Sexual interest and the Perimenopause & Menopause

Firstly, let’s be clear what we are talking about here and what’s ‘normal’. There are many terms we hear people use, such as sexual interest, desire, drive, libido and strong societal messages telling you what you should or should not be feeling and doing, and even what ‘sex’ is.

It can all get rather confusing and perhaps stressful, particularly if you feel you are not ‘hitting the mark’/ meeting expectations/ not doing what you think you should be doing or as often as you should.

Do we have an inbuilt ‘drive’ for sex like a hunger or a thirst (because the media often make it sound like we do)? or is it more of an ‘interest’ that can vary depending on context, often needs to be cultivated and nurtured (especially in long term relationships) and needs a positive outcome (making sure that our sexual needs are met, not just our partner’s) to motivate us to want to do it again.

I would suggest that the answer is, it can vary, but the latter is probably the best way to think about it. Instead of passively waiting for spontaneous sexual desire to land on (or enter) your head, as you busy about your day, trying to meet deadlines or hastily make your dinner etc, it is more helpful (and accurate, backed up by sex research) to understand that desire is often not spontaneous. Indeed if you don’t feel frequent and spontaneous desire this is actually normal. If it takes someone to make a sexual advance (you might feel neutral/ weren’t thinking about sex) and you feel aroused. Then you experience desire as a result of this and have a positive sexual experience…this is statistically ‘normal’.

Indeed, the good news is that you can have a happy, fulfilling and great sex life, whatever your gender, sexuality, relationship status or duration. However, it might need a bit of effort, but that’s ok, right? As most things in life that are worth doing, need a bit of attention and effort and may not happen spontaneously. A great place to start (and finish) to dismantle some sex myths, gain up-to-date (evidence backed) knowledge and understanding that ‘responsive desire’ is normal, is with Karen Gurney’s, brilliant book, Mind the Gap: The Truth about Desire and how to Futureproof your Sex Life.

The medical definition of low sexual interest and arousal includes a loss of responsive desire, absent sexual thoughts / fantasies, for more than 6 months and needs to cause distress.

So with this in mind, let’s think about the many things that can impact your sexual interest. Indeed low sexual desire is one of the commonest sexual problems we see in our sexual function service. This can happen at any age, the most common reasons being relationship issues or low mood. But let’s focus on specific changes at the time of the perimenopause / menopause which might have an effect on your sexual functioning.

We can think about these changes under a few main headings:

Changes in your body that can affect your sex life:

The perimenopause is the time when your oestrogen and testosterone levels reduce and this can cause a number of common symptoms that include: reduction in sexual interest (spontaneous and responsive), hot flushes, night sweats, sleep disturbances, joint pains, mood changes, irritability, forgetfulness and loss of energy. None of which are great for your positive sexual wellbeing.

Changes in your genitals:

This reduction in oestrogen commonly causes changes in your genital area: the skin gets a bit less stretchy, thinner and drier, causing vaginal dryness and /or problems peeing. This can lead to painful sex and poor arousal, which in turns reduces your interest in having sex (and can negatively affect one’s self esteem and quality of life). In one study of post-menopausal women, nearly half experienced these symptoms, but only 4% linked them to the menopause and most didn’t seek help.

Other events happening in your life

This is the time in your life when you might have multiple demands on your time/ energy including elderly parents with additional needs and / or children and a demanding job and/ or financial concerns. Sex is not likely to appear in this busy schedule without some scheduling of emotional and physical intimacy to trigger arousal and desire (back to the need to put some work in and dispelling the unhelpful ‘sex needs to be spontaneous’ myth).

The positives

Sometimes this is a time in your life when you have less stresses, perhaps more financial security, children (if you have them) may have left home and indeed more time and space for your sex life. If periods and risk of pregnancy have been a concern for you, then being postmenopausal can have a freeing, positive, effect on one’s sex life (there is no risk of pregnancy when you are over 50 and have not had a period for a year). You may have reached a point where you feel more confident in yourself including having more sexual confidence, you may have good communication with a partner and feel less inhibited. Indeed, not all people going through menopause experience a reduction in sexual interest, despite the hormonal changes and some report the best ‘sex’ ever.

There is help out there! What to do if you are not happy with your sex life

Many of the general symptoms listed above are easily reversed with HRT (sometimes also testosterone). Depending on your symptoms, you may only need help in the genital area: always use a good quality lubricant for any kind of sex (solo or partner sex) and try to use it in a sexy way like a sex toy (rather than ‘stop I’m dry’). Vaginal moisturisers are also important and can be effective for addressing dryness/ poor arousal (see below for a few recommendations). If these simple measures don’t work, see your GP and make sure you get examined. You may need topical oestrogen creams to apply to your genitals. The good news is these creams are safe and extremely effective at reversing the low oestrogen effects on your genitals.

If you look at the research, ‘good’ sex is not so much about function or frequency but more about connection, experiencing pleasure and ultimately about good communication and taking time over physicality (see Peggy Kleinplatz’s excellent writings on how great lovers are not born but made). You can get the sex life you want (at any age) with a bit of effort, an understanding of how sexual desire actually works and (as needed) professional help e.g. medical input and / or sex therapy. Please do not put up with a sex life that isn’t working for you. See your GP (and ask to be referred to a menopause clinic or a sexual function clinic as needed) and/ or find a good sex therapist.

Lastly, if you are not interested in having any kind of sex and this is not in any way bothering you, please know this is completely ok too and you don’t need ‘fixing’. Whatever anyone says.

Dr Ali Mears is a Consultant physician in Sexual health. She works in the NHS and in the private sector at the Havelock clinic in London.

Useful resources

1. Mind the Gap, by Karen Gurney
2. Any Ted talks / books / online lectures / podcasts etc by Esther Perel About Esther Perel | Her Story and Inspirations
3. Magnificent Sex by Peggy Kleinplatz (or any of her podcasts/ papers)
4. International society of sexual medicine website, public section: Public – ISSM
5. Any books/ talks etc by Lori Brotto eg Better sex through mindfulness
6. Royal College of Obstetricians and Gynaecologists Sex and relationships after the menopause | RCOG
7. COSRT public factsheets COSRT Factsheets: PDF Downloads: Information for the public on therapy
8. Apps: Erika Lust (ethical porn), Dipsea, OMG Yes
9. The Havelock clinic resource page (and practitioners and online courses) Resources – The Havelock Clinic, London
10. Finding a sex therapist: Find a Therapist | cosrt, www.thehavelockclinic.com , Home | Relate
11. Lubes and Vaginal moisturisers: YES Natural and Organic Intimate Lubricants (yesyesyes.org), About Sylk · Sylk Natural Intimate Lubricant, Replens™ Moisturiser – Vaginal Atrophy & Dryness Relief (make sure you read about the different types of lubes and what can / can’t be used with condoms and sex toys)