Has your sex drive taken a dive since you entered menopause? Are you experiencing vaginal dryness or pelvic pain? Have you developed a “ho-hum” attitude about sex with your partner? On the other hand, is your sex life now better than ever?

Menopause can significantly impact a woman’s sexuality—physically, emotionally, and mentally. The reasons vary, and nearly all of them are either directly or indirectly linked to fluctuating and declining hormone levels. Let’s take a look at the sexuality shakeup that’s going on.

Women’s sexual activity phases

The four phases of a woman’s sexual activity are Desire, Arousal, Orgasm, and Resolution (DAOR). During desire, which may last minutes to hours depending on the circumstances, breathing and heart rate rise, the inner vaginal lips and clitoris swell, muscles tense, the vagina becomes lubricated, and the skin may become flushed.

Read about menopause and loss/low libido

Arousal occurs immediately before orgasm and involves a continuation of the changes that occurred during desire. In addition, there may be an increase in emotional involvement along with additional physical changes, including muscle spasms, a rise in dopamine levels, increased blood flow, and more clitoris sensitivity.  

The shortest of the four phases is typically the orgasm, which involves muscle spasms, contraction of the muscles of the uterus, vagina, and pelvic muscles, and a sudden release of tension. Blotchy skin is a common response as well.

Resolution follows orgasm, as the body returns to its unaroused state. Some women feel calm and tired after orgasm.

Female Sexuality in Perimenopause and Menopause

Women are more prone during perimenopause and menopause to develop a variety of symptoms and conditions involving their sexuality. As levels of estrogen and testosterone decline and fluctuate, women can experience changes in their sexual feelings, arousal, and behaviors. That’s because these hormones significantly impact changes in nerve neurotransmission and blood capillary response. Low estrogen and testosterone levels, for example, can reduce sexual desire and make it more difficult to become aroused. On the other hand, declining progesterone affects menstrual periods much more than sexual function. 

Read about menopause and vaginal dryness

• Vaginal dryness. Declining estrogen levels means a less stretchable vagina and less vaginal lubrication. This can result in vaginal pain, burning, or soreness. The use of a water-based vaginal lubricant can reduce discomfort during intercourse. Natural oils such as coconut oil, extra virgin olive oil, and almond oil can be effective as well. Coconut oil has natural soothing and moisturizing properties. Olive oil contains vitamin E, which improves hydration and water retention. Almond oil also is naturally soothing. Wash your hands before you massage any of these oils around or inside your vagina.  
• Vaginal muscle contractions. Involuntary vaginal spasms or contractions are known as vaginismus and may also involve the perineum (the area between the vagina and anus). Vaginismus sometimes appears for the first time among women in menopause because of estrogen deficiency and vaginal atrophy. The contractions may be accompanied by burning or stinging sensations. Treatment options include pelvic floor muscle exercises, the use of a vaginal dilator to stretch the vagina, biofeedback, cognitive-behavioral psychotherapy, sex therapy, and relaxation exercises.
• Hypoactive sexual desire disorder. This disorder is characterized by a lack of sexual thoughts, desire, or drive as well as low testosterone levels. The low hormone levels are also a cause of the poor self-esteem and emotional instability often associated with the disorder. Research indicates that while sexual dysfunction among all women ranges between 25 and 63 percent, among postmenopausal women it ranges between 68 and 86.5 percent. A wide range of factors may be involved in this disorder, ranging from physical discomfort (pelvic pain, vaginal dryness) to past sexual trauma, mood swings, insomnia, stress and anxiety, and relationship issues. Working with a health care provider and/or a mental health or sex therapist can help women and their partners discover the causes of their disorder and then map out a solution. 
• Symptomatic vulvovaginal atrophy. Estrogen helps maintain the hormonal balance of microorganisms in vaginal tissues. As estrogen levels decline, an accompanying reduction in the bacteria Lactobacilli can throw off the pH balance in the vagina, which can result in vaginal burning, itching, and dryness. Probiotic supplements and foods containing beneficial bacteria may be helpful for restoring balance in the vagina. Water-based lubricants or natural oils (extra virgin olive oil, almond, coconut) can help with vaginal dryness. 
• Orgasmic and arousal dysfunction. These related dysfunctions are characterized by difficulty in getting aroused or achieving orgasm even with sufficient sexual stimulation. Physical symptoms such as vaginal dryness and irritation may be factors. A woman and her partner should learn to communicate their fears, desires, and needs, and a mental health or sex therapist can be instrumental in helping this process. Kegel exercises may help tighten and relax pelvic muscles, while masturbation or use of a vaginal or clitoral stimulator may help women better focus on what pleases them.

Use of bioidentical hormone therapy also may be an option for management of sexuality issues in menopause. The pros and cons and appropriateness of using hormone therapy for your specific issues should be discussed with your healthcare provider. 

Bottom line

Perimenopause and menopause can have a significant impact on sexuality. While some women experience an increased sex drive and a more relaxed and satisfying sex life, others experience challenges in their sexuality. Those challenges can be managed with a variety of natural remedies.