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Sex & relationships

Menopause can affect your relationships and your sex life. Symptoms such as a dry vagina can make sex painful and you may find you have less desire for sex. Knowing what to do and where to get help for both you and your partner is helpful.

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Sex & menopause

Research from the National Ageing Research Institute and the University of Melbourne, called the 'Women's Healthy Ageing Project' (a large study of women begun in 1990) found that as women transition through menopause, there can be a significant decline in sexual functioning.

The study found the decline is associated with a reduction in the hormone oestradiol (the main oestrogen), but not testosterone. The exact relationship between hormone levels and sexual dysfunction is still not clear, and it appears to be quite complex. Researchers have identified that sexual problems are worse for women with early/premature menopause or surgical menopause. This might be due to a larger, sudden drop in hormones that happens with these types of menopause.

At midlife and menopause, many things are likely to be happening, both to your body and in your relationships. There might be partners, children and ageing or unwell parents to consider, as well as work demands and even your sense of identity as a woman. These changes can affect your sexuality and, together with the hormonal changes, sexual problems may occur.

Dr Elizabeth Farrell, Medical Director of Jean Hailes Medical Centre and Gynaecologist, shares five things to know about sex in later life in this video.

The impact of symptoms

One of the key symptoms of menopause is a dry vagina.

Lower levels of oestrogen directly affect your vagina and can make the skin thinner, drier and less elastic. Testosterone levels fall gradually with age and this can have an impact on your sexual function and libido after menopause.

The domino effect of menopausal symptoms such as hot flushes, sleeplessness and fatigue can make it less likely you will want sex as much.

Some women are concerned by the changes menopause causes to their sexual lives, and others are not so worried. It really depends on you, your attitude to sex, your age, how menopause has affected you, whether you are in a relationship, whether you want to have sex and whether there are other things happening in your life you are more concerned about.

Different types of menopause can also affect your sex life. If you have had a surgical or chemotherapy-induced menopause, symptoms can be worse due to a more rapid drop in oestrogen and testosterone.

Happy couple

Ways to support

Download a fact sheet for partners and family members.

Management & treatment of sexual problems at menopause

Dry vagina treatments

There are several options to treat changes to your vagina caused by menopause. Go to 'Menopause management'.

Painful sex

Because a dry vagina makes sex painful, even thinking about sex can make you anxious, and then you can start to fear sex. This can set up a negative 'pain cycle' where you fear sex, avoid sex, get frustrated and anxious, and then sex is likely to hurt more. If this is happening, treat the physical symptoms first to reduce the pain, and then the fear of pain during sex may also decrease.

However, some women find that although they feel physically better after treatment, they still fear sex will hurt, and they might become anxious even thinking about sexual activity. This is common. If this happens to you, it can be helpful to:

  • learn and practise relaxation exercises
  • see a pelvic floor physiotherapist to learn pelvic floor relaxation, as these muscles often become tight, increasing sexual pain
  • talk to a psychologist or sex therapist who specialises in sexual problems in women – you may need only one or two sessions, but understanding what you can do to help yourself and your partner in this situation may stop a problem becoming more serious.

There are many reasons we find ourselves having difficulty when it comes to sex. For more information, please see our webpages on 'Sex and sexual health'.

Libido at menopause

Libido (sexual desire) tends to be lowered in some women at perimenopause and menopause. It is difficult to have desire if:

  • you have experienced pain because of a dry vagina
  • you are exhausted because of menopausal symptoms
  • you feel moody or frustrated by all the changes
  • you feel like you do not want to be touched as much.

Some women may improve with a trial of menopausal hormone therapy (MHT) or with use of vaginal moisturisers/lubricants or vaginal oestrogen to improve vaginal dryness. It is an important issue to discuss with your doctor.

Testosterone therapy for libido

The area of wellbeing and libido is very complex, and research tells us these are likely to be influenced by psychological factors more than testosterone. For example, a woman's individual situation, her relationship status and satisfaction, her past experience of sexual problems and whether she is experiencing anxiety or depression are important influences.

However, testosterone therapy may be a suitable treatment for postmenopausal women experiencing a loss of sexual desire causing them personal distress. This condition is known as hypoactive sexual desire disorder (HSDD).

HSDD is a condition that is diagnosed clinically rather than by a blood test. Women with HSDD will not necessarily have low testosterone levels in the blood. So to diagnose the condition, a doctor will ask you questions and exclude all other possible causes of low desire such as depression, antidepressants, other medication and painful sex.

Low desire with distress in postmenopausal women (HSDD) is currently the only recommended use for testosterone, according to a 2019 statement from a group of menopause organisations and researchers worldwide. There is no evidence to support the use of testosterone in premenopausal women or for any other condition such as low mood, depression or osteoporosis[1].

Testosterone therapy will not be the answer for someone who is experiencing a loss of sexual interest and/or libido due to relationship problems, depression or poor wellbeing due to other causes, or low libido due to a chronic medical illness.

See more information about desire and testosterone in women here.

How is testosterone used?

A testosterone 1% cream (specifically for women) is now available in Australia and has been approved by the Therapeutic Goods Administration (TGA) for the treatment of HSDD. (The TGA is a government body that assesses and monitors the safety of medicines in Australia).

The cream is applied every night to the lower abdomen or outer thigh. Usually, your doctor will test your testosterone level after 3 weeks to make sure it has not gone too high and then again at 12 weeks. After that you should be seen every 6 months for a check up and to monitor blood testosterone levels.

If testosterone therapy is going to be of benefit you will start to notice some improvement after about 4 weeks. If after 6 months there is no improvement, testosterone treatment will be ceased.

If you are considering testosterone therapy, talk to your doctor to gain a clear understanding of what is currently known about this therapy. It is essential for women undergoing testosterone treatment to be supervised by doctors who are experts in this area.

What are the risks of testosterone therapy?

Possible side effects

In women using testosterone therapy, the levels of testosterone in their blood should not be higher than the levels in healthy premenopausal women.

Side effects from excessive use of testosterone can include: developing male characteristics (masculinisation) such as acne and excess body hair; fluid retention and adverse effects on blood cholesterol.

Note: These side effects are rare if the appropriate dose of testosterone is used.

If too much is used (ie male doses), serious side effects can occur and these include deepening of the voice and enlargement of the clitoris, both of which may be irreversible.

Who should not use testosterone?

Testosterone therapy is not suitable for the following women:

  • Women with severe acne
  • Women with severe excess body hair
  • Women who are pregnant, breast feeding or
  • Women who have a suspected cancer.

Managing contraception during menopause

Changes to your period during the transition to menopause often prompt women to ask, 'how long should I use contraception for?' Most women are aware fertility naturally declines with age.

The possibility of pregnancy in women 45-49 years is estimated to be 2-3% per year. After the age of 50, it is less than 1%. This is low, but the fertility of individual women is extremely variable. Perimenopausal women can ovulate twice within one cycle, and women can still ovulate up to three months before their final period, so contraception remains an important consideration.

When is it safe to stop contraception?

For women younger than 50, contraception is recommended for at least two years after the final period.

For women 50 and older, contraception is recommended for at least one year after the final period.

It is important to carefully consider your contraception options, as there are many different types available. It is a personal choice, but it is best to have a discussion with your doctor to help work out what is the most appropriate option for you.

Please note that MHT is not a contraceptive.

Relationships

Partners

It is hard to know if menopause influences your relationship with your partner, or if the relationship you have with your partner influences your experience of menopause.

Partner attitudes to menopause have an impact on your experience of menopause. Having an informed, supportive partner can help during this time. Help your partner to gain access to good objective information about menopause, and discuss your own experiences to help their understanding.

At midlife and menopause, different women are at different stages of their relationships. Relationships can be long-term or new, satisfying or unsatisfying. Any relationship difficulties a woman may experience during menopause can negatively affect her mood.

Menopausal symptoms and a chronic illness or premature menopause can take their toll on a woman and her relationship, making good communication in the relationship vital at this time.

What can you do to help your relationship?

One of the most important things is to be able to discuss your thoughts and problems openly in your relationship.

If this is difficult, perhaps your partner could visit your doctor with you and you can discuss your concerns together. Or, you could both visit a psychologist who specialises in couple's therapy. You might have to go for only one or two sessions, but the therapist should be able to help support you in your communication.

If sexual problems are causing difficulties in your relationship, it is helpful to sort out how many of them are due to the physical symptoms of menopause, and how many might relate to other issues, or both. When you have worked this out, then you can seek the appropriate help.

To learn more about how you can help your partner to understand menopause, please see our webpage for partners.

This web page is designed to be informative and educational. It is not intended to provide specific medical advice or replace advice from your health practitioner. The information above is based on current medical knowledge, evidence and practice as at December 2017.

References

Last updated: 16 July 2021 | Last reviewed: 17 December 2017

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