Low  Libido During Perimenopause and Menopause: Why it Happens and What Helps

By Leigh Anne Hulva, BSN, RN— Women’s Health Educator

William Conway, MD, Nashville

Low libido during perimenopause and menopause is common, but many women feel embarrassed to bring it up. Sexual desire can be affected by hormones, vaginal comfort, sleep, mood, body image, relationship changes, and stress. This article explains why libido changes happen and when to seek thoughtful women’s health care in Nashville.

Catching Up with Margaret from Nashville

We’ve gotten to know Margaret, aged fifty-six, pretty well over a couple of different articles. We’ve been with her through her journey with Genitourinary Syndrome of Menopause (GSM), which leads us pretty seamlessly here. Libido. Arousal. When your sensitive vaginal area isn’t feeling its best, it makes it that much harder to get in the mood. The symptoms of GSM and the more nuanced issues of libido overlap… but they aren’t exactly the same.

The good thing is that now that Margaret has a name for the group of symptoms that make up GSM, she feels empowered. She knows that her body isn’t broken; it’s just following an age-old journey beyond the reproductive years. The drive to want sex now, hormonally speaking, has nothing to do with wanting babies. Now she needs to think more about what else her body needs, how her mind and psyche need to be fed in order to feel desire again.

On the other hand, talking to a doctor about the vaginal dryness and recurrent bladder infections of GSM feels like dinner-table conversation compared to talking about what she needs to talk about. Now, she’s going to have to talk about her sex life. She hasn’t talked much about this with anyone, including her only sexual partner, her husband of almost three decades. And now here she is, about to talk about it in mortifying detail with her gynecologist, a man twenty years her junior.

The hard truth is, Margaret just doesn’t want to have sex. There’s nothing wrong with her husband. And she feels okay in her body, even with all the changes it’s gone through over the decades. There’s nothing she can really put her finger on. Her husband is kind and funny, and they have a companionable relationship that has seen them through parenthood, career changes, an emptying nest, and the loss of parents.

The experience of not wanting to be intimate with her husband hasn’t caused any strain on their relationship, as far as she can tell. Her husband, almost sixty and still working full-time, has a plethora of hobbies to occupy his evenings and weekends. There’s only so much energy to go around, after all.

But Margaret recognizes that a piece of their relationship is missing. She remembers feeling attracted to her husband, and she remembers wanting to have sex with him. She wants to feel that way again. She shyly mentions this to the gynecologist toward the end of her appointment. And he says something wonderful. He says, “I’m glad you told me about this. I think we can make this better for you!”

Why Sexual Desire Changes During Midlife

Changes in libido during perimenopause and beyond are perhaps the most common symptoms women experience. They’re also among the least discussed in a clinical setting, probably given the reticence of women to share something so personal that they feel they need to “fix” themselves. This quiet suffering is unnecessary; libido changes in midlife are often highly treatable.

Understanding what’s behind the changes is the first step. And libido is kind of tricky because desire is not a simple, singular phenomenon. It is complex, involving hormones, physical comfort, mood, relationship dynamics, self-image, even sleep quality. The menopause transition basically affects all of these. Finding a physician who can help you detangle the sometimes-chaotic nature of perimenopause is paramount at this point. You should feel seen. You should feel heard.

Hormonal Causes for Low Libido

The Role of Estrogen

Estrogen. This powerhouse of a hormone has her fingers in every pie. Estrogen contributes to libido in several ways. It aids in the brain’s response to sexual stimuli, maintains blood flow to the genitals during arousal, and keeps those tissues healthy.

The decline of estrogen can impact your sex life on many levels. Your genital tissues are less sensitive to pleasure while also becoming drier, thinner, and less supple. This means that arousal takes longer, natural lubrication is scant, and the resulting uncomfortable— or even painful— sex tends to be less satisfying. Over time, this can actually train the brain that it’s safest to avoid intimate contact.

For this reason, treating GSM (Genitourinary Syndrome of Menopause) as soon as possible is so important. If you can avoid reaching the point where sex is uncomfortable before getting treatment, then increasing your sex drive is going to be that much easier. Restoring vaginal comfort is a fairly simple issue, medically speaking. But if there’s a long delay in getting uncomfortable sex treated, the brain learns to dread sex (even subconsciously), due to our simple human desire to avoid discomfort first and seek pleasure later.

The Role of Testosterone

It might be surprising to hear that testosterone is the hormone most linked to sexual desire in women. Starting in early puberty, women produce testosterone throughout their lives, with a decrease beginning in their twenties and a fairly sharp drop-off during perimenopause. This drop in testosterone magnifies the effects of declining estrogen. This is something worth discussing with your provider in terms of getting levels tested and considering testosterone treatment.

Psychological and Relationship Factors

Low libido is rarely as simple a matter as declining hormones. Human beings just aren’t that easy. The changes in midlife are many. It’s not just perimenopause, menopause, and the years that follow, but also all the life changes that tend to happen at this stage: raising adolescent children or having children leave home; helping aging parents who might require care; career changes or retirement… the list goes on. Many marriages face new challenges at this point as well, and divorce is common during these midlife years.

Body image deserves a special mention here. Most of us are gaining weight. Even if we aren’t, weight often shifts from where we were used to (hips and thighs) to areas where our jeans fit poorly. The weight has shifted up and forward, and our bellies are softer than we’re used to. That’s nobody’s fault; that’s a hormonal shift.

Even if your domestic and work and family lives are all humming along, you’re probably still dealing with occasional disrupted sleep, hot flashes, mood changes, brain fog, anxiety, fatigue… the list or hormonal symptoms can be long, and you probably see yourself somewhere in it. I know I do.

H2: Treatment Options for Low Libido During Midlife

H3: Treat GSM (Genitourinary Syndrome of Menopause) First!

A reminder for readers who didn’t walk with Margaret through her diagnosis of Genitourinary Syndrome of Menopause: Treating GSM first is vital. Treating vaginal dryness and discomfort during sex is of the utmost importance and really needs to be prioritized. Once underlying physical problems have been addressed, low libido can be more effectively treated. Treatments for GSM can be found detailed in another article, but include options that are simple (gentle physical therapy), medicinal (vaginal estrogen and moisturizers), and for more immediate use (special lubricants).

The anticipation of discomfort during sex can be a powerful detractor. This is such an important issue for women in midlife that I have written a separate article on GSM. Restoring vaginal comfort has to come first! Low libido is an important symptom of perimenopause, but if you don’t treat the underlying physical issues first, you will create a frustrating loop for yourself.

H3: Hormone Therapy

For women who are experiencing low libido along with other symptoms of declining hormones, menopausal hormone therapy (MHT) can address these issues together. If you’re a candidate for MHT— and you and your provider can discuss this together— hormone therapy can improve not only libido, but many other symptoms that can contribute to it, such as sleep disruption, hot flashes, mood changes, and fatigue.

As far as testosterone therapy for women with low libido goes, there is not yet FDA approval for this, but the evidence is growing to support its use, and many menopause specialists prescribe it. Ask your provider if this is something that might be an option for you.

Low Libido Care in Nashville

For women in Nashville, low libido during perimenopause and menopause deserves an unhurried medical conversation. Dr. William Conway at Nashville Concierge Medicines provides private, physician-directed care for women in midlife. The goal is to understand the whole person, not rush through an uncomfortable topic

Conclusion

If midlife libido changes are holding you back, now is the time to find a healthcare provider with experience treating women in middle age. If this article resonates with you, consider talking to your doctor about potential treatments. Find a provider who helps you figure out how to move forward into your best life!

Frequently Asked Questions (FAQs)

Is it normal to lose sexual desire during perimenopause and after menopause?

Lower sex drive (libido) is common in women during midlife. But common doesn’t mean inevitable or untreatable. It certainly doesn’t mean you have to just deal with it. Low libido during perimenopause and beyond has hormonal, physical, and often psychological causes. Effective treatments are available!

Can hormone therapy help with loss of libido?

Hormone therapy can help with low libido in a number of ways. Estrogen therapy affects vaginal tissue health, mood, sleep quality, and energy, all of which affect sex drive. Testosterone therapy, which affects sexual desire more directly, is being studied more and more and is prescribed by many menopause specialists, although it is not currently FDA-approved for this purpose.

The most effective treatment is going to be specific to your needs, which is why it’s so important to find the right provider, one who will give you a chance for a thorough and unhurried conversation about these vital issues.

When should I talk to my doctor about my low sex drive?

As with anything else, as soon as something is affecting your quality of life, it’s worth talking to your doctor about. This is as true with libido as it is with anything else. Your concerns are real and legitimate, and you deserve timely, compassionate, evidence-based treatment.

Who is Leigh Anne Hulva, in her words

I’m Leigh Anne Hulva, BSN, RN- a registered nurse, women’s health educator, mother of teenage daughters, and passionate advocate for women navigating perimenopause and menopause. I recently completed the Harvard Medical School course on Women’s Health, and in these pages, I relish sharing what I learned there alongside what I know from lived experience. I bring to this work not only my training, but also the personal experience of navigating the very transition I write about. It is my privilege to share both because this work is personal to me. I hope it feels that way to you, too.

I have been on the other side of this conversation, and I understand how much it matters to feel truly heard. At Nashville Concierge Medicines, my work is supervised by Dr. William Conway, MD, and I work directly under his licensure as a nurse educator.

Who is Leigh Anne Hulva by William Conway MD.

Leigh Anne is currently unrecognized as a writer. This will soon change. Leigh Anne is a gifted writer who has insights and understanding rarely understood or communicated. Leigh Anne communicates from the soul, illuminating deep truths.

Leigh Ann should be read for the enriching insights that bring clarity to human life. Leigh Anne writes in the best tradition of American humanism.

Read Leigh Ann to understand your life. Her insights are both broad and focused. She articulates wisdom.