Sex drive, intimacy and vaginal dryness in perimenopause

Low sex drive and vaginal dryness are both common in perimenopause, and they often show up together. Falling and fluctuating estrogen can thin and dry the vaginal tissue, which can make sex uncomfortable, while poor sleep, stress and mood changes can quiet desire. Dryness has a clinical name, genitourinary syndrome of menopause, and there are treatments you can discuss with a doctor.¹

Most people lump the two together as "low libido". They behave very differently. Desire moves up and down, and for many women it recovers. Dryness is another matter: unlike hot flashes, which usually improve with time, it tends to get worse without treatment.² That difference is the most useful thing to know, because it changes what "waiting it out" means.

Why does perimenopause change your sex drive?

Desire is not one switch. It depends on hormones, but also on sleep, stress, mood, how your body feels and how connected you feel to a partner. In perimenopause, several of those move at once. Estrogen and progesterone swing unpredictably, and the signals your brain and body use to cue desire can get disrupted. Cleveland Clinic lists falling estrogen as one reason desire can drop.⁷ Add night sweats, broken sleep, anxiety and breast tenderness, and it is easy to see why sex slides down the list.

It also helps to know what research following women through the transition has found. In the large US SWAN study, desire tended to decrease by late perimenopause, and pain during intercourse became more likely.⁴ The same study found that health, psychological wellbeing and how much importance a woman placed on sex shaped her sexual experience, not hormones alone.⁴ If your desire has changed, you are far from alone.

Does desire come back?

For many women, it does. In Moody data, sex drive dips in the late thirties and early forties, then climbs again, with women over 55 reporting the highest desire of any age group. We explore it in what the textbook gets wrong about desire. A low patch in perimenopause is not a permanent verdict on your sex life.

There is also a different way desire can work. Clinical researcher Rosemary Basson proposed that many women, especially in longer relationships, do not feel desire first. Instead, they notice an opportunity, feel close to someone, become aroused, and the wish to continue arrives afterward. This is often called responsive desire, as opposed to spontaneous desire.⁵ If you are waiting to feel "in the mood" before anything begins, you may be waiting for a sequence that does not suit you. Many women find that desire follows touch, warmth or time together rather than leading it.

This is why there is no need to force desire, or to read its absence as a verdict on yourself or your relationship.

What is vaginal dryness, and does it go away on its own?

When estrogen falls, vaginal and vulvar tissue can become thinner, drier and less elastic. Doctors call the collection of symptoms genitourinary syndrome of menopause, or GSM. It can include dryness, burning, itching or irritation, pain with sex, and urinary symptoms such as urgency or more frequent urinary tract infections.²

Estimates suggest GSM affects somewhere between 27% and 84% of postmenopausal women. It is also underdiagnosed and undertreated: in one US survey of 1,858 women with genitourinary symptoms, half had never used any therapy.¹ Many women assume it is just part of aging and quietly put up with it. You do not have to.

It can start in perimenopause, which is why guidelines recommend asking perimenopausal women about it, and it is generally progressive without effective treatment.¹ That is the key contrast with hot flashes.

What is the difference between a vaginal moisturizer and a lubricant?

They do different jobs, and many women use both.

• Vaginal moisturizers are used regularly, often two to three times a week, whether or not you have sex. They are meant to keep the tissue comfortable day to day.¹,²

• Lubricants are used during sex to reduce friction. They come water-based, silicone-based or oil-based, and oil-based products can damage condoms.²

Many people start with a water-based product without added fragrance or other irritants, particularly if their skin is sensitive. Clinical evidence comparing over-the-counter products is limited, so if one stings or irritates, stop and try another, or ask a pharmacist or doctor.¹

What medical treatments exist?

If moisturizers and lubricants are not enough, a doctor can talk through prescription options. Low-dose vaginal estrogen, available as a cream, tablet or ring, acts directly on the tissue. The Menopause Society describes it as an effective and safe treatment, with improvement usually seen within weeks to months of consistent use.² Blood estrogen levels with low-dose vaginal products generally stay within the postmenopausal range, which is why its risk profile differs from systemic hormone therapy.¹ Symptoms are likely to return if treatment stops.¹

Other options a provider may discuss include vaginal DHEA inserts, an oral medicine called ospemifene, dilators, and pelvic floor physical therapy.³ If you have had breast cancer, Mayo Clinic advises talking to your healthcare provider about the small risks of vaginal estrogen before using it.⁶ Herbal remedies are sometimes suggested too. Evidence for these is limited, and supplements can interact with medicines, so check with a doctor or pharmacist first.

If you are unsure where to start, a gynecologist who works with midlife women is a good place. Our piece on why seeing your gynecologist is nothing to fear may help.

How can you stay close when sex feels like a lot?

Intimacy is wider than intercourse. Cuddling, holding hands and other touch without an expectation attached can keep closeness going while your body settles. Talking honestly about what has changed, including what feels good now, gives a partner something to work with instead of guesswork. Some women find that mindfulness practices such as body-scan meditation or slow breathing help them relax and notice sensation, and that new positions, tools or kinds of touch make sex more comfortable.

Some women describe sex after menopause as more connected and relaxed, partly because worry about pregnancy is gone. Sex therapists and relationship therapists can help if you and a partner are stuck.

The aim is not to get back to who you were at thirty. It is to find what feels good now, without pressure.

When should you see a doctor?

See a healthcare provider if sex is persistently uncomfortable or painful, if dryness, burning or urinary symptoms keep returning, or if changes in your sexuality are affecting your wellbeing or your relationship. The same goes for anxiety, sadness or low mood that makes intimacy harder. A provider can also check whether a medication or another health issue is playing a part.⁷

You can read about the wider picture in what are the symptoms of menopause and how estrogen works.

Read next: Perimenopause mood swings and anxiety, Perimenopause at work and in your relationships