Most of us, by the time we hit midlife, will have been having sex for decades. We might not have really focused on our sexual selves, though, until things start to change – which can often happen around this time, as perimenopause kicks in.
Perimenopause – the time leading up to menopause, when our reproductive hormones go on a bit of a rollercoaster ride and cause a range of mental and physical symptoms for many of us – can affect our sex lives, too. We might suddenly feel a loss of desire and libido. Sex can start to feel uncomfortable or even hurt. These things can come as a surprise; there can be an accompanying sense of grief or loss.
But menopause does not mean the end of our sex lives. It might, instead, be a whole new era – we may just need to make some tweaks, both physically and mentally.
What’s going on with my midlife libido?
There are many, many things that play into sexual desire and pleasure. Sex is not just physical; it’s psychosocial: it involves our bodies, our brains and a whole lot of external social conditioning we’ve likely absorbed from a young age.
It can get even more complicated as we age. It’s not just ageing – which happens to all humans, remember – but it’s also hormones. Perimenopause and menopause mean a decline in the hormones in women that drive us (oestrogen, progesterone and testosterone); affecting almost every system in the body. That’s why you’ll see lists of the symptoms of perimenopause that feature more than 40 seemingly unrelated things.
Some of those things are physical changes that affect the vulva and vagina that start in perimenopause – something we’re not always comfortable talking about, but which is extremely common – and body changes that might affect our self-image. Hormonal change can also independently impact our desire, responses and pleasure.
And of course, all the other stuff that perimenopause does can impact on our sex lives, too; there’s no doubt that if you’re not sleeping and you’re having flushes, fatigue, joint pain and mood swings, you’re probably not going to be able to flip into sexy time in a hurry.
So, where do we start with all of this?
Sex hurts! Physical changes
First, it’s important to address pain and discomfort. If sex is painful, it’s not going to be fun, no matter what else you do.
Genitourinary Syndrome of Menopause (GSM) is the overarching term for the changes that happen to most of us – up to 80% – at some time either during perimenopause or after menopause. It affects the tissues of the vulva, vagina and urethra, which – because they have lots of oestrogen receptors, and oestrogen is declining through this time – can become dry, irritated and thinner. The pH and microbiome in these areas can change, too, and all of it adds up to pain and irritation – sometimes all the time, and sometimes during sex.
Christchurch-based gynaecologist Olivia Smart told me women often put up with these symptoms for years before they seek help.
“So many times people say, ‘I didn’t know anything about this! No-one told me about it… everyone’s talking about hot flushes’ and they weren’t interested in it 12 months ago, because they were 47 and absolutely fine. And now a year later – things have changed,” she notes.
The first line of treatment for GSM is vaginal oestrogen. This is a game-changer: it’s the most effective treatment according to the experts and the evidence, improving the quality of the tissues in and around the vagina. It thickens the skin of the vagina and increases natural lubrication. It also restores the normal pH in the vagina, and it’s been shown to reduce the risk of UTI. It comes in the form of a cream that’s applied via an applicator inside the vagina and around the vulva, usually a couple of times a week.
Vaginal oestrogen is a safe treatment for most women; even breast cancer survivors in many cases. That’s because it’s not absorbed systemically; it’s only going to the tissues where it’s needed (don’t be alarmed by the package insert if you use this treatment.
Gynaecologists worldwide have been trying to get this changed for years; this is a very safe treatment that can be used lifelong if needed, which doesn’t have the same risk profile as systemic oestrogen).
Alongside vaginal oestrogen, you might also want to use vaginal moisturisers to keep the skin feeling comfortable all the time – there are lots of these around; they’re just like face moisturisers in many ways – and lubricants for sex to help everything feel more comfortable and pleasurable during sex. There are lots of lubes to choose from, ranging from super-natural plant-based versions to high-tech and flavoured varieties. Experts recommend finding one you like the feel of, and steering clear of fragrance and flavour for less risk of irritation.
I’m just not in the mood! Libido changes
Again, this is completely normal; no human being can expect their libido to be consistent throughout their whole life. Libido and desire wax and wane, and that’s down to many factors: biology, psychology, social and environmental. There’s no right or wrong here, either; who’s to say what ‘low sex drive’ really is? The answer will be different for everyone.
We do know a change in libido is very common. One study found low sexual desire ranged from 27% in premenopausal women to 52% in menopausal women. The NZ Menopause Survey found 64% of women respondents said they had ‘low sex drive’, whatever that meant to them.
A lot of perimenpausal changes in libido, desire and pleasure can be sorted by dealing with the other symptoms of perimenopause. That includes GSM of course, but also the big things like hot flushes and night sweats, mood changes, muscle and joint pain, sleep issues and fatigue. Again, that’s not an easy fix, and it’s multi-faceted. But getting the basics in place: a good whole-food diet; regular exercise including strength training; dealing with stress and prioritising sleep, is going to be a good foundation. Feeling good in yourself means you’re much more likely to feel sexy and sexual.
Then, on top of that, seeking advice on hormonal therapy is a good next step. Systemic menopausal hormone therapy (MHT or HRT) can be life-changing, and it can lead to a boost in libido.
Why should I care about this?
If you’re feeling ‘meh’ about all this – and you feel like you’d be quite happy to never have sex again – all good. Everyone’s different, and you might be in a place where sex is not a priority. Don’t feel bad about that.
Just know: it doesn’t have to be that way forever; things may change in the future, with new relationships or other life changes. And there are benefits to regular sex. Research has found that women who have more orgasms tend to be more satisfied with their relationships. And solo sex is health-promoting, too. One local study found women regularly use masturbation to deal with stress, anxiety, depression and boredom. There’s evidence showing orgasms do good things: they induce feelings of calm; promote sleep; relieve pain and even improve skin.
The partner piece
Of course, a really important part of the puzzle of desire and pleasure is our relationship with our partners. Fixing all the physical things going on is one thing; fixing a relationship is another.
Smart describes the sad way perimenopause can affect relationships, if it’s not talked about; it’s something she sees regularly in her patients.
“You might be tired; your libido’s fallen off; you’re not really interested in having sex with your partner, but you’ll put up with it because it makes them happy”, she says.
“But then it becomes painful. And that’s like the straw that breaks the camel’s back, isn’t it? It’s one thing just putting up with it, but if it’s then going to cause you pain – it’s a ‘no, thank you very much’.
“And I’m not going to talk about it with [my partner], ‘cause I don’t really understand why it’s suddenly painful, and it’s probably something to do with me and I don’t want to go there. So let’s just stop having sex’. And then men, those sensitive creatures, think it’s all about them, and take it personally. And then we are just turning the other way in bed at night. We stop having sex; there’s a breakdown in intimacy; a breakdown in the relationship and knock-on effects on self-esteem.”
All the sex therapists I’ve talked to emphasise that as we experience changes in libido and sexual response, we’re also likely to need to make changes to how we have sex. That requires sometimes tricky but ultimately rewarding conversations, if we’re brave enough.
Some things to think about: if you’re having heterosexual sex, it’s time to de-emphasise penetration. Spending more time not on what we might think of as ‘foreplay’, but on ‘outercourse’ – whenever that happens – will lead to greater pleasure for everyone. Also: we might have been conditioned to believe that sex ends with a male climax; but that’s not the case. You can keep going. And related: most women won’t orgasm via penetration, so getting to know ourselves, our wonderful sexual anatomy and our own responses – and learning to ask for what we want – will yield those feel-good benefits (and orgasms).