Too Tired for Desire: The Role of Sleep and Stress in Libido, Hormones, and Sexual Pain

When someone experiences low libido, difficulty with arousal, changes in lubrication, erection, trouble-reaching orgasm, painful sex. The advice they receive is often shockingly unhelpful. They may be told to just air quote relax, to make sex a priority, or more of a priority. To schedule it, to push through. This is the worst one, to have a glass of wine, to get their hormones checked, as though one lab result could explain the full complexity of sexual function. But what if the problem is not a lack of effort? What if the body is exhausted, chronically stressed, guarding against pain, or functioning without enough physiological margin for pleasure?

Sexual function requires energy, attention, blood flow, sensory awareness, hormonal communication, and enough nervous system safety for the body to become receptive. So in this episode, we will explore what not to say to someone experiencing sexual dysfunction or pain, what patients and partners can do instead. And then we want to talk about lifestyle medicine. How does sleep impact libido, hormones, arousal and pain. How does stress shift attention, muscle tone, and sexual response? And then finally, practical lifestyle medicine strategies that support sexual health. Because sometimes the first step towards better sexual function is not trying harder. It’s helping the body become rested, well-resourced, supported, and safe enough to respond.

Welcome back to the Vocal Pelvic Floor, everyone. I am your host, Dr. Ginger Garner, and I am coming to you today with a simple concept. Too tired for desire. Let’s talk about the role of sleep and stress in libido hormones and sexual function. First, let’s just get this out of the way. What do you not say to patients or partners? The first thing is just relax. It’s not helpful. Relaxation is not an on and off switch. It shifts responsibility to a person with symptoms without asking why the nervous system is activated. It can also imply that their pain or arousal is just their own, it’s just self-created, right? It ignores medical, hormonal, relational, and environmental contributors so flat out not helpful don’t say that how about let’s look at this instead ask these questions first get curious stay curious ask what helps your body feel less guarded what happens in your body when you feel like intimacy begins do you notice tension fear pain distraction what happens, what would help you feel less rushed and supported? Next thing not to say, it’s probably psychological. Yeah, super unhelpful. The brain and the body are not separate systems. Stress can impact pain processing, muscle tone, blood flow, even just attention and arousal. The symptoms are not imaginary. We can’t just think our way out of them. 

So dismissive language is going to delay getting evaluation, whether it’s pelvic floor, PT, OT, hormonal management, neurological vascular, or other genito-urinary, you know, assessment. So instead, let’s say this. Your symptoms are real, even when the nervous system is involved, and you can treat both at the same time. Stress may be indeed a factor, but we need to assess the whole person, physical and medical factors, all of the what we call in healthcare biopsychosocial. All the biopsychosocial factors. So simply saying, hey, I believe you, let’s take a look at the whole picture, or get you to someone who can look at the whole picture is important. The other thing that’s not helpful to say is your hormones must be off. I’m air quoting this one. Not helpful. Yeah, hormones matter. Yeah, it does, but libido is not controlled by one hormone or one lab value. Don’t even get me started on that. So you can’t just measure testosterone and say, it looks low normal. let’s just supplement that and it’ll be fine. It is so not that easy. Sexual function is affected by sleep, pain experience, other medications, lots of people get easily put on SSRIs, right? Antidepressants, anti-anxiety meds, beta blockers, whatever it is to control. I’m gonna air quote again, control that experience that they’re having. And then they’re not told it has a disastrous or can have a disastrous impact on sexual health and function. That’s also sexual function is also controlled by vascular health. So that needs to be cleared. Relationship dynamics, nervous system regulation, right? Normal lab values do not invalidate your symptoms. And a slightly off lab value also is not going to validate that you just need to replace a hormone. So abnormal values just may not explain the entire experience. You deserve to have everything looked at very comprehensively, very holistically. So let’s say this instead. In addition to what I just said, you can say, yep, hormones, they may indeed be a part of the picture, but they’re not the only factor. And lifestyle variables could actually be creating a false hormonal, not a false hormonal, but they could be skewing those lab values to make it look low normal, when in fact, if you changed lifestyle habits, they could normalize. You don’t want to throw, let’s just say for men’s health, or anyone who would take testosterone, women take it too. You don’t want to just throw testosterone at something thinking that that’s going to solve the problem. We have to consider sleep, stress, meds, tissue health, pain, pelvic floor function for starters. We’re going to evaluate rather than assume. 

Okay, here’s another one that’s unhelpful just schedule sex and just try scheduling protected time is helpful, yes. Scheduling a sexual obligation, that’s different. Pressure can increase anticipatory anxiety, pelvic floor guarding. Encouraging someone to override pain or exhaustion can just reinforce the association between intimacy and another thing to do, or intimacy and threat. So let’s look at it differently. Maybe say, sould we protect time for connection without having any expectation? What forms of touch currently feel safe or good to you? Can that person, can either person have the permission to stop without guilt or punishment or rejection? And could the goal not be performance? Can it just be connection? All right, up next is the one that I really hate the most. It’s the one that I hear my patients come to me with other providers having said it to them. And it’s this. Have a glass of wine and relax. I have to take a moment. If you’re watching this on YouTube, you’re gonna see my my mouth, you know, my whole body just tighten up. That is so unhelpful. Alcohol, yeah, okay, maybe it reduces inhibition, but it also interferes with erection, lubrication, orgasm, sensory processing, judgment, and restorative sleep. No one should have to numb to tolerate intimacy, right? And yep, alcohol can mask pain or relational discomfort, but it’s not addressing the root cause. So let’s do this instead. What helps you transition out of work or caregiving mode? And for a lot of people, everyone, all genders here. We’re all caregiving on a certain level. That creates compassion fatigue. You get all touched out. Like that’s the last thing on your list. So asking your partner or your patient if you’re working with them, what helps you transition out of that caregiving mode or work mode is important? Would quiet time? A shower, music, massage, dimmer, lighting, like that sensory overload is real.

We’re living in an age of information where everything is thrown at you all the time. You get a spare moment, you go, let me see if that person on social media answered me back. There are no breaks anymore. How can you schedule that downtime? We’ve got all these platforms for social media. We have texting, we have WhatsApp, right? We have the phone, we have our in-person interactions. We have all of the information around us. let me just check the news for a second, right? When are we going to realize that constant barrage of information is taking away from our awareness? How can we reduce that stimulation to improve our awareness and improve our presence? Okay, here’s another one that I don’t like. Your pelvic floor is tight because you’re anxious. My face just went flat, so unhelpful. Yeah, a person may have anxiety, but let’s just stop blaming the person. Stop blaming anxiety in the person on the situation. Pelvic floor guardian can have a bunch of contributors. I’m just going to list a few, and this is not comprehensive, okay? At the top of my list that I see all the time, endometriosis, pelvic vascular disorders, hypermobility, okay, EDS, Ehlers-Danlos Ehlers-Danlos syndrome. Those are the top ones that I see. Hip dysplasia. Okay, that’s another top one that I see and have to manage all the time. And then we’ve got some other things that kind of come with it as complications. vulvodynia, vaginismus, bowel bladder dysfunction, surgery, recent injury, hip or back pain, genitourinary tissue change. Think postpartum, things change postpartum, perimenopause, menopause, you know, drops in testosterone, that kind of thing. Trauma, for sure. Breathing and movement patterns. I spend loads and loads of time clinically repatterning, okay? Kind of pressing the reset button on people’s nervous systems. And if you’ve heard any other episodes with me, you know I often use not just manual therapy, but musculoskeletal ultrasound imaging to facilitate that. And then people can anticipate pain. If you’ve given birth, hello, all right, you’ve had extreme pain. And that deserves some therapy on its own, in addition to whatever manual therapy might be done. anxiety can amplify guarding for sure, but it it is not necessarily the sole cause.

So describing the pelvic floors as just tight oversimplifies a very complex neuromuscular response. So can we say this instead? Your pelvic floor appears to be guarding. Let’s explore what’s driving that response. The goal is not just forcing the muscles to relax. We need to understand why your body doesn’t feel safe or able to let go. All right, here’s another one. You’d want more sex if you made it a priority. Ugh. It’s just gross. So unhelpful. It it equates desire with commitment and effort and love. And that is not a good thing to do to someone. It ignores exhaustion, chronic pain, persistent pain, unequal labor, caregiving, compassion fatigue, illness and relationship distress. It makes intimacy feel like yet another, you know, box to tick, not where we want to put people. And it may believe that, it may reinforce a belief that one partner is owed sexual access, even though the partner may not think that, it can kind of reinforce a belief of that. And we don’t want to go there. So let’s let’s look at this instead. What is sucking away all your energy right now? Do you have enough privacy, that’s a big one, especially if you’re raising kids or whatever. Time. Do you have enough support? Do you have enough emotional connection? What responsibilities can be redistributed? What would make intimacy feel inviting rather than obligatory? And at this point you may be thinking, okay, she’s offering a lot of ways to shift the conversation. So maybe you want to like go back to the beginning, restart the podcast, listen to this with your partner. Right. Instead of like furiously taking notes and then becoming the overfunctioning partner who is sharing all this with your, you know, other partner and they may not be aware of what you’re struggling with, just sit down and listen to it with them.

Okay, so essentially what I want to just kick this off with is, and this took a while to get through because of the there’s a lot of unhelpful things to say, but this takeaway basically is it’s not to find a kinder way to pressure someone into sexual activity. The goal is to become curious about what the body needs to experience and explore, comfort, being receptive, giving both partners a sense of agency, focusing on connection and pleasure rather than some kind of performance. And we need to shift the the conversation out of judgment. It it’s not about wagging fingers at someone and just saying you need to try harder or do X, Y, or Z. It’s about remaining curious about their experience. It’s about moving from assumption to assessment. It’s about moving from pressure to invitation. It’s about moving from performance to connection. It’s about moving out of what’s wrong with you to hey, what would help? What conditions would help you? That’s where lifestyle medicine comes in. And that is something that I pursued probably starting about 30 years ago, before lifestyle medicine was even a phrase or a process. other cultures, indigenous systems of medicine recognized lifestyle as being essential to health, right? What we eat, what we consume mentally, who we hang around, how we sleep, all of these things incredibly important. Now they just come under one umbrella, lifestyle medicine. But when I started practicing yoga 30 years ago, yoga is a lifestyle medicine, right? Chinese traditional Chinese medicine, that’s a lifestyle medicine, Ayurvedic medicine, Native American medicine, all systems of lifestyle medicine and respecting and honor that means there are some incredible, incredibly powerful things available to us to improve sexual health, which is great. And so that’s what I do in my practice every day when I’m talking to someone who has endometriosis, who has EDS, who has hip dysplasia. I’m you’re gonna hear me talk about this. And you’re gonna hear we’re gonna go through some systematic reviews, we’re gonna get a little nerdy and talk about two of the pillars. There are six pillars of lifestyle medicine and I want focus on sleep and stress. These are not peripheral wellness practices. Okay, your sleep and stress management influences a bunch of things. Bear with me. I’m gonna list them. Endocrine regulation, so hormones, autonomic balance, your nervous system, cardiovascular function, inflammation, pain sensitivity, mood and cognition, energy availability, recovery, growth and repair and relationship capacity. And guess what? Sexual function is not produced by one hormone, one organ, or one muscle, or even one muscle group. It involves communication from the brain to the endocrine system, the autonomic nervous system, and basically all the things I just listed: cardiovascular, the peripheral nerve system, genital and pelvic tissues, the pelvic floor that includes is included in that pain processing and the emotional and relational environment. So, you know, here’s our anchor, okay? Lifestyle medicine asks not only, hey, what diagnosis does this person have, but also what conditions is this person and this body, this mind body being asked to function within? If it’s unsustainable, we gotta identify it and fix it. So lifestyle medicine should complement, not replace, but it should complement appropriate hormonal, medical, pelvic health, psychological, and relational care. 

So finding a provider that’s certified in that is important. And that’s usually clearly stated on their website if they have been through that training and they are certified. It’s it was incredibly important to me. I actually, started a lifestyle medicine certification for PTs and OTs after I went through my own experience with board certification because we needed something in the pelvic PT and orthopedic PT, and really all systems of PT and OT that actually would move our patients and help you towards optimizing your lifestyle in the context of therapy, which is a huge time saver, right? All right. So we’ll come back, we’re gonna circle back to that, okay? And and and things you can do. So hang with me for a few more minutes here. I also want to mention that this is such an important point. Sexual function requires physiological margin and logistical margin. If you’ve got no margin to give, it’s not happening, right? So if you are, how do you know? Like, how do you know if you have enough of enough margin? Well, are you able to mentally attend? Do you have enough physical energy? Because sexual response requires available resources. Do you have the emotional availability? Do you have the vascular responsiveness? Sensory awareness, muscle adapt ad adaptability. And these are the things that we end up looking at, right? That I as a pelvic floor and orthopedic therapist are going to look at all these things. And then you’ve got some things I mentioned already, like freedom from pressure, privacy and time.

If someone’s exhausted, caregiving, working late, managing pain, anticipating conflict, where they’re carrying the weight of the relationship, or just the majority of the household management, touch may begin to feel like just one more thing, damn it, right? Another demand, another responsibility, another performance, another opportunity for pain. Another person needing something from you. And that is not where we want people to live, right? So if we clinically reframe this, you know, low desire during chronic strain is not does not mean you’re defective. It’s not necessarily evidence of a defective libido, right? It’s actually an appropriate response to a lot of stress, to a lot of crap, right?

Inadequate physical, cognitive, and emotional resources. You don’t have enough margin. So the body’s not saying, I never want intimacy. It might be saying, I don’t have enough capacity for this. Right? So we need to make sure we have enough margin. Now sometimes that having enough margin comes back to what I was talking about sleep and stress, right? So let’s talk about sleep first. I’m going to get a little nerdy here. In the Journal of Sexual Medicine, Lang et al. This 2023, there’s a systematic review and meta-analysis that looked at sleep disorders, sleep quality, sleep duration, and sexual dysfunction. And they found an association between the two, between sleep and impaired sexual function. The literature included multiple sleep domains and problems. Most of the evidence was observational, but it supports a relationship. While not proving that poor sleep is the sole cause of sexual dysfunction, right? Because we can’t really do that, it does provide a relationship. So the systematic review examined obstructive sleep apnea and identified associations between sleep disordered breathing, and breathing is a huge problem that I see in practice all the time, and sexual function, no matter what the gender was. So when we look at

the sleep function, here are the things we need to consider. It’s going to create fatigue if you’re not sleeping enough. Reduce motivation and interest. Reduce attentional capacity. Impaired vascular function. So think erectile dysfunction. Sleep also is going to reduce testosterone levels, important in all genders. Metabolic dysfunction, not good because now you’re looking at cardiac issues, weight management issues, nervous system dysregulation, hormonal and circadian disruption, which I already mentioned, and then increase pain sensitivity, actually. So when I’m working with people who have pelvic pain, this is a massive issue because if they’re not sleeping well, and it’s why if you come in and sit down and talk to me and I’m your therapist, I’m gonna see, I’m gonna say every time, how’s your sleep? How’s your sleep? Let’s fix it.

It’s difficult to access desire if your body’s asking primarily for sleep. And you may absolutely adore and love and desire your partner emotionally in every other way, but have no usable physical or cognitive energy remaining at like 11 o’clock at night. It’s not rejection. It’s it’s depletion. So here’s some questions to ask. How many hours are you actually sleeping? Should be seven to nine. Okay, no, no arguments about it, just seven to nine. Is the sleep continuous or fragmented? It should be continuous. When I lay my head on the down on the pillow at night, I don’t want to be aware that I’m sleeping or waking up to roll over or anything else. I want to open my eyes and it be 6 :30 in the morning, which is when I get up. You want to feel restored in the morning. If you don’t wake up feeling refreshed and restored, it’s a problem. You’re not getting quality sleep. You might be getting enough sleep, but not quality. And that’s why we want to make sure that we screen for things like sleep apnea. And is intimacy primarily postponed until the end of the day when you’re most exhausted? Can you can you flip that script a little bit? And is pain, caregiving, menopause, nocturia, or sleep apnea disrupting sleep? That has to be evaluated. 

So let’s dig a little bit deeper. let’s let’s re- reduce, let’s, let’s, let’s can we avoid reductionistic comments about sleep and circadian rhythm and hormones? Because I hear this too much. One bad night causes low testosterone. Okay, it’s a little bit more complex than that. A systematic review and meta-analysis of sleep deprivation in healthy men found that total sleep deprivation lasting at least 24 hours did reduce testosterone. Short-term partial sleep deprivation did not produce the statistically same significant finding. So you gotta have interrupted, you know, sleep deprivation, well, interrupted sleep and sleep deprivation for more than 24 hours. Now, sadly enough, I mean, that’s usually a common kind of recipe. Kind of you don’t just sleep badly one night. your profession requires you to be sleep deprived. Okay. So lots of lots of issues. So that that article was from 2021, I believe sleep medicine. But another systematic review and meta-analysis found associations between sleep disorders, circadian disruption, reproductive hormones, and markers of male reproductive health. But the studies did vary considerably in design and population. So basically, we need to broaden the conversation beyond testosterone as a as a as a thing for libido, right? And also erectile dysfunction. It’s important for women too. So I’m not just talking about men, but if you have obstructive sleep apnea, there is a relationship with lower testosterone, especially as it gets more severe. Also, if you’ve gained weight, cardiometabolic health is going to be impacted. The older you are, the worse it gets. And other factors can kind of partially explain that relationship. But we do need to broaden the conversation beyond testosterone, which is important. It’s been in the mass media lately, just checking testosterone levels and then everyone having easy access to testosterone. That’s not a bad thing. But across sexes and genders, sleep and circadian disruption is going to interact with a lot of other things. Cortisol rhythm. Okay. Mood regulating neurotransmitters. How is your dopamine, right? How are the other neurotransmitters? Insulin sensitivity. I’ll often have patients do a continuous glucose monitoring inflammation. I will often, well always, but in this situation, I want to make sure I check high sensitivity C-reactive protein. That’s not the only measure of inflammation, but it’s a big gold standard. I want to look at vascular function, menopausal symptoms, energy availability, and their pain sensitivity. So hormones matter, yes, yes, yes, but libido is not a direct readout of testosterone, estrogen, or cortisol levels. Two people with similar hormone levels can have very different experiences of desire. It’s shaped by their entire biological and relational context. So we do not dismiss hormonal evaluation, but we also don’t stop the evaluation there. 

Next is sleep and pain. Pain interrupts sleep. Okay, so that’s one thing that you will be asked if you were seeing me as a patient. Fragmented sleep increases vulnerability and sensitivity to pain. And then increased pain creates fear, avoidance, or guarding around intimacy. And then distress, well, guess what? Further, you know, amplifies the sleep problem. So a 2018, that’s a little bit older, sexual medicine reviews study looked at and found that deteriorating sleep was associated with worse pain outcomes. So the direction from poor sleep to later pain appeared more consistent than the relationship from pain to sleep disruption, if that makes sense. So we need to fix sleep and pain will improve. And another more recent systematic review from Sun et al. looked at a it was also a meta-analysis, supported a bi-directional relationship from sleep and chronic musculoskeletal pain. So it can go both ways. Musculoskeletal pain interrupting sleep and sleep interrupting what we call MSK pain. So we need to address that. If you’re having pain, addressing sleep is going to improve your experience. So again, this goes back to the big list of things that I mentioned. Remember endometriosis, vulvodynia, vaginismus, genitor urinary syndrome of menopause or GSM, Painful bladder syndrome, which used to be called interstitial cystitis, chronic prosthetitis, pelvic floor overactivity, and then other things. You’ve got post-op pain, you know, from a surgery you had, or painful arousal of orgasm, or hip or lower back pain. Poor sleep, creates real a real pain problem. So treating that pelvic pain without addressing the sleep problem does not work. Okay. Telling someone just to sleep better, excuse me, without treating the pain is also like inadequate. Both sides of that cycle need attention.

Let’s talk about stress for a second. Stress changes attention. It does more than just increase cortisol. It changes what the brain notices. A stressed brain, a stressed-out brain is wondering and monitoring when is the pain going to start? When is the child or the or the parent you’re caregiving going to interrupt? When is a partner going to be disappointed? Whether the body’s going to respond correctly. What is tomorrow’s workload? How are finances? I, you know, you may be uncomfortable with body and your body image, have a relationship conflict, or be even worried about your personal safety. Pleasure requires enough attentional margin to note a subtle sensation. And that’s what sexual function is all about. And if you’ve got a brain that’s scanning, predicting, planning, protecting, it’s gonna struggle to recognize touch as pleasurable.

A systematic review in 2020, Mora et al. examined cognitive processing and sexual function and found association between sexual difficulties and distraction, negative automatic thoughts, performance concerns, and maladaptive sexual beliefs. That deserves some attention. Sometimes the problem is not that the body can’t feel. It’s like it’s too flipping busy scanning and anticipating and protecting to notice pleasure. So repeatedly asking your partner, are you aroused yet? Are you in the mood yet? Is like, no. or are you gonna orgasm, right? It’s another monitoring task, y’all. Just don’t do it. Be curious, be patient. That’s way more useful than some kind of performance surveillance.

So let’s talk a little bit about what happens to the autonomic nervous system in the pelvic floor when you have stress. Okay, this is a big one. The autonomic nervous system participates in genital blood flow, lubrication, erection, heart rate, breathing, visceral activity, muscle tone, and threat detection.

So sexual arousal requires some degree of parasympathetic availability. You need the margin to be chill and responsive. That the capacity associated with rest and digest, right? Blood flow, connection, and receptivity. It does not mean that someone has to be totally chill, okay? Erotic excitement includes activation. Pleasurable excitement is different from kind of defensive activation. And if you think about it in our workday, like what if your job by nature requires a lot of defensive activation?

What’s gonna happen to your body then? You have to somehow unlearn that defensive activation and get back to the into the parasympathetic side. Okay, what are we looking for with defensive activation? This is important. And I can think of a few careers that really would set this off. What are what careers are adversarial? I mean, you’re already thinking of them, right? Maybe you’re in sales and that feels a little adversarial. You’re constantly trying to convince someone. Maybe you’re in healthcare. It’s not adversarial, but you’re constantly trying to convince someone to do the right thing, right? law. You know, attorneys. I that’s that’s a big one. Finance. That’ll be another one, right? Business and finance. 

So what what happens? A person may develop shallow breathing, breath holding, abdominal bracing, jaw tension tension, gluteal gripping, pelvic floor guarding, urinary urgency, pelvic floor guarding that actually can create like a post void dribble after, especially for men, difficulty allowing penetration, difficulty reaching orgasm and reduced genital sensation. Ugh. Here’s another systematic review and meta-analysis from Meister 2023, found an association between persistent pelvic pain, non-cancer, okay, persistent pelvic pain, and pelvic floor muscle tone in women. So here’s the nuance. Stress is not the sole cause of pelvic pain or pelvic floor activity, overactivity. Things like endo – Not caused by stress, okay? Can it be made worse by stress? Yeah, everything can. Vulvadinia is not just, hey, you can’t chill, all right? You can’t relax. Chronic prostatitis symptoms are not just your anxiety running high, but chronic defense activation can contribute to that, guarding amplified pain sensitivity, restricted breathing, difficulty shifting into arousal, and persistent muscular holding. We’re not going to command a pelvic floor to relax, but we can help the system develop enough adaptability to contract, release, respond, and tolerate sensation without unnecessary guarding or protection.

Alright, here’s another truth bomb. Desire is not always spontaneous. It takes a little work.

Many people expect desire to work like this. I spontaneously want sex, so I initiate touch. But desire can also be responsive. You begin with emotional connection, you begin with a pleasurable touch, and desire develops afterwards. Responsive desire is not inferior desire. It can become especially common during these conditions. And I’ve mentioned some of them. If you already have a chronic illness, like endometriosis, for example, you’re going through menopause, maybe you have both. You are parenting. Ugh, that’s a big one. Caregiving, high periods of stress, long-term relationships that you’re in. that could include long distance relationship, pain recovery, and sleep deprivation.

So that connects this to stress stress and sleep. Fatigue and chronic stress are going to lengthen the runway into desire. A person may need more time, less urgency, emotional reconnection, non demand touch, privacy, pain free alternatives, permission to stop, and freedom from performance expectations. Responsive desire doesn’t mean someone’s gonna begin unwanted sexual activity and then hope that desire just appears. You know, there’s got to be willingness and consent and curiosity and the freedom to stop. So the goal here is not to force desire to appear, it’s to create the right conditions in which desire has a reasonable opportunity to emerge. Okay, so what can you do? We’ve been talking about what not to do and some things that are options, but what can patients and partners do? Well, protect sleep. Protect sleep. Create it, create enough time in bed to meet the body’s sleep requirement. Stop treating chronic sleep deprivation as a personality trait or achievement. It’s not. Consider whether sexual activity is always deferred until the last most depleted part of your day. Or if you’re just you’re expecting this to happen.

When you’ve done everything else you need to do, you’ve done all your work and all your caregiving and all your things, you’re depleted, you’re tired, you’re chronically sleep deprived, and then you turn to your partner and go, I have 10 minutes, or I have an open weekend, maybe, sort of. You need to ask these questions: like, is late evening the best time for intimacy? I’ve seen some social media influencers, which I there’s a lot of them that I follow and I really love, and they’re like, No, no, no. Intimacy before that dinner date, not after, right? Or if you’re lucky, before and after. ask your partner like would mornings, afternoons, weekends, like what what do you need for protected rest periods? What works better? And is what is one partner routinely losing sleep to meet the other partner’s schedule? That’s a big one.

Then anchor the circadian rhythm. Be reasonable. Wake up at the same time. Go to bed at the same time. If you do not fix that, nothing else is going to change. So please start there. As soon as you wake up, get outdoor light, open the drapes, go outside, whatever it is. You need to get that blue light. Reduce bright light and stimulating work near bedtime. You can do amber light, but I still think that that negatively can negatively impact sleep and sleep hygiene is a thing it is something that I spend a lot of time on. I have formal handouts on it. I do a lot of education around it. So I can’t tell you everything about how to normalize your circadian rhythm, but I’m telling you the biggest ones here and some important ones. Notice whether that irregular sleep schedule worsens your sleep mood, pain, or sexual symptoms. And build a predictable transition into rest. Create a routine and do the same thing every day. Thinking that you’re gonna stay up and be productive at night because that’s when you think you’ve been productive in the past is killing you. It’s sending you into, you know, early non-communicable disease, like all the things that I just mentioned. And it’s also going to kill sexual function. So fix the circadian rhythm. Also, screen for sleep disorders if you’re the either yourself or through a practitioner. don’t prescribe.

Sleep hygiene as a clinician when symptoms suggest a medical sleep problem. So if they have or if you have loud snoring, gasping or witnessed apnea, morning headaches, excessive daytime sleepiness, persistent insomnia, restless legs, night sweats, reflux, nocturia, getting up to go to the bathroom at night, frequent pain-related waking or medication or substance effects, please get that evaluated.

The other issue with sleep and sleep apnea is that you might have a much higher risk than of dementia and dementia related problems. So let’s not ignore that. So, what are some of the things that could be contributing to that? Well, you could have sleep apnea, yeah. it could be chronic insomnia that can be helped with clinical treatment. It could be menopausal, night sweats, which we call vasomotor symptoms. In the literature, that does have a higher relationship or a bigger relationship to dementia. So do not ignore vasomotor symptoms. Do not ignore hot flashes and night sweats. Get treatment for that. I mentioned restless legs, mood disorder, chronic pain, alcohol or any stimulant use or any medication or substance use at all is going to negatively impact that. As much as you think a little substance A or substance B helps you sleep, alcohol, weed, whatever it is, it it actually doesn’t. So you need to, instead of masking it with coping mechanisms, actually get to the root cause.

Create a transition out of a task mode to the nervous system may not immediately move from email, documentation, cleaning, caregiving, conflict, financial discussions, and parenting into erotic connection. Create a bridge, take a shower, take a bath, do 10 minutes of decompression, conversation, take a short walk, listen to music, sing. Change the lights, dim the lights, change clothes, do a cup of tea, do a gentle massage, but get the phones out of the room. Okay. Make a transition, a ritual. And also use non-demand touch. If every affectionate touch is assumed to lead to intercourse, that’s gonna be burdensome with time. You need to learn how to, you know, enact that non-demand touch, cuddling, kissing, holding hands, back rubs, massage. Just lying together quietly, mutual touch, sensation-focused style kind of exploration, and affection that doesn’t intentionally progress. So touch doesn’t create an obligation. And either person can stop, and you know, intercourse isn’t the only valid outcome, and orgasm is not required.

You can also use breathing. I work a ton on breathing using ultrasound imaging. Try just nose-only breathing. If you can’t just nose-only breathe, then that could be an indication to get allergies checked out or get checked out for congestion or sinus issues, because you don’t want that. Make sure your expansion is happening through the back ribs, not focused on flare of the front ribs. That’s important. You don’t want forced abdominal pressure. I spend a lot of time downtraining that. You want a slow, comfortable, non-forced exhale. And you do not want to push the pelvic floor downward. You’re also not going to force the belly outward as you inhale. But as you exhale fully, you should not feel pressure between the sit bones bulging downward. We’re just trying to shift towards unnecessary holding, not force the body into some kind of compliance.

Let’s also just nicks performance and pressure monitoring, like saying things like, are you going to orgasm? Why aren’t you ready? We never have sex anymore. You don’t find me attractive, you know. Replace that with what feels good right now? What would you like more or less of, or something different? Do you want to continue? Would closeness without sex help? Tonight or right now, how can I help make this feel less pressured? So when we’re looking at the actual source of stress, here are the things that manage stress. And fortunately, they’re all within the wheelhouse of what I do as a PT. Mindfulness, exercise, time outdoors, therapy, social support, and relaxation exercises. These are the things I use on a regular basis. But you gotta build a plan to make it happen. Sometimes stress management means redistribute household labor, delegate, especially when you’re self-employed, and I’m self-employed. So and I am a single parent. So there’s a lot that I have to consider there. Redistributing household labor, asking for caregiving help that looks different from me than someone who’s going to be in a partnered situation. You have to establish boundaries. You have to treat any pain that’s there. Address financial instability. That’s a huge stressor. Change an unsustainable work schedule. Find childcare. Find the person who can board the pet so you can take a weekend or whatever it is. Correct relationship inequity. And if it’s an unsafe situation, get to get to work with a therapist who can help you get out of that situation.

Stress management is not going to teach should never, and I have experienced this in my life, and I never want to be back in that place again. I used to use, and I’ll fully admit to this, I used to use stress management to teach myself to stay and tolerate in an impossible situation. I used it to tolerate an un you know an unsustainable situation. And to do it quietly and not speak up. So no breathing exercise, no stress management tool that you have can compensate for coercion, control, exhaustion, or lack of safety. That’s the dark side of resilience, y’all. And I don’t want you to go there. Now, how do you know when further evaluation is needed? When your symptoms, when your sexual function symptoms are persistent, distressing to you, painful. Maybe they’re sudden or getting worse, or they’re associated with other symptoms like weight gain or erectile dysfunction or something like that, right? Then that needs to be evaluated. you also want to evaluate, and bear with me, because I actually wrote these things down to not forget any of them. If you have pain with touch, penetration, erection, or orgasm. Okay, these are the things that as pelvic PTs and orthopedic PTs, we we can help with:

Okay, persistent loss of desire, erectile changes, lubrication difficulty, bleeding, genital numbness or loss of sensation, bowel or bladder symptoms, severe fatigue, sleep problems, maybe sleep apnea you suspect or your partner does, menopausal symptoms, postpartum symptoms, medications, trauma symptoms, or relationship concerns.

So, who could be a part of your team in correcting all of this? We are we are shoring up, I’m shoring up right now, the final episode in our season of sexual function. And so here’s your team, okay? I’m gonna say pelvic health PT, right? OTs also do it, but sometimes there’s overlapping, complex orthopedic conditions. And that’s where someone like myself who does both pelvic and orthopedic PT is gonna help. Lifestyle medicine, a lifestyle medicine professional. I’m also an integrative medicine specialist. I’m a little biased. I really do think the yoga and the mindfulness and the meditation helps. So consider that. Then you have gynecology, urology, your menopause specialist, which could be your pelvic PT and your gyne, right? primary care, sleep medicine, endocrinology, a certified sex therapist, and a trauma-informed mental health professional. Sometimes you’re lucky and you get five in one, right? And then sometimes you’ll need a bigger team.

But I’ve listed so many things that you should get help with, you know, with conditions. But let me list the kind of specific things that I want you to consider. If you have any of these things, this definitely means that you should be proactive, even if you don’t have sexual health problems and desire problems now. genito urinary syndrome of menopause, that’s vaginal dryness, fragility, change in color. Atrophy, that kind of thing that makes sex painful. Endometriosis, vulvodynia, vaginismus, pelvic floor dysfunction in general, and you’re not sure what it is, thyroid disease, anemia, cortisol problems, diabetes, cardiovascular disease, medications. Polypharmacy is a big problem with sexual function. So someone should be looking at that. Depression, sleep disorders, chronic pain, or relationship to stress. Lifestyle medicine belongs in this evaluation. It’s not used to replace medical care, but it is an essential part of your program and your plan. So let’s not separate sleep and stress management from sexual health. They help shape the internal environment that influences desire, arousal, comfort, and pleasure. It makes it possible. Rest is going to support hormone and circadian rhythms, vascular health, emotional regulation, energy recovery, and pain modulation. And when you are working on the nervous system, which is what I spend so much time on with patients, you’re gonna get better blood flow, better sensory awareness, better sensation, better connection, better pelvic floor resilience and adaptability, improved pleasure, and the ability to remain kind of present. So you might need more rest, more support, more time, better pain management, less pressure, less blame, greater safety, and you know, frankly, a more complete medical evaluation. So sometimes the first step towards better sex in the bedroom is not trying harder. It’s asking for help. It’s getting the help that you need. Stop carrying everything alone. Get to a professional who can help you focus on sleep and stress management and all of the little details that I that I mentioned.

I really hope that this has been helpful for you in your journey this entire season. And also I wanted to kind of encapsulate how important some of these other variables are to your sexual health journey across the lifespan because you deserve that. You deserve to have that lifestyle that you want, the sexual health that you want for as long as you want it. I am very, very excited to be closing out this season because we’ve had so many incredible professionals. And I’m also really looking forward to going into the next season, which will launch soon in a few months. 

So until then, please follow our content on YouTube and on Instagram. It’s also on Facebook, but Instagram and YouTube are our primary channels because we will be putting out new videos on a regular basis, new helpful tips and topics that relate to sexual health and function, particularly as it relates to EDS and hypermobility, hip dysplasia and endometriosis, because those things impact one of nine women, but also men have hip dysplasia too. Men have hypermobility too. And there are plenty of ways that treatment can help and transform your life experience because low libido and sexual pain don’t have to be treated, treated as isolated issues. They are truly a biomarker for whole body, whole mind and body, really health. 

So until then, until next time, remember that voice to pelvic floor connection, how important it is for your overall health that both the voice and pelvic health are biomarkers for how you’re doing overall in your life journey.