How menopause affects sex

Menopause can bring a lot of changes, including low sex drive.

Changes in the body can make sex less pleasurable — even painful. As the amount of estrogen and testosterone in a woman’s body goes down, libido can suffer. For some, the drop is sudden; for others, it’s more gradual.

Why menopause can lead to low sex drive

• Vaginal dryness
• Thinning of the walls of the vagina
• Reduced blood flow to the genital tissue
• Difficulty having an orgasm
• Lack of interest in sex
• Difficulty sleeping
• Mood fluctuations
• Concerns about body image

There’s seldom just one reason a woman in mid-life is less interested in sex. Typically, it’s the cumulative effect of many changes, all of them happening at the same time.

Sex drive is a common problem post-menopause

Some studies show that up to 75% of women experience changes in their sexual function during the menopause transition. That can include a decline in desire, arousal, lubrication and satisfaction.

Among my patients, typically nine out of 10 report problems with sex, which they consider secondary to other menopause-related symptoms they’re facing, such as night sweats, irritability and brain fog.

Problems relating to sex sometimes begin in perimenopause, which can start as early as a decade before menopause, the point at which a woman has gone at least 12 months without having a period. Menopause typically happens around the age of 51.

It’s common for women to stop initiating sex after menopause and sometimes before. That’s not necessarily because they’ve lost interest, but because they anticipate sex will cause pain or frustration. Unfortunately, these issues are underreported and undertreated, often dismissed as just a part of aging that you’re stuck with.

Possible solutions to problems with sex around menopause

Declining hormones are a normal part of aging. But putting up with the symptoms doesn’t have to be the norm. Here are some tactics to try:

• Regular exercise enhances cardiovascular health, increasing blood circulation. This improves genital blood flow, enhancing arousal and lubrication and causing increased sensitivity and stronger orgasms.
• Pelvic floor exercises can reduce the pain in sex improving orgasm intensity, preventing urine leaking and enhancing control and sensation.
• Nonhormonal medications such as FDA-approved non-hormonal treatments for low sexual desire:
  • Addyi, a daily oral medication
  • Vyleesi, an injectable used as needed, approximately 45 minutes before sexual activity.

    Both medications are prescribed for hypoactive sexual desire disorder (HSDD), when having little to no desire for sex causes a lot of distress. The medications are approved by the FDA to be prescribed for premenopausal women. But sometimes, a health provider may prescribe them “off label” for a postmenopausal woman.

• Hormonal treatments:
• Vaginal estrogen can be in the form of a cream or suppository that’s applied and absorbed only in the vaginal area. The estrogen can significantly enhance vaginal comfort and lubrication.
• Systemic hormone replacement therapy are hormones taken as a pill, patch, ring, spray or gel that are absorbed into the bloodstream and affect the entire body. Systemic hormone replacement therapy can improve or eliminate symptoms keeping you uninterested in sex. At the same time, the hormones you replace can help you live longer.

Hormone replacement therapy can support sexual health and promote healthy aging by:

• Reducing the risk of osteoporosis by helping maintain the natural balance between bones breaking down and bones forming.
• Improving heart health by lowering LDL (“bad”) cholesterol and potentially increasing HDL (“good”) cholesterol.
• Potentially lowering the risk of dementia by influencing brain metabolism and slowing the accumulation of amyloid plaques, though this benefit is still being researched.
• Helping regulate blood sugar by improving insulin sensitivity and glucose metabolism, which can reduce the risk of type 2 diabetes.

Timing matters with hormone replacement therapy

When started within 10 years of menopause or before age 60, hormone replacement therapy is associated with a lower risk of breast cancer and cardiovascular benefits for many women. However, starting the therapy more than 10 years after menopause may increase the risk of heart disease and other complications.

If you’re more than 10 years post-menopause and want to start hormone replacement therapy, speak with your health care provider to complete a comprehensive risk assessment.

How can lack of sex drive affect relationships?

Changes in libido or having sex infrequently can create tension in relationships. That’s especially true if partners have mismatched expectations, or if they’re not communicating openly. However, regular sex is not a requirement for a healthy relationship. It depends on the couple.

What matters most is mutual understanding and emotional intimacy. For some couples, this phase opens up new conversations and ways of connecting that aren’t solely focused on intercourse.

Menopause doesn’t always hinder sex. Some women feel more sexually liberated after menopause, no longer worrying about pregnancy, periods or people-pleasing. If they’re in a supportive relationship, have addressed vaginal symptoms, and feel empowered in their bodies, desire can return or even improve.