As women get into menopause, many find that their interest in sex fades. The transition is associated with declining oestrogen, the predominant female hormone.
As levels fall, Dr Maina Muriithi, a consultant obstetrician-gynaecologist at Aga Khan University Hospital, says most women experience symptoms that affect quality of life, including lack of interest in sex, hot flushes, night sweats, mood changes, memory and concentration loss, vaginal dryness, headaches, and joint and muscle stiffness.
“The frequency and intensity of these symptoms vary from individual to individual and thus as some women go through menopause undisturbed, others might experience extremely bothersome symptoms,” he explains.
Low sexual desire is a recognised menopause-associated symptom, he notes, and although not universal, it is driven by declining oestrogen.
“It is mainly attributed to vulvovaginal symptoms like dryness and reduced lubrication that can make sexual intercourse painful and the resultant effects of fatigue and mood changes associated with menopausal transition,” he says.
Testosterone, the predominant hormone responsible for desire in women, also declines gradually with age. Dr Maina points to other known contributors, including depression, anxiety and chronic stress, relationship conflict, thyroid disease, diabetes, painful conditions and some medications, such as antidepressants. “A woman can also have more than one contributing factor, and so it is important to get evaluated in totality,” he adds.
However, the transition does not dampen desire for everyone. Although perimenopause is associated with fluctuating and eventually declining ovarian hormones, Dr Maina says some women experience a period of increased sexual interest, arousal or sexual confidence.
“There is no single explanation for these changes, and the experience varies considerably between individuals,” he explains. “First, women continue to produce testosterone from the ovaries and adrenal glands. It contributes to sexual desire, although its relationship with libido is complex and individualised.”
Mindset plays a role in a woman’s desire for intimacy. For some women, the midlife years bring greater self-awareness, confidence and comfort with their sexuality.
“They may feel more secure in their bodies, more confident communicating their sexual needs, or less constrained by earlier social expectations. These changes can increase sexual interest independently of hormonal fluctuations.”
Then there is freedom from worry. “Some women might notice an increase in sexual desire due to factors like freedom from pregnancy concerns and changing life circumstances.” For women who have completed their families, the perimenopausal years may bring a greater sense of sexual freedom, particularly if pregnancy-related anxiety decreases.
However, women going through menopause can get pregnant, as Dr Maina explains, “Ovulation can occur unpredictably until menopause is fully established, so contraception remains important when pregnancy is not desired.”
Whether sexual desire has risen or fallen, Dr Maina said, it is worth discussing at routine wellness checks. The first step is usually to look at when the change began. Treatment for reduced sexual desire and libido is usually tailored to the underlying problem.
“Vaginal lubricants are commonly used in women with vaginal dryness. If the response is not satisfactory, local vaginal estrogen can be used to treat the dryness and improve lubrication,” he shares.
However, systemic hormonal therapy is not solely used as treatment for reduced sexual desire. “It is mostly used to treat systemic symptoms of menopause like hot flushes with a resultant benefit in improving sexual desire,” he explains. “Testosterone therapy can be considered for select patients with hypoactive sexual desire disorder. It is not recommended simply because a woman is menopausal, tired or has a low testosterone result and should only be given by a doctor’s prescription.”
He notes that sex therapy, cognitive behavioural therapy and couples counselling can be helpful when anxiety, sexual pain, negative expectations, relationship conflict or communication difficulties contribute to symptoms. Where pain is associated with pelvic floor dysfunction, pelvic health physiotherapy may also be appropriate.
Still, Dr Maina says a woman, regardless of age, should consider seeking medical advice if reduced desire persists, causes personal distress, affects her relationship in an unwanted way, or occurs alongside other symptoms that concern her.
“Open communication can help couples understand that changes in sexual desire are not necessarily a reflection of love, attraction or commitment.”
