Sex after menopause can mark a new chapter in your life, full of both positive changes and unique challenges.
First, the good news: Your sex life may get better once you’re no longer dealing with periods.
“You may find that your sex life is improved when you don’t have the ebbs and flows of menstrual cycles and if you reduce the anxiety around pregnancy,” says UNC Health family nurse practitioner Stephanie Roberts.
Now, the not-so-good news: You may have to address some common challenges of menopause to achieve a satisfying sex life.
“Menopause can affect a person’s sex life in a several different ways,” Roberts says. “You might already have factors like your work, relationship and other stressors affecting your desire to have sex, but then you add on menopausal symptoms like fatigue, hot flashes, weight gain and vaginal dryness. Together, that’s going to have an impact.”
While these changes can be difficult, Roberts says there are solutions if you speak to your provider. Here’s what you need to know.
Sexual Problems During Menopause
The fluctuating levels of estrogen during perimenopause (the years before your period stops) and the flattened levels post-menopause (after you’ve been without a period for a year) cause a variety of symptoms in the body, such as night sweats, mood issues and joint pain. Those changes in estrogen also have a major impact on the vulva and vagina.
“The vagina and vulva are sensitive to estrogen,” Roberts says. “In puberty, estrogen causes changes that lead to the full development of the vagina and vulva, but in menopause, it causes them to start to lose elasticity and stretchiness. It also can affect the urinary system.”
These vaginal and urinary tract changes are cumulatively known as genitourinary syndrome of menopause. Urinary symptoms include urgency or incontinence and painful urination, and some women experience more frequent urinary tract infections. Vaginal symptoms include dryness, irritation and discomfort, which can be experienced at any time throughout the day, but during sexual activity, these changes can cause difficulty with arousal, lubrication and orgasm, and pain and bleeding.
Roberts says these vaginal changes are more common in the decade after menopause, but they can happen during perimenopause as well.
Other symptoms of menopause may affect your desire to have sex.
“Any big hormone shift has an increased risk of anxiety and depression, which can affect your libido,” Roberts says. “If you’re having difficulty sleeping, that’s going to have an impact on your mental and emotional well-being. It all plays a role.”
Improving Your Sex Life During Menopause
Everyone’s relationship to sex is different, so for some, changes in libido might not be a problem. But if you have concerns about your sex drive or difficulties with intercourse and you want to have sex, Roberts encourages you to talk to your provider.
“It could be as simple as changing lubricants, because some women become more sensitive to lubricants and can’t tolerate ones they were previously using,” she says. “There are a lot of treatment options available, but it’s important to be evaluated and have someone take a look at everything thoroughly.”
Your provider will consider the big picture—some vaginal irritation might be a yeast infection, rather than an effect of menopause. Some medications for other conditions can affect sex drive.
“The treatment will depend on what’s going on and the most bothersome symptom,” Roberts says. “If someone has a lack of sex drive, but they’re not sleeping, the first treatment might need to address sleep. If depression or anxiety is impacting sex drive than an antidepressant can help some people, or changing antidepressants can help. Pelvic floor physical therapy can be a great resource if muscle tension, painful intercourse or urinary frequency is an issue.”
Roberts says there are also prescription medications that increase sex drive in women that you can ask your doctor about, but she advises caution about any over-the-counter supplement promising it can improve libido, as these supplements are not regulated by the Food and Drug Administration and don’t have any clinically documented benefit.
Many of the symptoms associated with genitourinary syndrome of menopause, including UTIs, urinary urgency and vaginal discomfort, can be addressed with a prescription for local hormone therapy, such as estrogen creams, rings or tablets that are applied directly to the vagina.
“Estrogen cream inserted into the vagina two times a week goes a long way to help tissue regain elasticity and become a little thicker,” Roberts says. “Because it’s topical, you absorb very little systematically, so it’s very safe.”
While systemic menopause hormone therapy, delivered through a patch or pill, may help with these and other menopause symptoms, the local application is considered most effective for these specific vaginal and urinary symptoms. Many women use both systemic and topical estrogen therapies to manage changes during menopause. But because the absorption of vaginal estrogen is minimal, women who aren’t pursuing systemic menopause hormone therapy because of other health concerns, such as a history of breast cancer, are sometimes able to use local estrogen—if their oncologist gives the OK.
You can also help to maintain your vaginal tissue by making a point to regularly engage it, whether you’re solo or partnered.
“Any vaginal stimulation, from a vibrator or toy or from a partner, can be very helpful to maintaining those tissues, because those tissues can be kind of ‘use-it-or-lose-it,’” Roberts says. “Frequent activity is helpful to the tissue, but every person is different, so there’s not a right answer for how frequent that needs to be. It really depends on the person or couple as to what’s enough.”
If you find you can’t tolerate vaginal or vulvar stimulation due to pain or discomfort, or you’re never in the mood and want to be, talk to your health care provider.
“Don’t just throw it under the rug or ignore it if anything is impacting your ability to function or your ability to live life to the fullest,” Roberts says. “All of these things—lack of desire, pain, discomfort, difficulty achieving orgasm—can be addressed, and if you feel your health care provider isn’t listening to you on this, find someone else.”
If you’re experiencing discomfort or pain with sexual activity, talk to your provider. If you need a health care provider, find one near you.