the case of L, who earlier had had sexual desires.

Understanding the complexities of desire has enabled doctors to evaluate the cause of HSDD.

Sexual desire has three components - biological, social and psychological.

The biological component is defined as spontaneous sexual interest which varies in individuals and declines with age. It can be easily dampened by mental exhaustion, depression, physical fatigue and work stress.

Medical conditions such as heart diseases and diabetes mellitus or hormonal derangement, which may occur during lactation and menopause, may also curb the sexual desire.

Other causes include medications such as antidepressants and hormonal therapy.

The social component includes expectations, beliefs and values about sex. HSDD may be a consequence of repressive family attitudes towards sex or rigid religious beliefs.

The psychological component is motivation. If a couple is experiencing relationship problems such as conflicts, anger and mistrust, a wife may not want to have sex with her spouse even if her desire is high. With time, her sexual interest will diminish.

In L's case, her lack of desire in intimacy started after delivery. She was working with no domestic support and she hardly had any time to rest. In this instance, fatigue, both mental and physical, probably played a major part in causing HSDD.

Breastfeeding, by reducing the female hormone oestrogen, was a further aggravation. Her vagina was dry and sex was painful and difficult.

Treatment of HSDD depends on its cause. If it is due to a medical condition, therapy is aimed at a cure or amelioration of that condition.

Currently, there is no consensus on approved drug or pharmacological treatment for HSDD although antidepressants, testosterone (male hormone) and drugs used for male erectile dysfunction have been tried with varying degrees of success.

If HSDD is the result of attitudes and experiences of a long-standing nature, changing how a patient thinks and feels about the problem and her sexuality is crucial.

When there are relationship issues between the couple, counselling, which has to be individualised, is the treatment of choice. Some couples need to enhance their relationship before focusing on spicing up their sexual activity.

Changing the monotony of intimacy is useful while improving communication skills and strengthening interpersonal relationship help.

L was asked to talk to her husband frankly about what turns her on or puts her off during sex.

Simple lifestyle modifications and stress management go a long way in improving intimacy.

L was advised to take short breaks and to get domestic support. She was told to avoid sex on days when she was very tired or preoccupied. Vaginal lubricant was prescribed to reduce pain during sex.

Fortunately, her husband is very patient and supportive of the treatment and L is making slow but steady progress.

Dr Peter Chew
peterchew45@yahoo.com.sg

Dr Peter Chew is a senior consultant gynaecologist and obstetrician at Gleneagles Medical Centre. He is the founder chairman of aLife (www.alife.org.sg), a charitable organisation with a mission to nurture and promote healthy family life.

This article was first published in Mind Your Body, The Straits Times on Oct 30, 2008.