Sexual health is important to one’s overall sense of self and well-being, but it is important to note that there is no standard to meet when it comes to sexual activity and desire. Some experience a significant decline in desire at midlife, some have an increased interest, and others notice no change at all. Only you or your partner can know whether your sex life meets your needs.

Sexual Dysfunction

Sexual dysfunction can be a major disruptive force. There are four areas in which this may occur: sexual desire, arousal, orgasm, and sexual pain. These problems frequently overlap—for example, someone who doesn’t experience sexual desire may also experience difficulty with arousal or having an orgasm. 

• Sexual desire: Reduced production of estrogen at menopause causes hot flashes and night sweats. Not having restful sleep might reduce interest in sex. Falling estrogen levels result in vaginal dryness and thinning vaginal lining, making penetrative sex painful.  

• Hormone changes: These are only part of a complex set of factors that influence sexual activity at midlife and beyond. Social changes, such as changing partners (divorce, dating), children leaving home, adult children living at home, or the need to care for aging or ill parents, often take place at this time.  

• Partner sexual problems: These might also affect desire and factors such as changes in body image and self-esteem as well as concerns about aging. Sexual interest after menopause also depends on your past level of sexual interest.  

Medical problems: These may result in low sexual desire. Some medications, such as those used to treat depression, can interfere with sexual function. 

Sexual Challenges

Beyond sexual desire, there are three other categories of sexual problems for women: 

• Difficulty with arousal: Some women may find themselves unable to develop or maintain genital arousal.  

• Difficulty with orgasm: Whether a new development or a lifelong concern, some women may struggle to experience an orgasm.  

• Sexual pain: Pain can be caused by a number of factors. If caused by vaginal dryness, lubricants and vaginal moisturizers can help maintain moisture and reduce friction. Low-dose vaginal estrogen therapy (ET) is also an option. 

Seeking Help

Understanding these factors and sharing one’s sexual concerns with a healthcare professional can improve desire and sexual satisfaction. An evaluation by a professional can help identify any underlying medical or psychological causes of low sexual desire. Although many find it difficult to discuss their sexual problems, healthcare professionals are a good resource to help achieve optimal sexual health. Counseling can help in coping with difficult medical, relationship, or family issues contributing to sexual health concerns. Healthcare professionals also may help by referring you to clinicians who specialize in treating sexual concerns. 

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Drug Therapy

Many sexual problems can be successfully treated with prescription therapies. 

• Estrogen: Some women with vaginal dryness or pain with sexual activity may benefit from prescription ET, either low doses applied directly to the vulva and vagina or higher doses taken systemically. Systemic ET affects the whole body, providing relief not only from vaginal dryness but also from hot flashes and night sweats.  

• Intravaginal dehydroepiandrosterone: Intravaginal dehydroepiandrosterone is a local vaginal therapy that is beneficial for treating sexual pain caused by vulvar and vaginal changes related to menopause. 

• Ospemifene: The nonhormone oral medication ospemifene (a selective estrogen-receptor modulator) is approved to treat symptoms of genitourinary syndrome of menopause, thus alleviating vaginal dryness and pain associated with sexual activity. 

• Flibanserin: This medication is approved in the United States and Canada to treat low sexual desire in premenopausal women. It works by reducing serotonin activity and increasing the activity of dopamine and is taken daily at bedtime.  

• Bremelanotide: This nonhormone medication, delivered via an auto-injector (like an EpiPen) is approved in the United States to treat low sexual desire in premenopausal women.  

• Testosterone: There is evidence that testosterone may help with low sexual desire in both perimenopausal and postmenopausal women. Adverse events such as acne and facial hair growth may occur, and long-term risks are still being investigated.  

Treatment of a partner’s sexual problems may be important to improving a woman’s sexual function and satisfaction. 

Practice Safe Sex

Sexuality doesn’t—and shouldn’t—end with menopause. Still, even with advancing age, safe sex is critical. After menopause and without the risk of pregnancy, it’s easy to let protected sex slide. But anyone who is not in a long-term, monogamous relationship and has unprotected sex is at risk of sexually transmitted infections (STIs). You need to be aware of the many infections you can get and take the necessary precautions. Postmenopausal women are especially vulnerable to STIs because having fragile vulvar tissues can allow these viruses to enter the body more easily.  

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