Intimacy & desire: what to do next

What this often points to

This path covers two different things that often overlap: vaginal dryness or discomfort, and lower desire. They have different causes and different treatments.

Dryness and discomfort: genitourinary syndrome of menopause (GSM)

• GSM affects about 27% to 84% of postmenopausal women. The Menopause Society says it is "likely underdiagnosed and undertreated" ¹.
• As estrogen falls at menopause, the Society says the vulva and vagina can become "thin, dry, and less elastic", with less lubrication. This can cause pain during intercourse and during pelvic exams, plus burning, itching or irritation ².
• Many women don't notice GSM in perimenopause. For some it doesn't become a problem until several years after menopause ². Unlike hot flashes, it tends to persist or progress.

Lower desire

• The Menopause Society says "there is no standard to meet when it comes to sexual activity and desire". Some women have less interest at midlife, some more, some no change ³.
• Hormone changes "are only part of a complex set of factors" ³. The others it names:
  • poor sleep from night sweats
  • pain from dryness
  • medicines
  • medical conditions
  • relationship and life changes
• Clinicians call one recognized form of low desire hypoactive sexual desire disorder (HSDD). The Global Consensus says diagnosing it should be based on a thorough clinical assessment guided by available diagnostic criteria ⁴.

The hormone picture

• Estrogen and progesterone. ACOG says that from your 30s and 40s, the amount of estrogen the ovaries make "begins to fluctuate" ⁵. The Menopause Society says perimenopause brings "the ovaries' erratic production of hormones and less-frequent release of an egg (ovulation)" ². The FDA says the body "slowly produces less of the hormones, estrogen and progesterone" ⁶.
• Testosterone. The ovaries make testosterone too ⁵. The Global Consensus, endorsed by The Menopause Society, says testosterone levels decline during the reproductive years ⁴. The Menopause Society notes that surgical removal of both ovaries causes "a significant decrease in testosterone that does not occur with natural menopause" ⁷.

Can a blood test settle it? Usually not, for either question.

• Perimenopause. ACOG says: "You probably don't need hormone testing." Your age, symptoms and period changes usually tell the story. Testing may be offered if you're under 45 with bleeding changes, especially under 40 ⁸. NICE advises against hormone and ovarian tests to identify perimenopause at 45 or over ⁹.
• Low desire. "A blood total testosterone level should not be used to diagnose HSDD" ⁴. Diagnosis takes a full clinical assessment ⁴.

What to track for 2 weeks

• Dryness or discomfort day to day, 0–10. Note where: vulva, vagina, or with urination.
• Pain during intimacy, 0–10, and what helped (for example, a lubricant).
• Any bleeding after intercourse, or any bleeding at all if you're past menopause.
• Desire, 0–10. Separately: how much a change in desire bothers you, 0–10. The second number matters as much as the first.
• Urinary symptoms: urgency, frequency, burning, infections.
• Sleep, night sweats and mood.
• Medicines. Note any breast cancer history and treatment.

Questions to ask your clinician

1. "Could this be genitourinary syndrome of menopause? Would an exam help confirm it?"
2. "Should I start with an over-the-counter moisturizer or lubricant? When would we move to a prescription?"
3. "Is low-dose vaginal estrogen an option for me, given my history? If I've had breast cancer, should we involve my oncologist?"
4. "Could any of my medicines be lowering my desire?"
5. "My lower desire bothers me. Does it meet the criteria for HSDD, and what are the options, including a referral to a clinician who specializes in sexual concerns?"
6. "If testosterone comes up, what exact product would it be, is it FDA-approved for women, and how would you monitor it?"

The options on the table

These are the authorities' own grades and words. They aren't a ranking for you.

For dryness and discomfort (GSM)

Want to hear a specialist talk this through? On the podcast unPAUSED, OB/GYN and Certified Menopause Practitioner Dr. Mary Claire Haver talks with Dr. Rachel Rubin, a board-certified urologist and sexual medicine specialist at Georgetown University, about vaginal dryness and discomfort, vaginal estrogen and DHEA, and pelvic floor therapy. It's a good listen if you've been told discomfort is just part of getting older: Menopause, Hormones and Women's Sexual Health with Dr. Rachel Rubin. Dr. Haver sells Pause-brand products on the same site, and we don't endorse them or use affiliate links.

For lower desire

Limitation

Desire is personal, and the trials measure averages. A medicine that adds one satisfying event a month on average may matter a lot to one woman and not at all to another. Most trials are short and exclude women with breast cancer.