Sex & fertility

Your sex drive before, during, and after menopause

by Marcy Holmes, Women’s Health NP,
& Dixie Mills, MD

• Women’s sexuality changes throughout their lives
• Physical changes that affect libido
• Low libido solutions - do hormones or drugs work?
• The effects of stress on sex drive

Asking a woman about her sex drive and sexual satisfaction is all part of our unique intake questionnaire at Women to Women. Some feel awkward about giving their answers, but most welcome this chance to talk about what’s happening in their bodies, their vitality and their interest in sex. After all, sex is a physical function that’s key to overall wellness. Plus it can make you feel more vital and alive.

During life’s biggest physical and emotional changes — perimenopause, postpartum phases, and menopause — our reproductive hormones can become imbalanced. This is when lots of women first experience low sex drive, fatigue, insomnia, hot flashes, mood swings, weight gain, and even digestive issues, all common symptoms of fluctuating hormones. These sensations can make you feel like a stranger in your own body — which affects your sexual self too, because when you don’t feel well, your interest in sex may dwindle. That’s why, for many women, feeling better physically is the first step to improving libido.

Women often note other aspects of their lives changing during these transitions as well. Maybe you’re finding the confidence to express yourself more freely and openly, or you’re reflecting on your life, thinking about taking the plunge into new activities. But you may also discover that just as you find your true voice, you’re under greater stress, with rambunctious teenagers in the house, or aging, and even “challenging,” parents to care for. You may be dealing with financial pressures or greater demands at work.

Perimenopause, menopause, and the postnatal months are common times for women to encounter relationship problems, which may or may not encompass sexual issues. Your idea of sex — both what it means and how important it is — may also be in transition.

Changing and evolving, and going with the flow — sexual identity in menopause

We’ve seen “up close and personal” how women’s sexuality evolves throughout their lives. The notion of holding onto youth is an increasingly outdated and limits a woman’s sexual potential, especially as she gets older. Instead, we see sexual identity evolving along a continuum — like a flowing ribbon — and that’s the beauty of it. Once we realize how much easier it is to be who we really are at every age, we’re presented with all sorts of opportunities for fulfillment, fun, and pleasure.

We encourage you to welcome the changes that enrich your sexuality as you transition physically and emotionally during perimenopause and menopause. Understanding the physical changes that are occurring helps you make practical choices, so you can create a sex life that suits you now — one that can be — believe it or not — better than ever.

Some perimenopausal and menopausal women say they are enjoying the “best sex of their lives.” With menopause we’re free of the fear of pregnancy, though women should use some form of birth control until they’ve gone a full year without periods, and practicing safe sex is a necessity. With this new sense of freedom, good sex, even great sex, is a real possibility for all women at midlife and beyond.

Sexual desire: subject to change

A woman’s level of sexual desire is affected by a range of interdependent physical and emotional factors. We delve into the complex emotional aspects of rekindling desire and rebuilding libido in a separate article.

Meanwhile, it makes practical sense to consider the physical aspects, because often they are surprisingly straightforward to address and improve.

When we look at the physical causes of low libido, it’s apparent that most fall under the umbrella of hormonal imbalance. Low libido is commonly accompanied by other symptoms of hormonal imbalance — insomnia, fatigue, night sweats, vaginal dryness, fuzzy thinking. These symptoms can make daily life miserable and can also affect how you perceive yourself. Some women say their symptoms make them feel “old and used up,” as if they’re losing their womanhood. In other words: not very sexy.

But when women get their hormones back in balance, they find relief from unpleasant physical symptoms, and that can significantly increase their sexual desire. (This symptom relief is the focus of our Personal Program for Menopause.)

Physical changes in the vagina that affect libido

At some point in their lives, approximately 50% of women experience thinning, tightening, dryness, and atrophy (a decrease in muscle mass) in the vulva and vagina. These changes can cause irritation, soreness, itching, and severe pain during sex, as well as embarrassing urinary frequency and urgency.

“Genitourinary” changes like these, most common as estrogen levels diminish, can interfere with every aspect of a woman’s life: exercising, sleeping, socializing, and body image, as well as intimate relations with your partner. Women may be so discouraged and frustrated by urogenital aging that they won’t talk about it at all. It even makes some women rule out sex completely.

We advise women to speak to their practitioners at the very first sign of vaginal discomfort. For most women, the situation is not permanent, but you should take action right away in order to help keep your tissues in good shape.

Sometimes these changes are not obvious until a woman undergoes a pelvic examination or attempts to have sex, and unfortunately, the pain can be extreme. But there are effective treatments for vaginal dryness, so don’t hesitate to ask for help.

Low libido solutions — do hormones or drugs work?

At the clinic, we treat both the symptoms and the underlying causes of vaginal dryness, vaginal thinning, and associated conditions. If symptoms are relatively new or mild, we suggest using vitamin E vaginal suppositories twice weekly. Another option is to add dietary soy, which contains phytoestrogens that promote “plumping” of the tissues and vaginal lubrication. All-natural, over-the-counter vaginal lubricants can greatly reduce friction during intercourse. And to keep the mucous membranes moist, it’s essential to drink plenty of water every day.

For lasting improvement, it’s important to address the root causes of vaginal dryness and associated changes. Even with ovarian estrogen production declining, the body is designed to produce adequate estrogen from secondary sites, such as subcutaneous fat and the adrenal glands, as long as you provide the raw materials and support. Dietary adjustments, nutritional supplements, and targeted endocrine support are key parts of a combination approach to help relieve vaginal dryness and other symptoms that impair a woman’s libido.

Some women simply have less estrogen on board than others, and if symptoms persist, there are many topical estrogen products available for localized application (see our chart on estrogen products for vaginal dryness for options). But you will need to get a prescription from your practitioner whether you choose a brand name or an individualized, compounded product such as low-dose estriol vaginal cream. And if one does not work well, don’t be shy about asking for a different one. Generally, these topically-applied products do not appear to carry the same health risks of oral menopausal hormone therapy.

In the vast majority of cases, urogenital health can be improved. Once the causes are addressed, and the symptoms relieved, regular use of the vaginal muscles during sexual activity will help keep them healthy and toned.

Testosterone and libido: not just for men

Sometimes referred to as “the life-force hormone,” testosterone is fundamental to our sex drive because it influences the entire “circle of sex”: interest, arousal, sexual response, lubrication, and orgasm. Normally, estrogen levels fall relatively quickly in women after menopause, while testosterone levels taper off more slowly. This leaves us comparatively “testosterone dominant” after our change of life, while men trend in the opposite general direction.

But for many possible reasons, some women don’t have “normal” circulating testosterone levels. One of the biggest obstacles to optimal sex hormone production is chronic stress. That’s because when we’re under stress, progesterone, the precursor molecule to testosterone, is converted into stress hormones instead of sex hormones. And over time, this switchover results in lower testosterone levels and reduced libido, among many other possible health problems.

Testosterone production in women is a multi-step process that takes place in both the ovaries and adrenal glands. When ovary-produced hormones decline in perimenopause and menopause, the adrenals can and will take on greater sex-hormone production — if adrenal reserves remain strong. But if a woman has experienced undue stress over the years, her adrenal reserves can be tapped out.

Some women maintain good testosterone production throughout perimenopause and menopause, and with few complaints. They may have better adrenal function and healthier metabolism due to good nutrition and a less stressful lifestyle.

In other women, such as the many thousands who undergo hysterectomy each year, levels of testosterone can be very low or barely detectable. Even women who retain their ovaries may experience this outcome post-hysterectomy, from compromised ovarian circulation. Nearly one in four women enters menopause as a result of surgery or medical treatment that causes her ovaries to lose normal function. This abrupt transition causes sexual issues for millions of women of all ages.

Should you take a prescription to improve your sex drive?

Some women go on prescription testosterone in hopes of experiencing rapid improvement in sex drive and sexual response. But based on experience with over 100,000 patients in the past 25 years, testosterone should only be prescribed after careful, thorough evaluation and testing, to verify the need.

For women, there does not seem to be a simple pharmaceutical fix for sex drive. For years, drug companies have been trying to concoct a Viagra-like medication for “female sexual dysfunction.” But our libidos are more complex physically and emotionally than men’s (a good thing!), and there is no “magic pill” that provides consistent results for all women.

Anyway, in most cases, lack of testosterone isn’t the core issue but just an associated symptom. For many women, emotional or relationship issues are connected to low libido, so no prescription hormone is going to resolve the dilemma. Along with establishing (or reestablishing) fundamental emotional connections with your partner, we advise taking the most natural, least-invasive approach to restoring hormonal balance. For most, improved libido is the natural result!

The recommendations we offer as part of our Personal Program for Menopause are effective because they help restore hormonal balance through a combination of techniques: nutritional supplementation, endocrine support, and dietary and lifestyle adjustments. This multi-pronged method helps relieve many other symptoms, which improves your overall outlook on sex as well.

Endocrine support helps provide the building blocks that your body converts into hormones as needed, whether it’s progesterone, cortisol, estrogens, or testosterone. Some women notice immediate improvement, while others need a little more time, but relief will be long-lasting.

If your symptoms don’t respond to these techniques, your practitioner can have your hormone levels tested. When hormone tests of our clinic’s patients are normal, it indicates to us that other factors are at play.

We have all heard stories from women who are patted on the head and told there are no options for them, that the sexual part of life is over! But I wouldn’t particularly want, or trust, a 30-something practitioner advising me about my sexual needs at age 60, either. As with other health issues, it is essential to find a healthcare provider who listens to you, treats you like an adult, and knows her stuff, or is at least willing to explore alternatives with you.

More about the effects of stress on sex drive

Most of us know that chronic stress isn’t healthy, but we may not realize the toll it takes on libido. The body interprets ongoing stress as life threatening, so naturally, survival is prioritized ahead of pleasure. Stress over-burdens the adrenal glands, “stealing” the substances normally used to make estrogens and testosterone, both vital to desire and sexual response.

Many women we talk to at the clinic and in our Personal Programs tell us they feel overwhelmed by stress. This puts them at significant risk for adrenal imbalance. If you are under constant stress, you’re not going to feel much like having sex. So in the interest of your health, and your sex life, it may be time to reassess the conditions that are creating stress in your life.

There’s also a connection between nutrition and libido, because nutrient deficiencies stress your internal systems and set the stage for hormonal imbalance. Many women diet continually to improve their appearance, unaware that ongoing nutrient deprivation can have a drastic impact on physical health, energy levels, and self-image. All of these effects make you feel awful and drain your sex drive. Note that low-fat diets are especially problematic, because your body needs lipids and cholesterol to make hormones, including the testosterone needed for sexual response.

Your sexual needs go beyond the physical

It’s been said that the brain is the most important sexual organ, and it follows that your beliefs about sex and what sort of behavior is “age-appropriate,” can alter your sex drive. We believe that desire and satisfaction depend as much on emotional and psychological factors as on the purely physical — sometimes more so.

A woman’s sexuality evolves in perimenopause and menopause. For many of us, early sexual identity was rooted in our sense of attractiveness to others, which was typically based on having a youthful body. As our bodies change, we might compare our appearance to how we looked in the past, or to other women, and forget to update our self-image to include the richness of our life experience. If you feel undesirable or even ugly, it’s less likely you’ll be interested in sex. But remember the old saying “Love is blind,” and check out the couples holding hands — they come in all sizes and shapes.

Biologists say we’re the only species in which females are sexually aroused by their own pheromones (naturally-occurring, sex-signaling chemicals) — and “feeling sexy” is an important component to sexual desire. But over the years, some women drift away from their sexuality, find themselves without partners, or feel that sex just isn’t important anymore.

Still others believe that sexual desire is shameful or even inappropriate, especially as they get older. Women who’ve been unassertive about their sexuality in the past may be prepared to sacrifice their sex lives rather than speak up now about their sexual needs. And single women may be daunted by the prospect of “dating” again and just close themselves off from the whole idea of sex. But you don’t need a partner to enjoy the health benefits of self-cultivation. I think this is an ideal time of life for women to rediscover and “fall in love” with themselves. They can have fun, trying things they’ve always wanted to experience and, who knows what — or whom — they will find in their futures?

Bringing out the best in your partner

If you have a partner, it’s impossible to talk about improving sex drive without looking at your relationship with that person. For many women, this opens a vortex of issues. First off, men and women are as different as night and day when it comes to libido. For men, arousal is mostly a physical experience, but for many women, the relationship itself is equally, or even more, important. No matter who your partner is, it’s absolutely essential to foster good communication between the two of you.

Some questions to ask:

• Are your needs being met in the relationship?
• Do the two of you deal with problems openly and constructively?
• Do you treat each other with respect and fairness?
• Is your partner self-absorbed, or even self-destructive?

Your answers to these questions will help measure the amount of intimacy and trust — elements that keep sexual desire alive — you have with your partner. Women ask us why they react so strongly now to behaviors their partners have exhibited for years. In perimenopause and menopause, women often shift their attention to finding and using their own voices to express what may be long-denied wants and needs.

If we don’t learn how to make our feelings known, our health will be affected. So even if an issue has been brewing for years, the midlife transition may prioritize finding a solution — your patience, humor, and compassion will help your partner welcome this “new you.”

Remember — change is good!

Your sexuality is naturally meant to evolve in perimenopause and menopause, and your life experience will help you chart a new course. Your sexual desire may diminish or even disappear temporarily, but it can and will come back. We see it happen all the time! That’s why reducing physical symptoms by restoring hormonal balance and supporting your emotional health are so important.

We encourage you to make the most of this invitation to rediscover your body. Make a date with your partner, and begin to imagine fresh ways to explore your sexuality. While no one has to know what you do or think to feel sexy, showing or telling that certain someone what you need can jumpstart the process.

A little mystery, openness to new ideas, and a whole lot of laughter will guide you through this new stage, learning as you go. Our best advice is to trust your intuition to reveal what’s best for you. Your sexuality is an expression of your creative life force, with great influence on your health and well-being. And you get to choose what you want at this turning point in your life.

Related to this article:

References & further reading on low sex drive

 

Last Modified Date: 04/19/2011
Principal Authors: Marcy Holmes, NP, Certified Menopause Clinician
& Dixie Mills, MD, FACS