Libido and sex drive can begin to change pretty drastically in your late 30s, 40s, and 50s. Contrary to how women are often depicted in the media, this is not an expectation to normalize and says a lot about what women are going through and how women's sexual health is considered in the world at large.
Perimenopause and its associated hormone changes can start affecting your sex drive and vaginal health years before your period ever stops, and most people are never taught to look out for it. It often creeps up!
Questions that come up about desire and drive in my clinical practice in Ontario, Canada include:
Where did my libido go? Is it perimenopause? Do we need to test my testosterone?
Some of the comments I hear from women in perimenopause and beyond go something like:
"I don't really feel like having sex."
"Sex has become really painful recently and it's affecting my relationship."
"I'm so tired at the end of the day ... intimacy is the last thing on my mind."
"I feel so uncomfortable in my body, and I don't really want my partner to see me."
"I feel so disconnected from that part of myself."
So, let's talk through what's happening, why it happens, and what actually helps.
It's not a straightforward answer because it's rarely JUST one thing. We want to point our finger at something, and often testosterone is who we're pointing it at (and, sure, it can be part of the picture). BUT, libido in perimenopause is affected by a whole interconnected chain of changes happening all at once:
Usually, there isn't a simple switch to turn desire back on overnight. For most of us, it usually takes addressing a few of the above that apply to you together or one by one.
This is a common question I get and that I see online.
The answer: maybe.
So far, the research on testosterone therapy for libido is far less impressive than what you'll read online. When testosterone is given to postmenopausal women, the improvement in desire tends to be modest at best.
This doesn't mean hormones have no role to play. It simply corroborates what I wrote above: libido and sex drive are multifactorial.
This is an important concept that Dr. Dolores Fernandez, ND MSCP and I talked about in a session of The Perimenopause Summit that you can watch on Sept 22-25 for free online.
Spontaneous desire is the "movie version" of desire: Your desire kicks in immediately, out of nowhere. Research suggests spontaneous desire in a long-term relationship typically lasts around seven months, on average, before it naturally fades.
Responsive desire is different: It shows up after something else happens, like physical touch, closeness, even just deciding to be receptive to intimacy before you feel "in the mood." Dr. Fernandez describes it being like agreeing to going to a party you weren't excited about, and having a great time once you're there. Arousal comes first, and desire follows.
After that early spontaneous-desire phase fades in a relationship, responsive desire becomes the norm for most women.
If you're noticing that you don't really feel that instant desire the way you used to, it's actually what's the norm. I really think that understanding this is often a huge relief for people, because it reframes "my libido is gone" or "there's something wrong with me" into "my desire just works differently now."
Painful sex is common and UNDER-DISCUSSED symptom of perimenopause. It happens because of estrogen declining.
As estrogen goes down, the vaginal tissue changes in several ways:
These changes fall under the term genitourinary syndrome of menopause (GSM). It refers to changes in the vulvar, vaginal, and urinary system due to change in hormones, especially a decline in estrogen. More on GSM here.
GSM symptoms are usually described as something that happens years AFTER your last period, but many women experience these changes years before menopause is reached, i.e., they start getting GSM in perimenopause. If you're in your late 30s or 40s and experiencing these symptoms, it's not "too early" for this to be perimenopause-related.
For vaginal and urinary symptoms of GSM, vaginal moisturizers and low-dose vaginal (local) estrogen are standard treatment options.
Vaginal estrogen comes as a cream, tablet, or ring, and there's no strong evidence that one form works better than another. The best option is whichever one you'll actually use consistently.
Local vaginal estrogen therapy has an excellent safety profile because it acts locally. It goes to work directly in the vulvovaginal and urinary tissues and does not circulate systemically throughout your entire body. This means it won't get rid of your hot flashes, but it also means it avoids the systemic risks and/or symptoms that may occur with certain forms of systemic hormone therapy.
It's usually a long-term commitment. Unlike hot flashes or sleep issues, which often improve on their own over time, vaginal and urinary changes from declining estrogen tend to progressively worsen if left untreated. Most people need to stay on treatment indefinitely to maintain results.
A standard protocol often looks like a daily loading dose for two weeks to rehydrate and saturate the tissue, followed by a maintenance dose of twice a week for the long haul. It can be super effective for preventing recurrent UTIs, rebuilding tissue strength, making intimacy more enjoyable, decreasing urinary leakage, and improving your overall quality of life!
Vaginal DHEA (brand name: Intrarosa(R)) can also be used for GSM.
You don't have to be postmenopausal to use it. Many perimenopausal people benefit from vaginal estrogen well before their period stops, it simply needs to be be tailored around your cycle.
While they both help with comfort, they do different things and should be used differently.
Vaginal Moisturizer: Exactly as it sounds, this is a treatment to increase your own tissue's hydration. It can be used daily, or can be used more frequently. Most moisturizers on the market will recommend using it daily for some time and then decreasing it to 2-3 times per week. A good vulvovaginal moisturizer is used regularly to treat dryness, soothe, and protect the skin.
A major ingredient studied for vaginal moisturizers is hyaluronic acid. As estrogen drops, we make less hyaluronic acid, which binds water and keeping tissue plump.
If you're using both a moisturizer and vaginal estrogen, a simple approach many providers recommend is using the moisturizer on the days you're not using estrogen, so you're supporting the tissue continuously without overdoing either product.
Lubricant (Lube): Lubricant is used as a management strategy whenever we need to reduce friction, whether that's for intimacy, pelvic physiotherapy, or tampon insertion. It doesn't actively treat or heal the underlying tissue dryness, but can really help increase pleasure and decrease discomfort when used.
Mostly because of stigma! Less than 15% of people bring up these symptoms with their healthcare providers! That's despite how common and treatable they are--moisturizers and local estrogens work well and they work fast!
A lot of people quietly assume this is just something they have to manage on their own, or feel embarrassed bringing it up at an appointment meant for "bigger" health concerns. Please move away from this type of thinking! Vaginal health, sex drive, and intimacy are a legitimate, significant part of your quality of life. If it's affecting you, it's worth bringing it up!
Your sex drive changing in perimenopause isn't a personal failure, and it isn't something you have to just live with. It's a hormonal and physiological shift with real, well-studied explanations and well-studied treatment options!
Therapy, learning more about intimacy, getting to know what you like, working on energy levels are all worthy aspects of your life and health to explore.
None of this is medical advice, but you should really talk to your ND, MD, or NP about these changes and get care. I prescribe vaginal hormone therapy for patients regularly (when appropriate, obviously!) in my practice in East Gwillimbury and Innisfil (and virtually!). If you're in Ontario, you can book an appointment here.
Many of my patients wonder why they waited so long and are pleasantly surprised at how much of a difference it makes in intimacy (and their day-to-day life, like being able to wear jeans they haven't work in a long time, and not getting recurrent UTIs!).
