Still Got It: A Real Talk Guide to Sex After Menopause

Have you recently found yourself feeling distant or disconnected during moments that once brought closeness and intimacy? Maybe you’re experiencing an unexpected sense of discomfort or even dread about something that used to feel natural and enjoyable. 

Perhaps you’re noticing dryness that’s uncomfortable, or even painful sensations during sex. It’s essential to know that these experiences aren’t because of anything you’re doing wrong—they’re common, real physiological changes related to sex after menopause, and they’re more normal than you might think. These changes are closely linked to the hormonal shifts of perimenopause and the menopause transition¹.

What causes sexual problems after menopause?
A drop in estrogen leads to dryness, thinner tissues, and discomfort. These physiological changes affect arousal, libido, and orgasm—but treatments and solutions exist.

What’s Really Happening?

As you enter perimenopause, your body begins producing less estrogen and, to a lesser extent, testosterone. These hormones play crucial roles in maintaining the health of your vaginal tissues and your sexual response. With decreasing estrogen, vaginal walls become thinner, less elastic, and drier—a condition now commonly termed Genitourinary Syndrome of Menopause (GSM). GSM includes not only vaginal symptoms but also urinary symptoms (such as urgency, frequency, or recurrent urinary tract infections), creating discomfort and impacting sexual intimacy2.

Here’s how common these symptoms are3:

• Low libido: 40-55% of women experience reduced sexual desire (feeling less interest, drive, or enthusiasm towards intimacy)
• Vaginal dryness: reported by 27-60% of postmenopausal women
• Pain during sex (dyspareunia): affects approximately 12-45% of women
• Orgasmic changes: difficulties reported frequently, due to reduced blood flow and nerve sensitivity

Why Do These Symptoms Occur?

Primarily, reduced estrogen levels cause significant changes in your vaginal tissue. The thinning of vaginal walls (vaginal atrophy), decreased lubrication, and loss of elasticity result directly from these hormonal changes. Reduced testosterone, although less pronounced, also impacts libido and sexual responsiveness. Additionally, decreased blood flow and nerve sensitivity can affect orgasmic response.

It’s a domino effect: vaginal dryness and pain can lead to avoidance of intimacy, reduced libido, and diminished sexual satisfaction, forming a challenging cycle that’s difficult to break without intervention.

What Can You Do?

Fortunately, science has plenty of options to help you manage these symptoms effectively. Let’s talk about both hormonal and non-hormonal approaches4, 5.

Hormonal Therapies

Hormonal therapies can be powerful tools for restoring comfort, desire, and confidence in sex after menopause. These treatments target the root hormonal changes that affect vaginal tissue, libido, and sexual response. Whether applied locally or taken systemically, each option offers different benefits depending on your symptoms, medical history, and personal preferences. Let’s break them down so you can better understand what might work for you.

Local Vaginal Estrogen
Highly effective for vaginal dryness, pain during sex, and reversing vaginal atrophy. Delivered directly to vaginal tissues as a tablet, cream or a ring with minimal systemic absorption, making it safe and targeted.

Intravaginal DHEA (Prasterone)
It’s a newer hormonal option, consisting of dehydroepiandrosterone (DHEA) applied inside the vagina. A daily intravaginal DHEA suppository has been approved to treat moderate to severe pain during sex due to menopause. Prasterone works very similarly to estrogen and can be a good alternative.

Systemic Estrogen Therapy (HRT)
It’s beneficial if you also experience hot flashes or other widespread menopausal symptoms. Taken orally or via skin, it improves lubrication and reduces discomfort, but it’s generally reserved for women needing broader symptom relief.

Estrogen Plus Progestogen (HRT)
It can offer small to moderate improvements in sexual function, especially in women who are early in the postmenopause journey or dealing with bothersome symptoms. It works similarly to estrogen alone but is used when a woman still has her uterus.

Tibolone
A synthetic steroid is often used in some countries as an alternative to traditional HRT. It may have a mild benefit on sexual function, but the evidence behind it isn’t as strong or consistent as it is for estrogen.

Testosterone Therapy
Primarily for women experiencing significant loss of libido (HSDD). Delivered through patches or gels, testosterone can notably enhance sexual desire, arousal, and satisfaction. It is generally used off-label for women, as formal approval and availability vary significantly across different regions.

Non-Hormonal Therapies

Not ready for hormones? You’ve still got options. Non-hormonal therapies can offer real, science-backed relief for sex after menopause—especially for women who prefer a gentler, targeted approach or who can’t use hormones6, 7, 8. From everyday moisturizers to emerging treatments like laser therapy, these solutions support comfort, pleasure, and confidence without altering your hormone levels. Let’s explore what’s out there.

Vaginal Moisturizers
They can be used regularly (several times a week) to hydrate the vaginal tissues and help restore elasticity over time. They’re not for sex itself, but rather to improve daily comfort and reduce irritation from dryness. Products with ingredients like hyaluronic acid or polycarbophil are commonly used.

Lubricants
On the other hand, lubricants are used just before or during sex to reduce friction and ease discomfort. They come in water-based, silicone-based, or oil-based forms and provide instant relief, but they don’t do anything to improve vaginal tissue health in the long run.

Vaginal Inserts
Sometimes called pessaries or suppositories are a type of non-hormonal moisturizer that you place inside the vagina. These slow-release treatments deliver deeper, longer-lasting hydration and can be especially helpful if dryness or pain during sex is more severe. Many women find them easy to use and feel real, noticeable relief.

Selective Estrogen Receptor Modulators (SERMs)
Like ospemifene offer a non-hormonal prescription option for treating vaginal dryness and painful sex. While they don’t contain estrogen, they mimic some of its effects in vaginal tissue, helping restore moisture and comfort. They’re especially useful for women who can’t or prefer not to use hormone therapy.

Phosphodiesterase Type 5 (PDE5) Inhibitors
Like sildenafil, used off-label, may help with arousal and lubrication, especially in women whose sexual difficulties are linked to antidepressant use. While they’re not routinely prescribed for this purpose, some women do report improvements.

Neuromodulators
Medications that influence brain chemicals like serotonin, dopamine, or norepinephrine are being explored for their potential to improve desire, arousal, and orgasm. Most aren’t yet widely approved for this use, but research is ongoing, and they could be an option in the future for certain women.

Pelvic Floor Physical Therapy
Particularly beneficial if pain during sex is associated with muscle tension or pelvic floor dysfunction. Exercises, relaxation techniques, and dilators can greatly enhance comfort and enjoyment. 

Emerging Therapies (Laser Treatments)
Laser therapies (fractional CO₂ lasers) show promise in rejuvenating vaginal tissues by stimulating collagen and improving elasticity, although long-term efficacy is still being studied9.

Curious Facts

Regular Sexual Activity Helps: engaging regularly in sexual activity or intimate touch can actually help maintain vaginal elasticity and improve blood flow, potentially reducing symptoms of vaginal atrophy and dryness. It’s a gentle reminder of the “use it or lose it” principle.

Mindfulness and Sexual Satisfaction: research has found that mindfulness practices, including mindful breathing and meditation, can significantly enhance sexual desire and satisfaction. Mindfulness helps by reducing stress and improving emotional connection, highlighting that mental well being profoundly affects sexual health10.