Postpartum Low Libido — Free SCA Practice Case
Postpartum Low Libido
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Chloe Martin
Age
31 years
Consultation Type
VideoAge
31
Situation
Telephone or Video Consultation (Routine).
Reason for Encounter
"Patient booked a routine telephone review. Triage note states: 'Wants to discuss low sex drive. Having relationship issues because of it.'"
Medical Records
- ●PMH: G2P2 (Two vaginal deliveries, ages 3 years and 9 months. 2nd degree tear with recent delivery, healed well). Mild Postnatal Depression (PND) following the first pregnancy (resolved with CBT).
- ●Medications: Desogestrel 75mcg (Progestogen-Only Pill) – started 6 weeks postpartum.
- ●Allergies: NKDA.
Recent Notes
- ●6-week postnatal check (7 months ago): Mother and baby well. Commenced POP.
Patient Script
For the friend playing the patient role
Character Overview: You are Chloe, a 31-year-old mother of a toddler and a 9 month old baby. You are profoundly sleep-deprived. You are currently breastfeeding the baby twice a night. You are calling because you have absolutely zero interest in sex, and it is causing major friction in your marriage. Your husband is not violent, but he is becoming increasingly passive-aggressive, making comments about you two being "just roommates." You feel immense guilt, assuming there is something hormonally "broken" inside you. You read an article on the BBC last week about women being prescribed a "miracle" testosterone gel to cure low sex drive. You are convinced this is the quick fix you need to save your marriage. If the doctor doesn't offer it, you will specifically ask for it. Crucially, the few times you have tried to have sex recently, it has been quite uncomfortable and "sandpapery." You haven't told anyone this because you assume the dryness is just happening because you aren't "aroused enough." You are at home. Your husband is downstairs with the children. You are in your bedroom with the door closed, but you are anxious he might walk in. You will not volunteer information about the pain/dryness or your husband's passive-aggressive behavior unless the doctor conducts a thorough assessment and ensures you are in a safe space to speak.
ICE — Ideas, Concerns, Expectations
(Actor guidance: Do not volunteer any of the following unprompted. These responses surface only if the candidate directly explores your perspective.)
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Ideas: You are convinced this is a hormonal problem — something inside you is "broken" since having the baby. You read the BBC article about testosterone gel and latched onto the idea that your hormones just need "topping up." You haven't considered that breastfeeding, exhaustion, or the dryness itself could be contributing — you see the low desire as the single root cause of everything.
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Concerns: Your deepest worry is that your marriage is falling apart. You feel like you are failing as a wife and that if you don't fix this soon, your husband will either leave or the relationship will become permanently cold. You are also quietly frightened that something is permanently wrong with you — that you'll never want sex again and this is just who you are now.
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Expectations: You want to leave this consultation with a prescription for the testosterone gel. You see it as a concrete, medical solution to a problem you can't solve on your own. If you can't have testosterone, you at least want to be told there is something practical you can do — you cannot cope with being told to "just wait it out."
Consultation Flow & Responses:
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The Opening:
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If the doctor asks an open question: "Hi Doctor. This is really hard to talk about. Basically, since I had the baby 9 months ago, my sex drive has completely vanished. It's causing massive arguments with my husband. I read a news article recently about testosterone gel for women's sex drives, and I was wondering if I could try that?"
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Data Gathering (The Layers):
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Layer 1: The Remote Safeguarding / Confidentiality Check (Crucial):
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If the doctor asks if you are somewhere private/safe to talk: "Yes, I'm upstairs in the bedroom. My husband is downstairs with the kids, so he can't hear us."
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Layer 2: The Biological / Obstetric Screen (The Hidden Key):
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If asked if sex is painful or uncomfortable (Dyspareunia/Dryness): "Actually... yes. The few times we tried, it felt really dry and quite sore. But I just figured that was because my sex drive is broken."
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If asked about breastfeeding: "Yes, I'm still feeding him myself, usually twice a night."
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Layer 3: The Psychological & Social Screen (Safeguarding/PND):
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If asked about your mood or how your husband reacts: "I'm just exhausted, not depressed. But my husband is grumpy. He makes snide comments. I'm perfectly safe, he's never violent, I just feel like I'm failing as a wife."
If Asked — Medical History and Medications
(Actor guidance: Respond naturally if the candidate asks about any of the following. Do not volunteer this information unprompted.)
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If asked about the contraceptive pill / Desogestrel / the mini pill: "Yes, I was started on the mini pill at my six-week check. I take it every day, haven't missed any. To be honest, I did wonder if it could be affecting things — I've read online that the pill can kill your sex drive — but I wasn't sure if this one does that."
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If asked about the perineal tear / birth injury: "I had a tear with the last delivery — the midwife stitched it up and said it healed well at my postnatal check. It doesn't hurt anymore, but I do wonder sometimes if things feel... different down there since then."
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If asked about previous postnatal depression or mental health history: "After my first, I did feel quite low for a few months. The GP referred me for talking therapy — CBT — and it really helped. I don't feel like that this time though. I'm not depressed, I'm just knackered and frustrated."
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If asked about allergies: "No, no allergies to anything."
Social History and Lifestyle Impact
(Actor guidance: This context can be woven into your responses naturally when discussing your situation. You do not deliver it as a monologue.)
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Occupation / daily life context: You are currently on maternity leave from your job as a teaching assistant at a primary school. You are due to go back in four months and are already anxious about it. Your days are consumed by the baby and the toddler — feeding, nappies, school-run prep. Your husband works full-time as a plumber and is out of the house from 7am to 6pm most days.
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Lifestyle impact of the condition: The lack of intimacy has turned your evenings into a minefield. You dread bedtime because you know your husband will either make a comment or roll over in pointed silence. You have started staying downstairs pretending to tidy up until you know he's asleep, just to avoid the tension. Last week he said, "I don't know why I bother coming home," and it broke you — you cried in the bathroom after he fell asleep. You feel completely torn between the physical demands of the baby and your husband's emotional needs, and you have nothing left for yourself.
If Asked — Associated Symptoms
(Actor guidance: Respond only if the candidate directly asks about these symptoms. Keep answers brief and natural.)
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If asked about vaginal discharge: "No, nothing unusual. Just normal stuff."
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If asked about bleeding between periods or irregular bleeding: "My periods haven't come back yet — the nurse said that's normal while I'm breastfeeding and on the mini pill."
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If asked about hot flushes or night sweats: "No, nothing like that. I get warm at night but that's just from having the baby in bed with me half the time."
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If asked about urinary symptoms (frequency, burning, incontinence): "Well, I do leak a tiny bit if I cough or sneeze hard — I keep meaning to do my pelvic floor exercises but I never get round to it. No burning though."
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If asked about fatigue or energy levels: "I am absolutely shattered. The baby is still waking twice a night for feeds and the toddler is up at six every morning. I can't remember the last time I slept more than three hours straight."
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If asked about appetite or weight changes: "My appetite is fine. I'm eating more than usual if anything — I'm breastfeeding so I'm always hungry. I haven't lost any weight but I haven't been trying to."
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If asked about headaches: "No, not really. The odd one when I'm really tired but nothing out of the ordinary."
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If asked about joint pain or body aches: "My back aches from lugging the car seat around but that's it — nothing in my joints."
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If asked about skin or hair changes: "My hair has been falling out a bit more than usual since the baby — I find it all over the pillow — but I know that's a postpartum thing. My skin is fine."
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If asked about self-harm or suicidal thoughts: "No, absolutely not. I get frustrated and tearful sometimes, but I would never think about hurting myself."
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If asked about alcohol or recreational drug use: "I have the odd glass of wine at the weekend, nothing more. No drugs — never have done."
Negotiation & Collaborative Management Plan:
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If the Doctor agrees to prescribe Testosterone:
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Reaction: "Oh, great! Just send it to the pharmacy. Will it get into my breastmilk?" (Candidate critically fails for off-label prescribing, ignoring NICE guidelines, and risking neonatal exposure).
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If the Doctor just dismisses it as "normal" and tells you to rest without addressing the Testosterone request:
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Reaction: "But what about the hormone gel I asked about? The article said it fixes it. And 'just resting' doesn't fix my marriage." (Candidate fails for poor communication and missing the clinical intervention).
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If the Doctor declines the Testosterone, identifies the Dryness/Breastfeeding, and explains the 1-year timeline:
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Reaction: "Ah, I see. The article didn't mention it was only for menopause. I definitely don't want to risk anything while breastfeeding. So the dryness is a physical hormone drop from the milk, not my fault? And you're saying almost half of women feel this way at 9 months?"
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If the Doctor suggests lubricants/moisturizers and offers psychoeducation/signposting:
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Reaction: "So a proper vaginal moisturizer could actually fix the pain, which might help the desire come back naturally over the next few months? Just knowing this is a normal medical phase, and not just me being broken... I think I can explain that to him. Thank you."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Navigating the "Testosterone Trap" (NICE NG23)
- ●NICE NG23 recommends testosterone supplementation only for postmenopausal women with Hypoactive Sexual Desire Disorder (HSDD) in whom HRT alone has not restored libido. It is not licensed, not indicated, and not evidence-based for premenopausal women.
- ●In a breastfeeding woman, prescribing testosterone is a critical prescribing error: her ovarian axis is physiologically suppressed by prolactin — the ovaries are not deficient, they are correctly responding to lactation. Adding exogenous androgen is biologically inappropriate.
- ●There are also significant safety concerns in lactation: testosterone passes into breast milk and carries risk of neonatal androgen exposure and virilisation. No safety data exist for this use.
- ●Decline the request clearly, warmly, and without hesitation. Validate the patient's initiative in seeking information before explaining the clinical rationale — then immediately pivot to the safe alternatives that are available.
Lactational Hypoestrogenism — The Root Cause
- ●Prolactin (elevated during breastfeeding) suppresses pulsatile GnRH release from the hypothalamus, which in turn suppresses LH and FSH, resulting in profoundly reduced ovarian oestrogen production.
- ●This creates a temporary, reversible, oestrogen-deficient state physiologically similar to the genitourinary syndrome of menopause — affecting the vaginal mucosa, libido, and overall sexual function.
- ●Vaginal dryness and superficial dyspareunia affect up to 64% of breastfeeding women. Patients rarely volunteer this symptom — they commonly attribute discomfort to inadequate arousal rather than a mucosal cause. Always ask directly.
- ●Low libido is a normative postpartum state: approximately 46% of women report significantly reduced desire at 6 months postpartum. Framing this as a recognised, temporary physiological phase — not a personal failure — is clinically meaningful and often transformative for the patient.
- ●Symptoms typically improve progressively as night feeds reduce and weaning approaches, with most women reporting substantial recovery by 12 months postpartum.
First-Line Management of Lactational Atrophy (NICE CKS)
- ●Non-hormonal vaginal moisturisers (e.g. Replens MD, Yes VM) are first-line. Applied proactively two to three times per week, they rehydrate the vaginal mucosa and maintain tissue integrity — they are not just for use during intercourse.
- ●Water- or silicone-based lubricants should be recommended for use during intercourse to reduce friction and discomfort. Oil-based products degrade latex condoms and should be avoided if relevant.
- ●Addressing the physical dryness directly often facilitates the gradual return of desire — the brain's conditioned aversion to painful sex is reversible once the physical cause is treated.
- ●If non-hormonal measures are insufficient after a trial of 4–6 weeks, low-dose topical vaginal oestrogen (e.g. Vagifem pessaries, Estriol cream) is a safe and effective escalation option. Systemic absorption from topical vaginal oestrogen is negligible, and it is considered safe during breastfeeding — do not withhold this option until weaning.
The Desogestrel POP — Proportionate Assessment
- ●FSRH guidance indicates that progestogen-only pills, including desogestrel 75mcg, have a weak and inconsistent association with reduced libido — causation is not established, and the effect (if present) is modest.
- ●Do not attribute all symptoms to the POP without a holistic assessment. In this case, lactational hypoestrogenism is the primary driver.
- ●Do not stop the POP without a clear, agreed alternative contraceptive plan in place. A closely spaced unintended pregnancy in a sleep-deprived woman with a PND history would be significantly harmful. Contraceptive continuity is a clinical priority.
- ●Lactational amenorrhoea is expected on the POP during active breastfeeding — reassure the patient this is normal and does not indicate a problem.
Pelvic Floor Rehabilitation
- ●A second-degree perineal tear and two vaginal deliveries are significant risk factors for pelvic floor dysfunction. Always take a brief pelvic floor history in any postpartum woman.
- ●Stress urinary incontinence (leakage on coughing or sneezing), if disclosed, should be actively addressed — not noted and left. First-line management is structured pelvic floor muscle training (Kegel exercises).
- ●The NHS Squeezy app is a free, evidence-based resource to support supervised pelvic floor training and is appropriate to recommend. If symptoms are persistent or functionally impactful, refer to a women's health physiotherapist.
Psychosocial Dimensions and Referral Options
- ●Low postpartum libido frequently has a relational impact that exceeds the clinical problem itself. The patient's primary concern may be the relationship, not the symptom — explore this.
- ●Screen for postnatal depression in any postpartum woman, particularly those with a documented PND history. Sleep deprivation, tearfulness, and loss of interest are not automatically explained by infant care — a structured mood assessment (e.g. Edinburgh Postnatal Depression Scale) is appropriate at follow-up if any doubt exists.
- ●Screen for domestic abuse and coercive control. Passive-aggressive behaviour, emotional withdrawal, and statements such as "I don't know why I bother coming home" are potential markers of a coercive dynamic. Ask directly and tactfully in a private setting.
- ●Offer couples counselling (e.g. via Relate) or psychosexual therapy as active, proactive options — not as a last resort. The relational dimension of this presentation warrants a clinical offer, not just a biomedical fix.
- ●Equip the patient with a clear medical framework to share with her partner: the low desire and dryness are a documented, temporary physiological consequence of breastfeeding that is being actively treated. This shifts the dynamic from personal failure to shared medical context.
Safety-Netting and Follow-Up
- ●Arrange a specific follow-up review at 4–6 weeks to assess the response to vaginal moisturisers, review mood, revisit the domestic situation, and determine whether escalation to topical oestrogen or onward referral is needed.
- ●Give clear criteria for earlier contact: worsening mood or any concerns about self-harm, relationship safety concerns, or significant deterioration in symptoms.
- ●Before closing, check the patient's understanding of: why testosterone is not appropriate, how to use the moisturisers correctly, and what to do if things worsen. A visibly anxious patient leaving without a clear plan is a consultation that is not finished.
Safety Netting for PND Relapse
Given the documented history of PND, candidates should safety net for relapse. Red flags warranting urgent review include: persistent low mood beyond two weeks, any thoughts of self-harm or suicide, and any concerns about the safety or welfare of the infant. Candidates should advise the patient to contact the surgery urgently or call 111 if any of these arise before the follow-up appointment.
Anticipatory Guidance — EPDS
The validated screening tool candidates are expected to use or offer is the Edinburgh Postnatal Depression Scale (EPDS). A score of 13 or above warrants urgent follow-up; any score on question 10 relating to self-harm requires immediate assessment regardless of the total score.
Mapped to the RCGP curriculum topic: Sexual Health.
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