Sexual health changes during menopause are common, yet most women never discuss them, with a partner or with a clinician. In short: lower desire, vaginal dryness and pain during sex have real hormonal causes, and safe, effective treatments exist that can bring back comfort and pleasure. You do not have to put up with it in silence.

What changes:

  • Decreased sexual desire (libido)
  • Decreased arousal and natural lubrication
  • Pain or discomfort during intercourse (dyspareunia)
  • Difficulty reaching orgasm
  • Changes in sexual satisfaction and in how you feel about your body

Desire is not a single thing:

Desire is usually described as if it were one feeling that switches on by itself. In practice there are at least two kinds, and it helps to know which one you are missing.

Spontaneous desire arrives out of nowhere and creates the interest. Responsive desire arrives after something has started — touch, closeness, time, a relaxed evening — so the wanting follows the arousal rather than preceding it. Both are normal. Responsive desire is common in midlife and after menopause, and it is common in long-term relationships at every age.

This matters because it changes the question. If you are waiting to feel a spontaneous spark before doing anything, you may conclude that your desire has gone when it has only changed shape. It also means that context is not an excuse; it is part of the mechanism. Privacy, time, not being exhausted, feeling well in your body and feeling close to your partner are the conditions in which responsive desire shows up. Remove all of them and it will not, whatever your hormones are doing.

None of this makes unwanted sex acceptable, and desire that never arrives is still worth investigating. But desire is not a single switch, and its absence on a Tuesday evening says less about you than it seems to.

Why it happens at menopause:

Both oestrogen and testosterone decline gradually with age, and sexual tissues respond directly to these hormones. Oestrogen keeps the vaginal lining healthy, lubricated and sensitive; when levels fall, the tissues become thinner, drier and more fragile — a change called menopausal vulvar and vaginal atrophy, part of the genitourinary syndrome of menopause (GSM). Testosterone, though present in women in far smaller amounts than in men, supports sexual desire. The SWAN Study has documented these changes extensively and found that sexual pain is one of the most consistent GSM symptoms across ethnic groups — a reminder that this is biology, not something wrong with you or your relationship. Context matters too: broken sleep, stress, fatigue and low mood during the transition can all amplify how these physical changes feel.

What else can cause the same symptoms:

The menopause transition is the most likely explanation for these changes at midlife, but it is not the only one, and treating everything as hormonal can hide something that would respond to different help. Worth separating out:

  • Dryness and soreness that built up slowly over months fits the pattern of falling oestrogen. Symptoms that came on suddenly, or that come with an unusual discharge, itching or odour, may have another cause and should be examined rather than assumed.
  • Pain at the entrance to the vagina is often about thin, dry tissue. Pain deeper inside, or pain that feels muscular, is more often about the pelvic floor and the way it has tightened in response to pain.
  • Pain that happens only in certain positions, or only with a particular partner, points somewhere different again.
  • Low desire with normal comfort and normal arousal is more likely to involve mood, fatigue, stress, relationship strain or a medicine than the vaginal tissue itself.
  • A medicine you take for something else can affect desire, arousal or orgasm. It is worth asking your prescriber to review the list, rather than stopping anything yourself.

The point is not to self-diagnose. It is to arrive with a description precise enough that the right thing gets looked at.

The pain cycle, and why it escalates:

Pain during sex rarely stays the same size. It tends to grow, and the reason is mechanical rather than psychological.

When the vaginal lining is thin and dry, friction causes small breaks and a burning soreness. The body learns to expect pain. The muscles around the vagina and the pelvic floor tense in advance, as a guard. A tight pelvic floor reduces blood flow and lubrication further, so the next time hurts more and the guarding gets stronger. Fear of pain joins in, anticipation rises, and sex becomes something to be got through.

Two things follow. First, the pain is not in your head. It begins in the tissue and it is worsened by a real muscular response. Second, because the loop tightens, waiting usually makes it worse. Starting treatment earlier is easier than starting later.

What The Menopause Society says about treatment:

  • Low-dose vaginal oestrogen relieves vaginal dryness and sexual pain caused by menopausal vulvar and vaginal atrophy
  • Ospemifene (a SERM) is approved to treat GSM
  • Flibanserin is approved for low sexual desire only in premenopausal women — not in postmenopausal women
  • Transdermal testosterone therapy is used in Australia and the UK for low libido; it is generally safe at appropriate doses but is not FDA-approved for women in the US
  • Regular vaginal sexual activity after menopause stimulates blood flow, maintains vaginal muscle tone and preserves vaginal length and stretchiness

What helps in practice:

  • Vaginal moisturisers and lubricants — give immediate relief and can be used as often as you like
  • Low-dose vaginal oestrogen — treats the underlying tissue changes and is very safe
  • Ospemifene (SERM) — an oral option for moderate-to-severe dyspareunia
  • Pelvic floor physiotherapy — can significantly improve sexual function
  • Couples counselling or sex therapy — valuable when the psychological side is significant

Everyday tips:

  • Do not wait until the discomfort becomes severe before seeking help
  • Longer foreplay and stimulation help arousal and natural lubrication
  • Silicone-based lubricants last longer and work well in water
  • Talk openly with your partner — silence tends to make things worse
  • A 2023 study in the International Journal of Transgender Health notes that non-binary and transgender people also experience menopause-related sexual health changes and often struggle to find supportive resources

Talking with a partner:

Most couples avoid this conversation for a long time, and the silence does its own damage. A partner who notices you pulling away without knowing why tends to invent an explanation, and it is rarely the right one.

A few things make the conversation easier:

  • Talk outside the bedroom, and outside the moment. Raising it while you are both already in bed, and already disappointed, rarely goes well.
  • Be concrete rather than apologetic. "Intercourse has started to hurt and I am getting it looked at" is easier to respond to than a general sense that something is wrong.
  • Say what still works before you say what does not. There is usually more of it than you think, and it gives you both somewhere to start.
  • Make the problem shared, not personal. This is a change in your body, not a verdict on your partner or your relationship.
  • Bring practical things into the conversation: lubricant, changes to what you do, and what you would like to try next.

Many couples find that once the subject is open, sex becomes easier rather than harder, because the pressure to perform and the fear of causing pain both drop.

Raising it with a clinician:

This is the conversation most women never have, and it is rarely for lack of wanting one. Clinicians are often reluctant to raise sexual symptoms themselves, so the subject usually has to be opened by you.

  • Say it at the start. "There is something else I want to discuss" takes a moment, and it stops the topic being squeezed into the last minute.
  • Use straightforward words. Dryness, pain, discomfort, sex, desire. Vague terms get vague answers.
  • Describe what happens, not what you think it means. "It burns for a while afterwards" is more useful than "I think something is wrong with me".
  • Say how it is affecting you, if it is. Sleep, mood, a relationship, your sense of yourself. These are legitimate reasons to seek help, not an afterthought.
  • Ask what the options are, and ask about the ones you have read about. It is reasonable to say you would like to discuss a particular approach.
  • If the response is dismissive, ask again or ask someone else. This is a recognised area of medicine with recognised treatment, and a practice with an interest in menopause or sexual medicine will be more used to the conversation.

What to have ready before the conversation:

A short note, written at home, does most of the work. It is easier than trying to construct a description while you are sitting on an examination couch.

  • What changed, and when it started
  • Where it hurts, or where you feel the dryness, and whether it is at the entrance or deeper
  • What it feels like — burning, tearing, aching, tightness
  • When it happens — every time, sometimes, only with penetration, only afterwards
  • What makes it better, including lubricant, moisturiser, time or a change in what you do
  • Whether you have noticed any bleeding, discharge, itching or odour
  • How your sleep, mood and energy are
  • Every medicine you take, including anything prescribed by someone else
  • How long since your last period, and whether your cycle has changed
  • What you would like to be different, in your own words

Take it with you on paper. Reading from it is allowed, and it makes the appointment shorter rather than longer.

If you are single, or not sexually active:

These changes are not caused by being in a relationship, or by how often you have sex. The tissue changes of GSM happen because oestrogen has fallen, and they happen to women who are single, women who are not sexually active, and women who have no interest in being sexually active.

They still deserve treatment. Dryness and soreness can make everyday life uncomfortable, and the urinary symptoms that belong to GSM are a reason to seek help on their own. Nothing about this conversation requires you to be having sex, or to want to.

If you are not currently sexually active, say so to the clinician. It is relevant to what they suggest, and it should not change whether you are offered help.

When to see a clinician:

Pain during sex is not normal at menopause and does not need to be endured — it is a treatable symptom. Seek help if dryness persists despite lubricants, if sex hurts, if low desire is affecting you or your relationship, or if you simply want to know your options; a gynaecologist or a sexual medicine specialist can guide you. One point that is often missed: postmenopausal women are more vulnerable to sexually transmitted infections, because fragile vulvar tissues let viruses enter more easily — so protection still matters.

Beliefs that keep women silent:

  • "It is just part of getting older." Ageing is why it happens. It is not a reason to accept it, any more than ageing is a reason to accept a broken hip.
  • "It means I do not love him any more." Desire and love are separate systems. A body that has changed is not a relationship that has failed.
  • "It is too small a thing to bother a doctor with." It is affecting your sleep, your relationship or your mood, or you would not have read this far. That is reason enough.
  • "My doctor will ask if there is a problem." They often do not. Not out of indifference, but because these questions are not always built into a short appointment.
  • "Using lubricant means something is wrong." Lubricant is a practical tool, not a verdict. Reading glasses do not mean your eyes have failed your marriage.
  • "If I bring it up, hormone therapy will be decided for me." Bringing it up opens a conversation about options. It does not commit you to any of them.

In short:

Menopause changes desire, lubrication and sexual comfort, but all of these respond to treatment — from lubricants and low-dose vaginal oestrogen to ospemifene, pelvic floor physiotherapy and couples therapy. Break the silence, ask for help early, and remember that pain-free, pleasurable sex is possible.