My patient, Debra, practically waltzes into my office. She is giggling and barely waits for the door to close before she announces: “I am having sex again and really enjoying it. Not only that, but I’m actually having random lusty thoughts.”

What a change from a couple of months ago, when sex was no more interesting to her than office furniture. Her husband is also delighted, she tells me. He plans to shower me with chocolates and flowers because I brought his wife back to Libido Land.

This patient and I started discussing her faltering sex life about two years ago, around her 49th birthday – a time many women come to me with concerns about their sex lives. There were so many possible causes: her stressful job, her husband’s stressful job, the demands of a rambunctious 6-year-old who still appeared unannounced in the parental bed, her husband’s widening girth, her own steady march into menopause …

I made lots of suggestions and Debra tried them all: couples counseling, more exercise for her and hubby, sleep training for the nocturnal son, stress reduction, aphrodisiacal foods and herbs, and books on improving sexual relationships with terms like “joyful lovemaking” in the title. There were glimmers of hope but nothing substantive.

Finally, we entered the world of hormones. Despite her midrange-normal estrogen and testosterone levels, I gave her an off-label prescription for testosterone: a dab to her buttocks daily. Two months later, she came steaming into my office.

Land of confusion

I am happy for my patient (and pleased about the forthcoming chocolates), but her report provides me with more vexing data as I struggle to help women of all ages (especially those in midlife) who are distressed about their sex life. According to a sexual health study at Harvard, that’s about one in eight women nationally.

A woman’s sexual experience depends on a complex interplay of her neuroendocrine system, her multiple sex organs and any number of social circumstances, and it stands to reason that there might be many places where the process can go awry.

Still, from my inexpert perspective as a family physician, there seems to be no rhyme or reason to treating sexual problems: I see women whose lab results mirror Debra’s yet who have no response to hormones and manage to boost their love life with exercise, therapy, books or lingerie.

Equally perplexing are those with rock-bottom testosterone levels who are off-the-charts randy. Numerous large testosterone trials only serve to further my confusion, as most women who take the hormone report that their lovemaking has increased by no more than two sessions per month.

In an attempt to develop a standard approach, I called Rosemary Basson, director of the Sexual Medicine Program in the Department of Psychiatry at the University of British Columbia in Vancouver. She has interviewed 6,000 women throughout her 22-year career in sexual medicine.

The first step, she said, is to encourage women to change their understanding of sexual dysfunction. Contrary to what is conveyed by romance novels and medical texts, Basson’s research suggests that it is normal for some women not to experience desire at the outset of a romp. In other words, if you would choose Sudoku over lovemaking but actually enjoy sex when your partner gets you going, then you are not disordered. Accepting that, Basson has found, leads many women to report much higher satisfaction with their sex lives.

Tactics that work

For those who still feel things aren’t right, Basson suggests they ask themselves: “What is interfering with your state of mind?” Depression should be treated with therapy and/or medication, pain can be addressed with therapy, and dissatisfaction with a partner might improve with couples counseling. Poor self-image, often a major factor for women who report sexual problems, can be improved through mindfulness therapies.

James Simon, a professor of obstetrics and gynecology at George Washington University, believes that a subgroup – 3 percent to 6 percent of women – suffer purely from a deficiency in brain neurotransmitters. He identifies them as good candidates for flibanserin, an experimental dopamine-type drug that, like Viagra, was serendipitously noted to have positive sexual effects during its failed trial as an antidepressant.

The initial flibanserin trial with premenopausal women produced results roughly similar to testosterone, an average of two more “sexually satisfying” encounters per month. (Women in the control group also reported one more encounter per month, so the mere act of taking a placebo can have a libidinous effect.)

When I asked Simon about the significance of this small number, he replied: “For the women who experience this increase, this is a highly significant number.”

Answer is intricate

I think back to my patient. What could account for her euphoria? Was it attributable to two extra sex sessions per month? Or, as Simon asserts, when it comes to raising the female libido, perhaps “one plus one does not equal two,” with behavior changes plus a medication having a far greater effect than either treatment alone.

Basson agreed that a neurochemical drug has the potential to boost arousal in a small percentage of women, but she was skeptical.

“Look,” she explained, “if there was a drug that was so potent that it could overcome all misgivings we have about ourselves, our sexual image, our uncertainty about our sexual partners, the kids banging at our bedroom door, you could not make it legal. It would be slipped into drinks. What are people looking for?”

Perhaps there is a silver bullet for a select group of women, but the majority will need to be satisfied with small positive changes. As for me, I am not sure whether I am any closer to developing a tidy algorithm for boosting women’s sexual health. But I am more at peace with the idea that it is an intricate affair.