Sexuality during menopause

At Evela, sexual health is not a marginal topic. Apart from sleep disturbances, hardly any other area runs as consistently through our consultations as changes in desire, arousal, and intimacy—especially among perimenopausal women. And yet sexuality is often treated as secondary in everyday medical practice: as a “nice-to-have,” as a relationship issue, or as something that simply has to be accepted with increasing age.

This classification falls short. Sexuality is not a luxury. It is an integral component of physical, mental, and social health—and therefore a relevant factor for healthy longevity. Leading experts now understand sexual health as part of a holistic longevity concept: it influences sleep, cardiovascular health, stress regulation, self-image, and relationship stability.

This article aims to provide clarity. About your body. About desire. About pain. And about the evidence-based medical options available today.

Sex is more than a moment of pleasure. It is a biopsychosocial process with measurable effects on central body systems.

After sexual arousal, and especially after orgasm, the nervous system shifts from activation (sympathetic) to regeneration (parasympathetic). Neurotransmitters such as oxytocin, prolactin, and dopamine promote relaxation, lower resting heart rate, and shorten the time it takes to fall asleep. Many women intuitively report: “Afterwards, something lifts off me.” That is not imagination, it's neurobiology.

Sexual activity corresponds to approximately 6–7 METs of moderate physical exertion. MET stands for “metabolic equivalent” and describes how much energy expenditure increases compared to resting state. 6–7 METs means the body uses six to seven times as much energy as at rest—comparable to brisk walking, tennis, or light jogging.

In longevity medicine, we often ask about the “marginal decade”: what would you like to still be able to do in the last ten years of your life? For many people, physical closeness and sexuality are naturally part of that. To enjoy them, sufficient cardiovascular capacity, muscular strength, and functional stress regulation are required—abilities that can be trained and maintained.

How often couples have sex varies widely and decreases with age. Population-based surveys from Europe and North America show that among 30–39-year-olds, about 45–55% of couples report having sex once or several times per week. Among 40–49-year-olds, this drops to about 35–45%, and among 50–59-year-olds to around 25–35%. This decline is normal and, in itself, not an indication of a problematic relationship.

What is more decisive for relationship satisfaction is not frequency but discrepancy in sexual desire. Sexual Desire Discordance describes a persistent mismatch in sexual need between two partners, when one person wants significantly more or significantly less sex than the other. Research in couples and sexuality shows that this discrepancy is one of the strongest predictors of relationship stress, emotional distance, and intentions to separate—stronger than low sexual frequency itself.

During perimenopause, typically between ages 40 and 55, about 50–60% of women report declining sexual desire. What is often distressing is not the idea of “not satisfying” a partner, but the loss of closeness, intimacy, and connection. Sexuality has a biochemical bonding effect, among other things through oxytocin, and creates a form of closeness that emotional connection or friendship alone often cannot fully replace.

A central and often relieving point is understanding that female sexual desire often functions differently from male desire. While social narratives often describe desire as spontaneous and “just there,” research paints a more differentiated picture.

Spontaneous desire—wanting sex without any external trigger (“I feel like it right now”)—applies long-term to only about 10–15% of women. It is more common in younger women or in very early relationship phases. For the majority, this model is not a realistic benchmark.

Far more common is responsive desire. Here, desire does not precede arousal but arises as a response to stimulation—physical or emotional. A helpful metaphor is the well-known party example: You sit tired on the couch in the evening and don’t feel like going out. You go anyway, and once there, with music, conversations, and atmosphere, enjoyment arises. Responsive sexual desire works the same way. You do not need to feel desire in advance—you only need to be open to the possibility that it might emerge.

Instead of waiting for spontaneous desire, it can be helpful to actively cultivate arousal. Desire does not arise in a vacuum—it requires stimuli, safety, and often relief from stress.

• Curating arousal: Consciously initiating arousal, for example through touch, fantasy, reading, audio, or aids, and observing whether desire follows.

• Stress reduction as real foreplay (“Chore Play”): Mental overload is one of the strongest libido killers. Relief lowers cortisol levels and creates the space in which arousal can arise. Crucially, this should not be transactional—pressure or expectation inhibits desire.

• Mindfulness: Staying present in the moment and gently redirecting attention to physical sensations whenever thoughts drift.

This perspective reduces pressure and shifts the focus from “Why don’t I feel desire?” to “Under what conditions can desire arise?” Structured psychological interventions, such as cognitive behavioral therapy, can also effectively support sexual concerns during menopause, particularly in cases of avoidance behavior or anxiety-related inhibition of arousal (1).

Female sexual anatomy is often underestimated or oversimplified. The clitoris is not a small point but a complex organ. Its legs, the so-called crura, extend deep into the pelvis and run along the vaginal walls. During sexual arousal, these structures swell and the surrounding tissue fills with blood. This explains why vaginal stimulation is indirectly clitoral for many women.

The type of nerve supply also changes with age. Fine C-fibers, which primarily respond to gentle touch, lose sensitivity with hormonal changes. A-fibers, which respond to pressure and vibration, remain more stable. This is why stronger stimulation or vibration is often perceived as more pleasurable over time. In this context, vibrators are not a “replacement” or “cheating,” but a neurobiologically meaningful aid in supporting orgasmic capacity.

Another important point is the so-called orgasm gap. Only about 30% of women reach orgasm through penetration alone. This is not a deviation, it is the norm. The often-mentioned G-spot anatomically usually corresponds to the internal clitoris on the anterior vaginal wall, about one-third of the way in, where the tissue often feels slightly textured.

Finally, time plays a central role. Arousal is a physiological process that does not occur instantly. Only after about 15–20 minutes does so-called “tenting” occur: the vagina becomes longer, wider, and better lubricated as the cervix moves upward. If this process does not occur, penetration can be painful. Foreplay is therefore not a matter of romance or technique, but a form of pain prevention.

More than 70% of women develop vaginal dryness during peri- and postmenopause. Medically, it is part of the so-called Genitourinary Syndrome of Menopause (GSM). This term summarizes the hormone-related changes in the vagina, vulva, urethra, and bladder that occur due to declining estrogen levels (2). It is not merely a moisture problem, but a structural change in tissue.

Due to estrogen deficiency, the vaginal lining becomes thinner, less elastic, and less well supplied with blood. At the same time, pH levels rise, the protective vaginal environment changes, and barrier function decreases. Typical consequences include dryness or burning sensations, pain during sex, micro-injuries, recurrent irritation, and increased susceptibility to urinary tract infections. Many women gradually withdraw from sexual activity—not because of lack of desire, but because of fear of pain.

Importantly, these changes are progressive. Unlike vasomotor symptoms such as hot flashes, they generally do not improve without treatment but worsen over time.

Lubricants and vaginal moisturizers can relieve symptoms short-term by reducing friction and improving comfort during sex. However, they do not treat the cause. They do not rebuild the mucosa, normalize the local environment, or prevent progressive tissue changes. In this sense, they are supportive but not therapeutic (3).

The evidence for local estrogen, however, is clear. Intravaginal estrogen is more effective than non-hormonal options and has been shown to improve dryness, pain during sex, and mucosal structure (4). The doses used are low, the effect largely local, and systemic effects minimal. Even in women with a history of breast cancer, current data show no increased risk of recurrence or mortality (5,6). Against this background, many experts increasingly argue that vaginal estrogen should be the rule rather than the exception, since nearly all women develop urogenital changes with age.

Systemic menopausal hormone therapy often affects sexuality indirectly. Estrogen can improve sleep, mood, and vasomotor symptoms, thereby creating important prerequisites for closeness, energy, and renewed sexual interest. However, estrogen is usually not the primary driver of sexual desire itself.

In women with persistent distress due to significantly reduced sexual desire, testosterone may play a relevant role. Testosterone is also an important female hormone whose levels decline significantly with age. Studies show that low-dose, physiological testosterone therapy in women with hypoactive sexual desire disorder can improve desire, arousal, and sexual satisfaction (7). The goal is not “more,” but an age-appropriate, physiological hormone level.

Such therapy requires careful indication, baseline hormone assessment, and regular clinical and laboratory monitoring. Crucial is not the lab value alone, but the combination of measurable changes and the woman’s subjective experience. When used appropriately testosterone can be a meaningful addition, once other factors such as sleep, pain during sex, or relationship dynamics have already been addressed.

1. Green SM et al. Cognitive behavioural therapy for sexual concerns during menopause: evaluation of a four session protocol. J Sex Med. 2025; qdaf085.
   

2. Pitkin J; British Menopause Society medical advisory council. BMS Consensus Statement. Post Reprod Health. 2018;24(3):133–138.
   

3. Sarmento ACA et al. Use of Moisturizers and Lubricants for Vulvovaginal Atrophy. Front Reprod Health. 2021;3:781353.
   

4. Ali A et al. Efficacy and Safety of Intravaginal Estrogen in the Treatment of Atrophic Vaginitis: A Systematic Review and Meta-Analysis. J Menopausal Med. 2024;30(2):88–103.
   

5. Beste ME et al. Vaginal estrogen use in breast cancer survivors: a systematic review and meta-analysis of recurrence and mortality risks. Am J Obstet Gynecol. 2025;232(3):262–270.e1.
   

6. McVicker L et al. Vaginal Estrogen Therapy Use and Survival in Females With Breast Cancer. JAMA Oncol. 2024;10(1):103–108.
   

7. Uloko M et al. The clinical management of testosterone replacement therapy in postmenopausal women with hypoactive sexual desire disorder: a review. Int J Impot Res. 2022 Nov;34(7):635–641. doi:10.1038/s41443-022-00613-0.