What is actually happening in your body  – and what you can do about it

You Are Not Alone – and This Is Not “Just Aging”

Sexual health changes during perimenopause and menopause are among the most common – and most frequently suffered in silence – experiences women face at midlife. Genitourinary syndrome of menopause affects more than half of postmenopausal women, yet women are often embarrassed to seek treatment, and healthcare professionals do not always actively screen for it. As a result, it remains profoundly underdiagnosed and undertreated.

This article covers what is happening hormonally, physically, psychologically, and relationally – and what the clinical evidence says you can actually do about it.

Part 1: The Hormonal Foundation  – What Changes and Why

Estrogen: The Architect of Sexual Physiology

Estrogen is not simply a reproductive hormone. It maintains the structural integrity of the entire genitourinary system  – the vagina, vulva, clitoris, urethra, and bladder. The genitourinary syndrome of menopause encompasses anatomical and functional changes in the urogenital tissues – the labia majora and minora, clitoris, vestibule, vagina, urethra, and bladder – mainly related to the hypoestrogenic state occurring in postmenopausal women.

Vulvovaginal symptoms associated with menopause include dryness, burning, and irritation. Urinary symptoms include urgency, frequency, dysuria, and recurrent urinary tract infections. Physical changes include labial atrophy, reduced moisture, introital stenosis, and clitoral atrophy. The vaginal surface may be friable and hypopigmented, with petechiae, ulcerations, and tears.

Unlike hot flushes, which typically improve with time, GSM is chronic and progressive, and symptoms are unlikely to resolve without treatment. This is a critical point many women – and some clinicians – are not aware of.

Testosterone: The Overlooked Driver of Desire

While estrogen dominates the conversation, testosterone plays an equally important – and frequently unaddressed – role in female sexual health. As women age, there is an overall decrease in androgen production due to decline of ovarian and adrenal function during menopause. Androgens have been demonstrated to play an important role in sexual motivation in women. A prevalent manifestation of the resulting female sexual dysfunction is hypoactive sexual desire disorder (HSDD) – the absence of sexual fantasies, thoughts, and/or desire for or receptivity to sexual activity.

The role of androgens on urogenital tissues includes increased expression of estrogen and androgen receptors, cell growth, nitric oxide pathway-mediated enhanced perfusion and vaginal smooth muscle cell relaxation, increased nerve density, increased mucin production, and reduced inflammation. In other words, testosterone is not just about desire – it actively maintains the physical tissues that make pleasurable sex possible.

The Vaginal Microbiome: A Hidden Casualty

One of the least discussed consequences of estrogen decline involves the vaginal microbiome. Changes in the normal flora – particularly a reduction in lactobacillus – increase vaginal pH, predisposing women to inflammation and recurrent infections of increasingly predominant gram-negative bacteria and anaerobes. This shift in pH can cause chronic irritation, discharge, and a persistent sense of discomfort that many women mistake for an infection, leading to repeated antibiotic courses that further disrupt the microbiome.

Part 2: Physical Changes – What to Expect and When

Vaginal and Vulvar Changes

The tissues of the vulva and vagina are among the most estrogen-sensitive in the body. With declining hormone levels, they progressively thin, dry, and lose elasticity. On physical examination, we can find labial atrophy, vaginal dryness, and clitoral atrophy. The appearance of the vaginal walls may appear friable and hypopigmented; there may be traces of bleeding, which can already be observed upon insertion of a speculum.

These changes affect not only sexual intercourse but daily comfort – sitting, wearing fitted clothing, exercising, and even routine gynecological examinations can become painful.

Pain During Sex (Dyspareunia)

Findings from the REVIVE survey, involving 3,046 postmenopausal women, found that 59% reported that their symptoms considerably decreased their enjoyment of sexual activity, and 23% reported an adverse effect on general enjoyment of life.

Dyspareunia – pain during sex – is not something to push through or accept as inevitable. It has a clear physiological cause and, critically, effective treatments exist. Avoiding sex because of pain can trigger a cycle of vaginal narrowing (from disuse), increased anxiety about intercourse, and further avoidance – making early intervention especially important.

Urinary Symptoms

The bladder and urethra are also richly supplied with estrogen receptors. Urinary symptoms include urgency, frequency, dysuria, and recurrent urinary tract infections – and the urinary symptoms associated with GSM are also linked with other common urologic conditions in older patients, such as overactive bladder, making identification, evaluation, and treatment complex.

If you experience frequent UTIs without a clear explanation, or urgency that has worsened since perimenopause, GSM may be contributing – and treating it can significantly reduce these episodes.

Changes in Desire and Arousal

The negative personal issues associated with decreased sexual interest include feeling less feminine, feeling like a sexual failure, low self-esteem, insecurity, inadequacy, and letting a partner down. A higher percentage of women with low sexual desire feel frustrated, concerned, unhappy, disappointed, hopeless, troubled, ashamed, and bitter, compared with women with normal desire.

It is important to understand that loss of desire is not a character flaw or a relationship failure. It is a hormonally mediated clinical condition with validated treatments.

Part 3: Psychological and Relational Impact

Body Image and Sexual Wellbeing

A more positive body image is associated with greater sexual wellbeing, adherence to various health-promoting behaviors, and better overall quality of life. Conversely, the physical changes of menopause – weight redistribution, skin changes, hair thinning – can significantly undermine how a woman feels in her body, which directly affects her sexual confidence and engagement.

A cross-sectional study of 231 postmenopausal women found that 62.8% reported female sexual dysfunction, and body image was a significant predictor of sexual function – with significant correlations between body image scores and all domains of the Female Sexual Function Index, including desire, arousal, lubrication, orgasm, satisfaction, and pain.

The Psychological Dimension: Anxiety, Depression, and the Brain

Sexual desire is not simply hormonal – it is profoundly neurological and psychological. When endogenous inhibitory mechanisms are tonically activated by situational variables such as stress and fatigue – or by compounds that reinforce inhibition such as SSRIs – or when sexual excitatory mechanisms are blunted by hormonal conditions, sexual symptoms may co-occur in the same woman.

This is why treating only the hormonal dimension while ignoring anxiety, depression, sleep disruption, and relationship stress rarely produces full recovery of sexual wellbeing. A biopsychosocial approach – addressing biology, psychology, and relationship context simultaneously – is the clinical standard.

The Relationship Dimension

Three main themes emerge from qualitative research on women’s sexual experiences during menopause: physical symptoms and cultural influences on sexuality; emotional, psychological, and relational responses including shifts in self-perception, body image, and relationship dynamics; and adapting to sexual changes during the midlife transition. Biological changes alone are insufficient to fully understand menopausal women’s sexual experiences.

Partners – regardless of gender – benefit from being included in conversations about these changes. The CLOSER survey found that women and their partners both believed that vaginal discomfort had a considerable impact on intimacy, yet many couples never discussed it directly. Open conversation, ideally supported by a healthcare provider, is itself a therapeutic intervention.

Part 4: What Actually Helps – The Evidence-Based Treatments

First Line: Lubricants and Vaginal Moisturizers

First-line treatments typically include lubricants and moisturizers for short-term symptom relief, as recommended by both the North American Menopause Society and the International Menopause Society.

These are not the same thing. Moisturizers (used regularly, 2–3 times per week regardless of sexual activity) restore baseline vaginal hydration and maintain tissue health over time. Lubricants are used specifically during sexual activity to reduce friction. Water-based lubricants are the most widely compatible; silicone-based last longer; oil-based can be deeply hydrating but are incompatible with latex. The WHO recommends lubricants with an osmolarity lower than 1,200 mOsm/kg, as higher values are toxic and irritating to the vaginal mucosa.

Local Hormonal Therapy: Vaginal Estrogen

Compared with placebo or no treatment, vaginal estrogen may improve vulvovaginal dryness, dyspareunia, most bothersome symptom, and treatment satisfaction. Low-dose vaginal estrogen – available as creams, rings, tablets, or suppositories – delivers estrogen locally with minimal systemic absorption, making it appropriate for many women who cannot or prefer not to use systemic hormone therapy, including most breast cancer survivors.

Vaginal DHEA (Prasterone)

DHEA used as a daily vaginal insert (Intrarosa, 6.5 mg) was approved by the FDA for the treatment of GSM. With the lack of the aromatase enzyme in the endometrium, vaginal DHEA is not converted to estradiol in the endometrium and does not exert any endometrial proliferative effects. This makes it a particularly useful option for women who wish to avoid even local estrogen.

Ospemifene: An Oral Option

Ospemifene, taken at a dose of 60 mg daily, was the first compound to receive approval from the FDA in 2013 and the European Medicines Agency in 2014 for treating moderate to severe dyspareunia caused by GSM in menopausal women. It is a selective estrogen receptor modulator (SERM) – it acts like estrogen in vaginal tissue but not in the uterus or breast, making it an option for women who prefer an oral route.

Testosterone for Low Desire (HSDD)

Testosterone is an important evidence-based therapy for hypoactive sexual desire disorder in postmenopausal women. Clinical practice guidelines state that the sole evidence-based indication for testosterone therapy is HSDD in postmenopausal women.

Transdermal testosterone dosed in a normal premenopausal range improves sexual desire and reduces sexually associated personal distress in naturally and surgically menopausal women, with and without concurrent estrogen and progestogen therapy. It also improves the frequency of satisfying sexual events, arousal, orgasm frequency, pleasure, responsiveness, and self-image.

Testosterone for women is currently prescribed off-label in most countries (with the exception of Australia), at doses approximately one-tenth of male doses. Side effects at therapeutic doses are generally mild, most commonly acne or mild hirsutism.

Psychological and Pelvic Floor Therapies

In patients with GSM and psychosocial and/or sexual health concerns, clinicians may refer to a credentialed therapist. In patients with GSM and pelvic floor dysfunction, clinicians may refer to a physical therapist specializing in pelvic health.

Pelvic floor physiotherapy deserves particular mention. It is vastly underutilized and can address pain, incontinence, tightness, and reduced sensation – often producing results that no topical product can achieve alone. Mindfulness-based cognitive behavioral therapy has also demonstrated efficacy for HSDD and is an important part of holistic care.

The Most Important Thing to Remember

Sexual health during menopause is a medical matter – not a lifestyle preference, not a vanity, and not something to endure silently. It is a duty of healthcare providers to address the issue of sexuality routinely in clinical practice. However, it is still quite difficult to engage in sexual conversation because of the misconception that sexual problems are a normal part of aging and do not deserve specific treatment.

If your healthcare provider has not asked – ask them. If they dismiss the topic – find one who will not. Effective, safe, evidence-based treatments exist for every aspect of sexual health during this transition. You deserve access to them.

For more useful articles and expert guidance, explore the Womeno app – your personal digital companion through the hormonal transition. Download the app HERE.

Sources

1. Nappi RE et al. Genitourinary syndrome of menopause: recommendations from the 5th International Consultation on Sexual Medicine (ICSM 2024). Sexual Medicine Reviews. 2026;14(1). doi:10.1093/smr/qeaf055
2. Ferrero S et al. Update on Genitourinary Syndrome of Menopause: A Scoping Review. Life (MDPI). 2024;14(11):1504. doi:10.3390/life14111504
3. Kaufman MR et al. Genitourinary Syndrome of Menopause: AUA/SUFU/AUGS Guideline 2025. Journal of Urology. 2025. doi:10.1097/JU.0000000000004589
4. Danan ER et al. Hormonal Treatments and Vaginal Moisturizers for Genitourinary Syndrome of Menopause: A Systematic Review. Annals of Internal Medicine. 2024;177(10):1400–1414. doi:10.7326/ANNALS-24-00610
5. Faubion SS et al. Genitourinary Syndrome of Menopause: Management Strategies for the Clinician. Mayo Clinic Proceedings. 2017;92(12):1842–1849.
6. Parish SJ, Kling J. NAMS Practice Pearl: Testosterone Use for Hypoactive Sexual Desire Disorder in Postmenopausal Women. Menopause. 2023;30(7):781–783. doi:10.1097/GME.0000000000002190
7. Goldstein I et al. Hypoactive Sexual Desire Disorder. Mayo Clinic Proceedings. 2017;92(1):114–128.
8. Rastrelli G et al. Evaluation and Management of Hypoactive Sexual Desire Disorder in Women: Recommendations from the 5th ICSM 2024. Sexual Medicine Reviews. 2026;14(1). doi:10.1093/smr/qeaf057
9. Nappi RE et al. Sexual Health in Menopause. Medicina (Kaunas). 2019;55(9). PMC6780739.
10. Vincent C et al. Associations Between Menopause and Body Image: A Systematic Review. Women’s Health. 2023. doi:10.1177/17455057231209536
11. Shafaie FS et al. The Association Between Sexual Function and Body Image Among Postmenopausal Women. BMC Women’s Health. 2021. PMC8650325.
12. Rathbone A et al. A Meta-Ethnography of Women’s Intimate and Sexual Experiences Across the Menopause Continuum. PMC12341554. 2025.