Why Sexual Changes Happen
Declining estrogen and testosterone affect multiple aspects of sexual function. These changes are common and treatable—you don't have to accept them as inevitable.
Hormonal Factors
- Low estrogen: Causes vaginal dryness, thinning, and reduced elasticity (vaginal atrophy)
- Declining testosterone: Reduces libido and sexual interest in some women
- Progesterone loss: May affect mood and energy, indirectly impacting desire
Physical Symptoms
- Vaginal dryness: Makes sex uncomfortable or painful
- Vaginal thinning (atrophy): Tissues become more fragile, prone to tearing or bleeding
- Reduced blood flow: Decreased arousal and lubrication
- Pelvic floor changes: Weakness or tension can cause pain during sex
Psychological & Lifestyle Factors
- Body image concerns and self-esteem changes
- Fatigue from sleep disruption
- Mood changes (anxiety, depression)
- Relationship dynamics and stress
- Partner's sexual health issues
Prevalence: About 50% of postmenopausal women experience vaginal dryness, and 20-40% report decreased sexual desire.
Vaginal Dryness & Painful Sex
Symptoms of Vaginal Atrophy (GSM)
Genitourinary Syndrome of Menopause (GSM) is the medical term for vaginal and urinary symptoms caused by estrogen loss:
- Vaginal dryness even when not sexually active
- Burning or itching
- Pain or discomfort during intercourse (dyspareunia)
- Light bleeding after sex
- Urinary symptoms (urgency, frequency, recurrent UTIs)
Treatment Options
1. Vaginal Moisturizers
- Use: Apply 2-3 times per week, even when not sexually active
- How they work: Provide ongoing hydration to vaginal tissues
- Examples: Replens, Hyalo Gyn, Me Again
2. Lubricants for Sex
- Water-based: Safe for condoms and toys; may need reapplication
- Silicone-based: Longer-lasting, slicker; not compatible with silicone toys
- Oil-based: Very moisturizing; not safe for latex condoms
- Avoid: Products with glycerin, parabens, or fragrances that may cause irritation
3. Vaginal Estrogen (Most Effective)
- Forms: Cream, tablet, or ring inserted vaginally
- How it works: Restores vaginal tissue thickness, elasticity, and lubrication
- Dosing: Initial higher-frequency dosing (daily or several times per week), then maintenance (1-2x per week)
- Safety: Minimal systemic absorption; safe even for women who can't take systemic HRT or have a history of breast cancer (discuss with your doctor)
- Effectiveness: 80-90% of women see significant improvement
4. Systemic Hormone Therapy
For women with both GSM and other menopausal symptoms (hot flashes, mood changes), systemic HRT (estrogen + progesterone if you have a uterus) may address multiple issues simultaneously. However, vaginal estrogen is often still needed for optimal vaginal health.
5. Ospemifene (Osphena)
- What it is: Oral selective estrogen receptor modulator (SERM) for painful sex due to GSM
- How it works: Acts like estrogen on vaginal tissue without systemic estrogen effects
- Use: For women who can't or prefer not to use vaginal estrogen
6. Laser or Radiofrequency Therapy
Procedures like CO2 laser (MonaLisa Touch) or radiofrequency (Viveve) claim to stimulate collagen production and improve vaginal tissue health. Evidence is emerging but not yet definitive; not covered by insurance.
Low Libido (Hypoactive Sexual Desire)
Causes
- Hormonal: Declining testosterone and estrogen
- Physical discomfort: If sex hurts, desire naturally decreases
- Psychological: Stress, anxiety, depression, body image concerns
- Relationship factors: Communication issues, unresolved conflicts, partner's sexual problems
- Medications: Antidepressants (SSRIs), blood pressure medications, others can reduce libido
Treatment Strategies
1. Address Physical Discomfort First
If sex is painful, treating GSM with vaginal estrogen and lubricants is the first step. Pain is the #1 reason for reduced sexual activity.
2. Systemic Hormone Therapy
- Estrogen therapy: May improve mood, energy, and overall well-being, indirectly supporting libido
- Testosterone: Some women benefit from low-dose testosterone for low libido, though it's not FDA-approved for this use in women
- Compounded options: If prescribed, work with a reputable compounding pharmacy and monitor levels
3. Flibanserin (Addyi)
- What it is: FDA-approved medication for premenopausal women with hypoactive sexual desire disorder (HSDD)
- How it works: Affects brain chemicals related to desire (dopamine, norepinephrine, serotonin)
- Effectiveness: Modest increase in satisfying sexual events (about 1 more per month)
- Side effects: Dizziness, nausea, fatigue; can't combine with alcohol
- Note: Limited data for postmenopausal women
4. Bremelanotide (Vyleesi)
- What it is: Injectable medication taken before anticipated sexual activity for HSDD
- How it works: Activates melanocortin receptors involved in sexual arousal
- Effectiveness: Modest improvement in desire and distress about low desire
- Side effects: Nausea (common), flushing, injection site reactions
5. Psychological & Relationship Support
- Sex therapy: Certified sex therapists can address psychological barriers, communication, and intimacy issues
- Cognitive behavioral therapy (CBT): Effective for anxiety or depression affecting sexual desire
- Couples counseling: Addresses relationship dynamics and communication
- Mindfulness-based therapy: Helps with present-moment awareness and reducing distraction during sex
6. Lifestyle Factors
- Exercise: Improves body image, mood, energy, and blood flow—all support sexual health
- Stress management: Chronic stress kills libido; prioritize relaxation and self-care
- Sleep: Poor sleep reduces desire and energy for sex
- Communication: Talk openly with your partner about needs, preferences, and concerns
Pelvic Floor Dysfunction & Pain
Some women develop pelvic floor hypertonicity (overly tight muscles) or vaginismus (involuntary muscle spasm) that makes sex painful or impossible.
Treatment
- Pelvic floor physical therapy: Teaches relaxation techniques, releases trigger points, and retrains muscles
- Dilator therapy: Gradual use of vaginal dilators to desensitize and stretch tissues
- Biofeedback: Helps identify and relax pelvic floor muscles
- Trigger point injections or botox: For severe muscle spasm
Redefining Intimacy
Sexual satisfaction doesn't require penetrative sex. Many women find greater pleasure and connection through expanded definitions of intimacy.
Broaden your perspective:
- Non-penetrative sex: Manual stimulation, oral sex, sex toys
- Sensual touch: Massage, cuddling, skin-to-skin contact
- Emotional intimacy: Deep conversations, shared experiences, quality time
- Self-pleasure: Masturbation helps maintain sexual function and desire
Focus on pleasure, connection, and what feels good—not "performance" or meeting external expectations.
When to See a Specialist
Consider seeing a gynecologist, urogynecologist, or sex therapist if:
- Vaginal dryness or pain interferes with daily life or sex
- Low libido causes personal distress
- Pelvic floor dysfunction or pain during sex
- Relationship stress related to sexual changes
- Psychological barriers (anxiety, trauma, body image)
The Bottom Line
Sexual changes during perimenopause and menopause are common but not inevitable. Vaginal estrogen is highly effective for dryness and painful sex, while low libido often requires a multifaceted approach addressing physical, psychological, and relationship factors. Open communication with your partner and healthcare provider is key.
You deserve a fulfilling sex life at any age. Don't suffer in silence or accept that "this is just how it is now." Effective treatments exist—advocate for yourself and seek specialized care if needed.