By Leanna Coy, FNP BC
Jane once led an active, intimate marriage. Then her interest in sex began quietly fading. Her relationship with her husband became strained. Jane’s experience is common among women in midlife who find a growing lack of interest or enjoyment in intimacy. For women who’ve had active sex lives that they would like to continue, these changes are often disturbing. For other women, it is a relief to have that stage of their life behind them. In both cases, differences in intimacy can challenge any partnership.
There are a variety of factors that can lead to shifts in intimacy – an unhappy relationship, depression, and a dislike for an aging body. But in menopause, hormones have a big impact. This does not mean your sex life is over because there are real solutions to manage your sex life through perimenopause and beyond.
How physiological changes in midlife contribute to changes in sex life
Four hormones play a key role in intimacy changes during midlife: estrogen, progesterone, testosterone, and cortisol. These hormones interact, influencing changes in sexual health and intimacy.
Stress triggers cortisol, and stress is common in midlife. Women often manage families and work, and some also care for aging parents. High levels of cortisol trigger a “fight or flight” response in the body, telling the brain that it’s not safe to relax. This can disrupt sleep and leave little motivation for intimacy.
High cortisol levels also reduce testosterone levels. This hormone drives libido for both men and women and is often overlooked in women. Low levels of testosterone can decrease the desire for sex, problems becoming aroused, and achieving orgasm.
Too much cortisol can interfere with the body’s ability to make progesterone. Add this to declining and unstable progesterone levels that start in perimenopause. The lower levels can cause changes in a woman’s mood, triggering anxiety, depression, and irritability. Low progesterone levels can also cause sleep problems.
As with most perimenopause and menopause issues, estrogen is the biggest culprit in changes to sexual health. In perimenopause, the ovaries begin producing less estrogen. This causes hormone levels to begin fluctuating and then drop dramatically in menopause. Estrogen helps to maintain the vaginal tissues. A lack of estrogen causes the tissues to become thinner, drier, and less flexible.
The Four Ways It Shows Up in Your Sex Life
There are four big ways that these hormone changes will show up in a woman’s sex life. Knowing these signs helps recognize and address issues early.
- Reduced or absent libido. The combination of high cortisol with declining estrogen levels has a huge impact on libido. With the lower or completely absent libido, the brain simply stops setting up any desire for intimacy.
- Physical discomfort. When estrogen levels begin to decline, women may not notice the subtle changes at first. Changes like a subtle loss of lubrication and arousal sensitivity. Left untreated, the lack of lubrication becomes clearer. Intercourse can become uncomfortable, even painful. These vaginal changes are called genitourinary syndrome of menopause (GSM). Micro-tears to the vaginal tissues and bleeding can occur. Some women will complain of itching or irritation, often mistaking these symptoms for a yeast infection.
- Difficulty with arousal or orgasm. The loss of estrogen reduces blood flow to the genitals. This can affect arousal by decreasing the sensitivity of the nerves in the genital area. The impact of the loss of sensitivity is that it may take longer for a woman to become aroused, and she may have a more difficult time reaching climax.
- Mood and relationship strain. The changes in estrogen levels often cause hot flashes and night sweats, which disrupt sleep. Add this to the poor sleep from high cortisol levels, and you have someone sleep-deprived. With a lack of restful sleep comes fatigue and depression. This can dampen any interest in sex or the ability to enjoy it. For couples who’ve had an active sex life, this can put a big strain on the relationship.
What You Can Do About It
Taking care of midlife intimacy issues requires a balance of medical and lifestyle management options. Start by talking with your primary care provider or gynecologist. They can work with you to determine if you would benefit from hormone testing and review treatment options with you.
Hormone replacement therapy (HRT) is often a good choice for many women – but not every woman. It’s important to understand the risks. Estrogen replacement increases the risk for a blood clot, stroke, breast or uterine cancer, and heart disease. The level of risk is different for each person. Personal health history, when they start the hormones, how long they are on HRT, and the dosage and method of taking the hormone all factor into the risk. There is good evidence that the use of HRT outweighs the risk if a woman starts treatment before age 60 or within 10 years of entering menopause.
Estrogen replacement comes in many forms. This includes daily pills, topical gels or patches applied to the skin, and a ring inserted vaginally. The topical forms of estrogen have the lowest risk and are often used in combination form. For example, a patch to manage vasomotor symptoms, such as hot flashes and night sweats, and a vaginal cream for GSM symptoms. Women who have a uterus need progesterone with estrogen to reduce the risk of uterine cancer.
Testosterone therapy is sometimes used to improve libido when estrogen therapy is not effective. Any use of testosterone must have close monitoring to ensure levels do not climb too high. Testosterone levels in women should stay in a much lower range than they would for a man. If the level climbs too high, a woman can begin to have hair loss on the top of her head, aggression, facial hair growth, and acne. Long-term high doses can cause a deeper voice and an enlarged clitoris. These changes can become permanent.
Lifestyle management of intimacy issues starts with self-care. Make sure you are getting enough restful sleep. Do this by keeping a regular sleep schedule with routine bedtimes and waketimes. Exercise daily to move your body and practice mindfulness. These steps will help with stress management and result in lower cortisol levels.
Pick up vaginal lubricants and moisturizers. These two both help with vaginal dryness from loss of estrogen, but are not the same. A vaginal lubricant is used just prior to intimacy to aid in reducing friction and discomfort during sex. A vaginal moisturizer is used routinely, like a lotion, to help treat vaginal dryness.
Openly communicating about what’s happening with your partner is important. Women need to realize that changes in intimacy are not a “you” problem, but a shared issue with their partner. Normalize the conversation with them and work with them to maintain your relationship.
Hormonal changes that disrupt someone’s sex life is a medical issue that has treatment options. Women are not flawed when these changes happen, and should not see the hormone changes as the end of an era. Often, the symptoms women experience are undertreated. This is because women don’t raise this issue with their healthcare provider. Know your body, track your symptoms, and speak up to your partner and healthcare provider. Don’t let your hormones hijack your sex life. Be proactive in discussing symptoms and seeking treatment for healthier intimacy.
