Menopause: Hormones, Sexual Health, and Treatment Options
What is Menopause?
Menopause is the permanent end of menstruation (periods) and reproductive years (fertility). It is a natural, biological ageing process. Menopause is determined when there are 12 consecutive months without menstruation (without other biological or medical causes). This occurs between the ages of 45 to 55, but typically around 51 in Western Countries. While menopause is a natural ageing process, menopause can also be induced or surgical such as when ovaries are removed in medical treatments.
Perimenopause is the time period leading up to menopause where the body slowly moves away from reproduction. It typically begins in the 40s but can start as early as the late 30s. This period can last between one to ten years. During perimenopause hormones fluctuate unpredictably. The rollercoaster of hormonal peaks and dips produces symptoms such as irregular or heavier periods, night sweats, difficulty sleeping, brain fog, mood changes, and hot flashes.
Postmenopause is the period after menopause: beginning after the one year milestone after the last menstruation. In postmenopause there is no longer the ability to reproduce. Hormone levels are consistently low, rather than rapidly changing such as in perimenopause. In postmenopause the body adapts to operating with low estrogen (oestrogen).
What Hormones are Involved in Menopause?
Estrogen, progesterone, and testosterone are reproductive hormones that support the health of the entire body. In perimenopause the levels of these hormones shift erratically towards overall decline.
When it specifically comes to sexual health estrogen and testosterone are key players:
Estrogen contributes to:
- Vaginal thickness
- Vaginal elasticity
- Vaginal lubrication
- Vaginal acidity (which allows the vagina to clean itself and protect against harmful bacteria)
Fluctuations of estrogen during perimenopause and the overall decline in menopause contributes to:
- Mood changes such as depression which can impact on sexual arousal
- Vaginal dryness
- Vaginal thinning
- Painful or uncomfortable vaginal intercourse
Estrogen is produced primarily in the ovaries. It contributes to a range of bodily functions beyond sexual health such as the bones and skin.
Testosterone contributes to:
- Sexual desire, especially spontaneous desire
- Arousal
- Sexual satisfaction
- Overall energy and mood (which supports sexual arousal)
Testosterone decline in menopause contributes to:
- Loss of spontaneous sexual desire
- Longer arousal response
- Less sensitivity in the clitoris
- Longer time to experience orgasm
- Orgasm may feel less intense
- Physical fatigue (which can impact arousal)
Testosterone is produced in the ovaries and adrenal glands. Although it is usually perceived as a “male” hormone, it is the most abundant active sex hormone in a woman’s body. Although there are shifts during perimenopause, this tends to be subtler and less erratic, as testosterone typically declines more gradually across age.
Progesterone also experiences shifts and a decline during perimenopause. Progesterone is more associated with reproductive health rather than sexual functioning, such as sustaining early pregnancy and shedding the uterine lining for periods. It also produces an overall calming effect and has a positive impact on sleep. Therefore a decline in progesterone during perimenopause is associated with sleep difficulties and heightened anxiety.
What are the Sexual Health Impacts of Menopause?
Up to 45% of women in menopause report painful sex. This reflects the vaginal changes experienced during menopause due to declining estrogen. It takes the vagina more time to lubricate, less lubrication may be produced, the vagina may not experience as much blood flow and full arousal. The thinning of the vaginal walls and loss of tissue flexibility can also contribute to this pain. A decrease in arousal can also mean that orgasms take longer to experience, and the orgasmic contractions may be fewer and weaker.
Desire may shift from spontaneous desire to primarily responsive desire. This may be a big adjustment to an individual that has relied on spontaneous desire to engage in sexual activity. To understand more about desire or “libido” read here.
Common Questions about Menopause and Sex:
Does menopause affect libido?
While the hormone-driven interest in sex may decline, connection remains a central human need. Within sexual intimacy this may be reflected in the want to maintain touch, pleasure, and sexual activity. Many women find that menopause is an opportunity to reinvent sexual intimacy: to slow down, prioritise and relish connection, and a newfound freedom and enjoyment from the cessation of periods and pregnancy.
Why is sex painful after menopause?
Sexual intercourse can become painful after menopause due to vaginal changes related to the decline in estrogen.
While it is common to experience pain due to the changes in menopause, it is not something to push through or an inevitable acceptable reality. Pain is highly treatable, and there is no need to suffer in silence. Medical and lifestyle interventions can restore vaginal comfort and improve vaginal health.
Can sex still be enjoyable after menopause?
Sexual intimacy can still be pleasurable and enjoyable after menopause. Especially when a flexible, adaptable definition of sex is adopted beyond sexual intercourse, many individuals find sexual activity in older adulthood more satisfying. Sexual aids can also be incorporated to enhance partnered sexual intimacy. These devices can provide support to comfort and pleasure, especially when there are physical health limitations.
What are the Treatment Options for Menopause?
As per any physical health issue, it is important to consult with a doctor and only utilise medications that have been prescribed.
Vaginal Estrogen: this is estrogen in a cream, slow-release vaginal ring, or vaginal tablets. Estrogen applied directly to the vagina (locally) restores the thickness and elasticity of vaginal tissue, supports natural lubrication, and maintains the acidity of the vagina for overall vaginal health,
Pros:
- Highly effective at eliminating painful sex
- Local application means minimal estrogen enters the blood stream
- Safe for most women
- Reduces urinary tract infections (UTIs)
Cons:
- Creams can feel messy
- Some treatments can be expensive such as the vaginal ring
Systemic Hormone Therapy: this is estrogen (often with progesterone) that is a patch, pill, or gel for the whole body. It is prescribed to treat a broader range of menopausal systems.
Pros:
- Effective for broader menopause symptoms such as hot flashes and night sweats
- Can improve sleep, mood, and energy which also supports libido
- Prevents bone loss
- Ideal for those in perimenopause or postmenopause under 60
Cons:
- Not suitable for those with cancer histories, blood clots or stroke
- Side effects such as irregular bleeding and breast tenderness
- More risks if started 10 years or more postmenopause
Testosterone Therapy: this is an off-label treatment (meaning that it is not an official use of the medication) prescribed to treat hypoactive sexual desire disorder. This may be in a cream or gel, at the fraction prescribed to men.
Pros:
- Clinical trials show a significant increase in spontaneous desire
- Increases in arousal
- Increases in sexual satisfaction
- Improvements to mood, energy, and muscle mass
Cons:
- An off-label, unapproved treatment
- Side effects (especially if dose is too high) include acne, unwanted hair growth, or voice changes
- Regular blood tests are needed to monitor levels safely
Non-Hormonal Prescription Medication: oral medications such as Ospemifene (Osphena) acts like estrogen and targets the vaginal tissues. This is a once-daily oral medication.
Pros:
- Approved medication that provides an alternative to hormone therapy
- Successfully treats vaginal dryness and pain
- Improves overall sexual health including sexual desire and arousal
- Safe for post-menopausal women
Cons:
- Daily use required
- Systemic effects due to bloodstream absorption
Lubricants and Moisturisers: these are over-the-counter products to manage dryness. They are non-hormonal. Lubricants tend to be water or silicone based and applied during sexual intimacy to reduce friction. Moisturisers are applied regularly to support vaginal tissues in retaining water.
Pros:
- Readily available without prescription
- No hormonal side effect risks
- Highly effective for mild to moderate dryness
- Can increase comfort and pleasure
Cons:
- They do not reverse underlying thinning
- They do not tend to target vaginal pH
- Some additives can be irritating
Pelvic Floor Physiotherapy: this is especially important when there is sexual pain. Both can occur: Sexual pain can often be the result of pelvic floor dysfunction, and sexual pain can lead to pelvic floor dysfunction. Pelvic floor therapy utilises pelvic floor exercises and can utilise vaginal dilators and vibrators to increase blood flow and massage tight muscles.
Pros:
- Drug-free, no medication side effects
- Maintaining nerve function and blood flow
- Skills that can be utilised long-term
- Improving overall sexual health
Cons:
- Requires patience and consistency
- Financial investment to see a physiotherapist
Sex Therapy: this supports the emotional and psychological impacts of menopausal shifts. It explores barriers to sexual intimacy such as body image issues, anxiety, and changing desire.
Pros:
- Re-defining sexual intimacy and increasing sexual confidence, pleasure, and satisfaction
- Improving communication
- Enhancing the couple as a sexual team
- No medical side-effects
Cons:
- Requires time, commitment, and financial investment
- Works best with a willing partner
Sex Therapy for Menopause
If menopausal changes are affecting your sexual wellbeing or relationship, professional support can help. Many women feel confused or isolated when sexual changes occur, especially when menopause is rarely discussed openly.
I offer online sex therapy across Australia, supporting individuals and couples navigating concerns related to sexual desire, intimacy, and sexual health during midlife and beyond. Therapy provides a confidential and supportive space to explore these changes and develop practical strategies for maintaining connection, comfort, and pleasure.
Final Reflection
Menopause is a natural stage of life, yet the changes it brings can sometimes feel unfamiliar or unsettling. Shifts in hormones can influence sexual desire, comfort, and arousal, but these changes do not mean that sexual intimacy must disappear.
With understanding, medical support or sex therapy where appropriate, and open communication, many women and couples discover new ways of experiencing intimacy during this stage of life. Rather than viewing menopause as the end of sexual wellbeing, it can become an opportunity to adapt, reconnect, and redefine pleasure in ways that feel authentic and satisfying.
Written by Justine
References
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3. Portman DJ. Ospemifene, a novel selective estrogen receptor modulator for treating dyspareunia associated with postmenopausal vulvar and vaginal atrophy. Menopause. 2013;20(6):623-630.
4. Castelo-Branco C, Cancelo MJ, Villero J, et al. Management of post-menopausal vaginal atrophy and atrophic vaginitis. Maturitas. 2005;52(Suppl 1):S46-S52.
5. Simon JA, Kingsberg SA, Shumel B, Hanes V, Garcia M Jr, Sand M. Efficacy and safety of flibanserin in postmenopausal women with hypoactive sexual desire disorder: results of the SNOWDROP trial. Menopause. 2014;21(6):633-640.
6. Kingsberg SA, Clayton AH, Portman D, et al. Bremelanotide for the treatment of Hypoactive Sexual Desire Disorder: two randomized phase 3 trials. Obstetrics & Gynecology. 2019;134(5):899-908.
