Sex and the Menopause
Why sex & intimacy can change during the menopause - and what can help
For many women, changes in sex during perimenopause and menopause can feel difficult to talk about - even with a doctor. Reduced libido, discomfort during sex, vaginal dryness, difficulty reaching orgasm, or simply feeling disconnected from intimacy are all incredibly common experiences, yet they are still surrounded by unnecessary embarrassment and misunderstanding.
At Clinic51, these are conversations that we have every day. There is nothing to feel embarrassed about - you are not alone, and there is help available.
Menopause can affect sexual wellbeing in several different ways, and there is rarely one single cause or one simple fix. Hormones can play a role, but so can discomfort, stress, relationship dynamics, exhaustion, body confidence, and the realities of a very busy midlife – in which we are pulled in multiple directions.
The good news is that there are effective treatments, practical strategies, and evidence-based approaches that can make a real difference.
Let’s start by banishing a myth - there is no such thing as a ‘normal’ amount of sex
One of the biggest misconceptions we hear is the idea that there is a ‘correct’ or normal amount of sex people should be having.
In reality, healthy sexual relationships look very different from couple to couple. Some couples may have sex frequently, while others may have sex rarely and still feel completely happy and connected.
What matters is not what anyone else is doing — it is whether your current situation feels right for you.
Many women notice a reduction in libido during perimenopause or menopause but are not personally distressed by it. For others, it may affect confidence, intimacy, or relationships. Sometimes the issue is not low desire itself, but the pressure surrounding it.
This is why conversations around libido are often more nuanced than simply asking whether someone wants sex more or less often.
Why menopause can affect libido
Sexual desire is complex. It is influenced by hormones, physical comfort, mental wellbeing, stress levels, sleep, relationship satisfaction, body image, and emotional connection. Menopause can affect several of these factors at the same time.
For example:
Falling oestrogen levels can cause vaginal dryness and discomfort
Poor sleep and fatigue can reduce interest in intimacy
Anxiety and low mood can affect sexual desire
Painful sex can lead to fear or avoidance of intimacy
Long-term relationship patterns can make intimacy feel pressured or disconnected
This is why there is rarely one ‘magic fix’ for libido.
Instead, it is often about understanding the bigger picture and addressing the factors that are contributing.
Painful sex is extremely common - and treatable
One of the first and most important things we discuss with patients is whether sex has become uncomfortable.
Many women experiencing reduced libido are actually dealing with vaginal dryness, irritation, or pain during penetration. If sex hurts, it is completely understandable that desire may reduce over time.
This happens because declining oestrogen levels during menopause affect the tissues of the vulva, vagina, and bladder. The tissues become thinner, drier, and less elastic. Women may notice:
Vaginal dryness
Burning or irritation
Pain during sex
Reduced sensation
Recurrent urinary tract infections
Discomfort with smear tests
These symptoms are extremely common, but many women assume they are simply something they have to put up with.
They are not.
Vaginal oestrogen can be transformative
One of the most effective treatments for vaginal symptoms is vaginal oestrogen.
Unlike standard HRT, vaginal oestrogen works locally in the tissues of the vagina and vulva and is absorbed systemically in only tiny amounts. It helps restore moisture, elasticity, resilience, and the healthy vaginal environment.
Many women notice significant improvements in:
Comfort during sex
Lubrication
Vaginal irritation
Urinary symptoms
Recurrent UTIs
Comfort during smear tests
Importantly, vaginal oestrogen is considered very safe for long-term use and can usually be continued indefinitely if it is helping. In fact, many women continue using it well into older age because it can have such a positive impact on quality of life.
Looking after the vulval skin matters too
The vulval tissues become more sensitive during menopause, so gentle skincare becomes increasingly important. We often explain that the vulva should be treated more like the delicate skin of the lips rather than like the skin on the rest of your body..
Helpful changes to make include:
Avoiding soaps, scented washes, and feminine hygiene products
Using emollients instead of soap for washing
Wearing breathable cotton underwear
Using vulval moisturisers regularly
Many women also benefit from switching to gentler lubricants designed for sensitive tissues – and the type you choose is important.
Lubricants: Small changes can make a big difference
Lubricants are often overlooked, but using the right products — and using them well — can make sex significantly more comfortable. Unfortunately, some common supermarket lubricants contain ingredients that can irritate menopausal tissues.
For women not using condoms, oil-based lubricants may provide longer-lasting comfort. For those using condoms, water-based or silicone-based lubricants are safer options. We recommend YES lubricants which are formulated without harsh chemicals and using natural plant-based ingredients.
Sometimes, combining a vaginal and or vulval moisturiser, vaginal oestrogen, and a good-quality lubricant is enough to completely change someone’s experience of sex.
When the body learns to expect pain
After painful experiences, the body can subconsciously begin protecting itself.
The pelvic floor muscles may tighten automatically in anticipation of discomfort, making penetration increasingly difficult even after the tissues themselves have improved.
This is not ‘all in your head’ - it is a very normal protective response.
For some women, it helps to slowly rebuild confidence and comfort with intimacy in a gradual, pressure-free way. Others benefit enormously from seeing a women’s health physiotherapist who specialises in pelvic floor dysfunction and painful sex. We have a regular women’s health physiotherapy clinic here at Black Barn.
Intimacy does not have to mean intercourse
One of the most helpful concepts for many couples is understanding that intimacy and sex are not the same thing.
For couples who have fallen into patterns of pressure, anxiety, or avoidance around sex, it can help to step away from the expectation of intercourse altogether for a while.
That may mean:
Spending time cuddling
Holding hands
Kissing without expectation
Having date nights
Rebuilding affection and touch
Creating time for intimacy without pressure for sex
This can help couples reconnect emotionally and physically without fear or performance pressure.
For many women, desire is not always spontaneous. Instead, desire often develops gradually once intimacy, relaxation, safety, and connection are already present. Understanding this can remove a huge amount of anxiety.
Testosterone: Helpful for some women, but not a quick fix
There has been a great deal of discussion about testosterone recently, often presenting it as the answer to low libido during menopause.
Testosterone can absolutely help some women — but it is not the whole picture.
We usually consider testosterone when women continue to experience distressing low libido despite optimising their HRT and addressing other contributing factors.
It may be particularly helpful for women who notice:
A complete loss of sexual desire
Reduced sexual responsiveness
Difficulty becoming aroused
Difficulty reaching orgasm
However, testosterone will not automatically solve relationship difficulties, exhaustion, stress, painful sex, or lack of emotional connection. It is one piece of a much bigger puzzle.
Before considering testosterone, it is important to ensure oestrogen levels and general menopause symptoms are well managed.
Oestrogen itself plays an important role in sexual wellbeing. Women who feel less exhausted, sleep better, have fewer hot flushes, and feel more emotionally stable often notice improvements in libido even before testosterone is considered.
This is why menopause treatment is often a stepwise process rather than an instant fix.
What to expect from testosterone treatment
When testosterone is prescribed appropriately for women, the doses are very low and carefully monitored. It is not designed to create dramatic overnight changes. In fact, benefits can take several months to become noticeable.
Women considering testosterone should also understand that:
Blood tests are needed before and during treatment
Side effects are usually dose-related
Too much testosterone can cause acne, excess hair growth, scalp hair thinning, or mood changes
Not every woman notices a benefit
For the right person, however, it can be extremely effective.
Let’s talk about sex…. (with your GP…!)
Many women feel embarrassed raising sexual concerns with a doctor.
In reality, GPs and menopause clinicians discuss these issues regularly.
If you find it difficult to start the conversation, it can help to prepare a simple opening sentence beforehand, such as:
‘Sex has become painful
‘I’ve completely lost my libido
I’d like to enjoy intimacy again’
You do not need to use perfect terminology or explain everything immediately. Simply opening the conversation is enough.
The bottom line
A fulfilling sex life during and after menopause is absolutely possible.
For some women, the answer is treating vaginal dryness and discomfort. For others, it may involve optimising HRT, considering testosterone, improving pelvic floor function, rebuilding intimacy, or understanding how female desire actually works.
Most importantly, these symptoms are common, valid, and treatable.
You should not feel embarrassed to ask for help.
At Clinic51 Women’s Health Clinic, we believe conversations about sex, intimacy, and menopause should be treated as a normal part of women’s healthcare — because they matter enormously to quality of life, confidence, relationships, and wellbeing.
If you are experiencing pelvic health issues, including some of those listed above, we offer Post-Menopausal Pelvic Health packages, that include a consultation with a doctor and with our women’s health specialist physio.
Further Reading & Resources
Mind the Gap
How Not to Let Having Kids Ruin Your Sex Life
- Both by Karen Gurney
Come As You Are – Dr Emily Nagoski
TED X Talk by Dr Karen Gurney
All images free for commercial use, courtesy of Unsplash August 2026
