Sexual health is more than desire
Sexual health extends far beyond just libido and orgasm. The World Health Organization (WHO) defines sexual health as “a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity.” (1).
Menopause is a natural biological process that marks the end of a woman’s reproductive years. It typically occurs in midlife, usually between the ages of 45 and 55, although the timing can vary.
It is a natural transition that occurs when a woman has gone at least 12 consecutive months without menstruating.
During menopause, a woman’s ovaries stop releasing eggs and produce lower levels of hormones like oestrogen and progesterone, leading to various physical and hormonal changes.
Although many women continue to have enjoyable sex late into their lives, some changes come along with menopause that may affect a woman’s sexuality.
Some of the changes that women may encounter during menopause include:
- vulval and vaginal dryness, less lubrication and less vaginal ‘stretchiness’, which can lead to discomfort or pain during penetrative sex,
- vulval and vaginal soreness and irritation, and thinning of the tissues, making the area sore to touch,
- changes in the sensitivity of erogenous zones, particularly the clitoris, either becoming less sensitive or highly sensitive in an unpleasant way,
- more urinary tract infections or bouts of thrush,
- a drop in levels of sexual desire.
How menopause changes sexual health
Hormonal shifts during and after menopause
Hormone fluctuations refer to normal changes in hormone levels that occur during puberty, menstrual cycles, pregnancy, and perimenopause.
Hormone levels can fluctuate daily, monthly, or throughout various stages of a person's life.
The two main female sex hormones are oestrogen and progesterone. Although testosterone is considered a male hormone, females also produce and require a small amount of it.
During perimenopause, the ovaries begin to produce less oestrogen and progesterone, with oestrogen levels dropping significantly. A perimenopausal woman’s hormones fluctuate unpredictably.
During menopause, levels of oestrogen, progesterone, and testosterone fall.
A decline in oestrogen and progesterone levels leads to changes in vaginal health. Lower testosterone is linked with decreased sexual desire (libido) after menopause.
Postmenopause is the time after menopause, when a woman hasn’t experienced a period for over a year. Postmenopausal women experience persistently low levels of oestrogen and progesterone while testosterone levels gradually decline with age.
Hormone-dependent sexual tissue
Vaginal, vulval, clitoral, and urethral tissues are highly hormone-responsive and particularly sensitive to changes in oestrogen levels.
During perimenopause and menopause, declining oestrogen levels can lead to thinner, drier, and less elastic vaginal tissues.
These changes often reduce the natural lubrication that makes sex more comfortable and contribute to vaginal dryness and discomfort during sex.
Oestrogen depletion leads to vascular changes in the genital area, reducing blood flow to the clitoris and surrounding tissues. This limits their ability to engorge during arousal, a process critical for sexual pleasure.
Lower oestrogen levels also affect the urethra and bladder. Thinning and increased sensitivity of bladder tissue can contribute to urinary symptoms such as urgency, increased frequency, or urinary leakage, which may further interfere with sexual comfort and confidence.
Thus, sexual discomfort after menopause is often primarily biological, reflecting hormone-dependent changes rather than psychological causes.
Genitourinary syndrome of menopause and sexual function
When a woman goes through menopause, her oestrogen levels decrease along with the levels of other sex-steroid hormones.
These decreases can lead to changes in certain areas of her body, such as the vagina, vulva, and bladder.
For example, oestrogen helps keep the vaginal tissues moist and flexible. But when oestrogen levels decline, the vagina can become dry, pale, and inelastic, and it may feel tight.
These hormonal drops can lead to a group of genital and urinary symptoms that are called genitourinary syndrome of menopause (GSM).
GSM is defined as a collection of symptoms and signs associated with a decrease in oestrogen and other sex steroids, involving changes to the vagina, labia majora and minora, clitoris, vestibule and introitus, urethra and bladder (2).
Symptoms may include:
- Vaginal dryness, burning sensations, and pain or irritation in the genital area,
- Poor vaginal lubrication during sex, discomfort or pain with intercourse, and impaired sexual function,
- An urgent need to urinate, painful urination, or recurrent urinary tract infections (UTIs).
GSM is highly prevalent, affecting over half of postmenopausal women. The condition is progressive, and frequently, symptoms worsen over time without treatment (3).
Different treatment options — ranging from nonhormonal lubricants and moisturisers to hormone replacement therapy — are available to alleviate symptoms and improve quality of life (3).
UTIs, infection risk, and sexual well-being
Why urinary tract infections increase after menopause
Urinary tract infections (UTIs) are common bacterial infections that affect the urinary system and occur more frequently in women.
The most common symptoms of UTIs include:
- painful urination,
- frequent urge to urinate,
- lower abdominal pain.
Menopause is a predominant risk factor for recurrent urinary tract infection (rUTI), and the urogenital microbiome changes as women age, often reducing a woman’s natural defence mechanisms against UTI (4).
Lactobacillus, a type of bacteria that produces lactic acid, thus lowering pH, helps establish a vaginal microbiome that can protect against other bacteria and pathogens.
During menopause, reduced oestrogen levels lead to a decline in Lactobacilli and a corresponding rise in vaginal pH.
This combination creates an environment that is more vulnerable to infection.
The impact of recurrent infections on sexual confidence and activity
Recurrent UTIs can have a significant impact on sexual function due to the pain, discomfort, and psychological stress they cause.
Studies show that women with rUTIs report significantly lower sexual satisfaction and higher rates of sexual dysfunction (5).
There is a significant social stigma surrounding urogenital infections. For many women, discussing urogenital issues is often not culturally acceptable, which can lead to feelings of shame and embarrassment (6).
Urogenital infections can affect mental health. These mental health impacts range from stress to depression and anxiety, and are more pronounced in women who experience recurrent episodes (6).
Why infection prevention is part of sexual health
Prevention plays a key role in reducing the risk of UTIs. One can reduce the recurrence of UTIs through preventive measures like proper hygiene, staying hydrated, and urinating before and after sexual intercourse.
Individuals who are not in a long-term, monogamous relationship and engage in unprotected sex are at increased risk of sexually transmitted infections (STIs).
Postmenopausal women are especially vulnerable to STIs because having fragile vulval tissues can allow these viruses to enter the body more easily.
Therefore, practicing safe sex remains essential at any age, even though pregnancy is no longer possible.
Why lubrication alone may not fully address sexual symptoms
Many postmenopausal women experience vaginal or vulval dryness, thinning of the tissues (atrophy), and pain during sexual intercourse.
To help with these symptoms, lubricants can be used during sexual activity as short-acting relief, while moisturisers are designed for daily use, similar to facial or body moisturisers.
When choosing lubricants or moisturisers, make sure to read the labels carefully.
Avoid ingredients such as glycerine (which may increase the risk of yeast infection), parabens (especially if you have a history of hormone-sensitive cancer), fragrances, propylene glycol, and sodium lauryl sulphate (SLS), as they can disrupt the natural balance of bacteria in the vagina and potentially cause irritation or infection.
However, there are some limitations to what lubricants and moisturisers can achieve for postmenopausal women experiencing GSM.
Lubricants and moisturisers will not be effective in treating the underlying cause of GSM, which is best addressed with prescription therapies including oestrogens and prasterone (topical dehydroepiandrosterone, DHEA).
Hormone support and sexual tissue health
Local hormone therapy refers to hormone treatment that is applied directly to the vulva or vaginal area to relieve the symptoms associated with GSM.
It delivers small doses of oestrogen, DHEA, or oestrone directly to the vaginal tissues.
This targeted approach is preferred because it:
- Restores moisture and elasticity to vaginal tissues,
- Provides more effective relief for GSM symptoms,
- Minimises the risk of systemic side effects (e.g., blood clots, increased cancer risk),
- Avoids the higher risks associated with oral hormone therapies.
Local hormone products are typically prescribed in a vaginal ring, tablet, or cream.
Unlike oral pills, which are systemic (meaning they affect your entire body), localised treatments deliver low doses of hormones only to the affected areas.
This type of delivery can, in many cases, also provide faster and more effective relief than oral pills alone. There’s no need to wait for the medication to travel through the bloodstream; it starts taking effect right away.
Local hormone therapy is typically safe for long-term use. This is different from systemic hormone therapy, where risks increase as someone ages.
DHEA
In the last decade, intravaginal formulations containing DHEA have been approved in the United States and Europe.
Within the vaginal tissue, DHEA is metabolized into oestrogens and androgens, both of which have been shown to enhance female sexual function, including sexual desire, arousal, and pleasure.
In menopausal women with severe vulvovaginal symptoms, intravaginal DHEA has shown significant beneficial effects in vaginal atrophy and possible improvement in sexual function (7).
However, at this time, no benefits of oral DHEA therapy have been demonstrated, and studies with larger sample sizes are required to evaluate its safety and efficacy in premenopausal and postmenopausal women (7).
Conclusion: sexual health is about comfort, function, and quality of life
Sexuality doesn’t — and shouldn’t — end with menopause. The narrative that menopause means the end of sexual pleasure is outdated, harmful, and simply untrue.
Understanding menopause sexual health is the first step toward reclaiming your intimate life and discovering that this transition doesn’t mean the end of pleasure, connection, or satisfaction.
While menopause does bring changes to your body, these changes are manageable, treatable, and absolutely not something you need to suffer through in silence.
The key is recognising that these changes are medical conditions with medical solutions, not inevitable consequences you must endure. They’re gradual, giving you time to adapt and seek solutions.
With the right knowledge, support, and medical care, your intimate life can continue to be fulfilling and enjoyable.
Literature sources:
- World Health Organization. Sexual health and well-being [Internet]. Geneva: World Health Organization; [cited 2025 Jan 21]. Available from: https://www.who.int/teams/sexual-and-reproductive-health-and-research-(srh)/areas-of-work/sexual-health
- Portman DJ, Gass ML, Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society. Menopause. 2014 Oct;21(10):1063–1068. doi:10.1097/GME.0000000000000329.
- Carlson K, Nguyen H. Genitourinary syndrome of menopause. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan– [updated 2024 Oct 5; cited 2025 Jan 21]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559297/
- Jung C, Brubaker L. The etiology and management of recurrent urinary tract infections in postmenopausal women. Climacteric. 2019 Jun;22(3):242–249. doi:10.1080/13697137.2018.1551871.
- Medina-Polo J, Guntiñas-Castillo A, Arrébola-Pajares A, Juste-Álvarez S, de la Calle-Moreno A, Romero-Otero J, Rodríguez-Antolín A. Assessing the influence of recurrent urinary tract infections on sexual function: a case-control study. J Sex Med. 2025 Apr 8;22(3):454–463. doi:10.1093/jsxmed/qdae198.
- Thomas-White K, Navarro P, Wever F, King L, Dillard LR, Krapf J. Psychosocial impact of recurrent urogenital infections: a review. Women’s Health. 2023;19:17455057231216537. doi:10.1177/17455057231216537.
- Tang J, Chen LR, Chen KH. The utilization of dehydroepiandrosterone as a sexual hormone precursor in premenopausal and postmenopausal women: an overview. Pharmaceuticals (Basel). 2021 Dec 29;15(1):46. doi:10.3390/ph15010046.
