If you frequently lack sexual urges or thoughts, have little desire to engage in sexual activity, and have difficulty becoming aroused then by definition you have low sex drive.
First off, it's natural to feel frustrated or sad if you aren't able to be as romantic and intimate as you want or used to be. A healthy, active sex life with a partner leads to feelings of greater emotional connection and higher relationship satisfaction, not to mention the many physical benefits. So getting to the bottom of what is going on with your body and where your libido went is not a frivolous pursuit. And while there are many factors that can contribute to a low libido, including emotional and relationship issues, this article will focus on the decline in sex drive that begins during the menopausal transition and is caused by hormonal changes.
During menopause it is normal for libido to decline. Physiological changes in our bodies can make it more difficult to get aroused, more painful to have intercourse, and more difficult to climax, making sex less enjoyable and satisfying. So why does this happen, and what can be done?
The relationship between testosterone and men’s libido is well understood, but the interplay between sex hormones and sex drive in women is less clear and more complex. While our understanding is still evolving, we do know that estrogen and testosterone play important roles in regulating a woman’s sexual desire and readiness.
During menopause it is normal for libido to decline. Physiological changes in our bodies can make it more difficult to get aroused, more painful to have intercourse, and more difficult to climax, making sex less enjoyable and satisfying.
Until recently it was believed that estrogen is responsible for vaginal readiness, making sex more comfortable for women, while testosterone is responsible for sexual desire. And while these things are true in part, the full picture is more complex, nuanced, and unclear. More recent research indicates that estrogen may also play a role in libido alongside testosterone. Let’s take a closer look at each of these hormones, and what we know about the role they play in a woman’s sex drive:
Estrogen is made primarily in the ovaries and it is the main hormone responsible for the development and maintenance of a woman’s reproductive system as well as secondary sex characteristics like breasts, and plays various other roles in the body including helping to maintain bone density. Estrogen helps maintain healthy genital tissue, keeping the vagina responsive and prepared for sexual activity. When estrogen supply is low, blood flow to the vagina decreases as does natural vaginal lubrication, leading to thinning, tightening, dryness, and atrophy (thinning of vaginal mucous membranes) of the vagina and vulva. These changes can cause irritation, soreness, and even pain during sex, known as dyspareunia, which in turn can lead to anxiety or dread associated with sexual activity. Dyspareunia affects half of postmenopausal women and is one of the most common reasons women in this age group shy away from sex. Additionally, low estrogen can lead to delayed clitoral reaction time, thought to also be due to decreased blood flow to the region, although it is not clear if it impacts orgasmic response.
Testosterone is an androgen, a primary male hormone, and while men’s bodies do produce far more of it than women’s, it is produced in small amounts in the ovaries and the adrenal glands of women’s bodies. Although the exact functions of testosterone in women remains poorly understood, it is thought to play an important role in sexual desire and arousal, but research around this is also mixed. In a meta-analysis published in 2019 in the Lancet, testosterone significantly increased sexual desire, arousal, and orgasm, and decreased sex-related anxiety in postmenopausal women. Other studies on the effects of testosterone on menopausal women’s libido are less clear, with inconsistent results. While results of studies are mixed, many women do show improvements in libido when testosterone levels are increased to the high-normal range.
In more recent years, some studies have been published suggesting that estrogen may also play a role in stimulating libido. It has long been known that the surgical removal of the ovaries results in a significant drop in libido, but since both estrogen and testosterone are produced by the ovaries, it is difficult to isolate either hormone as the cause of the resulting drop in sexual desire.
In one study published in 2013, estradiol levels in the saliva were positively correlated with sexual desire in premenopausal women, peaking each month around ovulation. And in a meta-analysis published in 2015 the authors’ analysis showed that estrogen therapy does increase libido. However, another study published in 2017 showed that women on standard doses of estrogen therapy reported a modest 10% improvement in subjective domains on the standard FSFI rating scale, a questionnaire measuring sexual function in women.
While the effects of estrogen on women’s sex drive remain disputed and inconsistent, and the dosages needed to achieve an impact unclear, it is nevertheless important to recognize that estrogen may indeed play a role in regulating libido.
So given what we know and what the data show, what can be done?
The good news is that you can enjoy sex in perimenopause and menopause. The sexual dysfunction caused by drops in ovarian hormones over the course of the menopausal transition is treatable with hormone therapy (HT).
Specifically, estrogen therapy is highly effective in treating the low vaginal readiness and responsiveness that results from decreasing estrogen levels in midlife. It does this by increasing blood flow to the vulva and vagina, natural lubrication, and vaginal sensitivity, effectively mitigating the issues of vaginal dryness, atrophy, and dyspareunia that are common in women of a certain age. This leads to decreased pain during sex, and greater enjoyment and sexual satisfaction. The positive psychological boost resulting from less fear of painful sex can in and of itself increase sexual desire. These effects of estrogen are well known and undisputed, so if you suffer from any of these conditions, you should consider trying estrogen-based hormone therapy.
As for libido, the jury is still out on whether estrogen- or testosterone- based hormone therapies can increase it, with the research mixed, as we discuss in some detail above. Testosterone medication is sometimes prescribed off-label to help women suffering from low sex drive, but it has not been FDA-approved for women, and data on safety is limited.
It is important to remember that sexual function in women, from desire to arousal to sexual responsiveness to orgasm, is complex and multifactorial, and there is no one-size-fits-all panacea that will work for every woman. This is why pinpointing the specific issues at play is the first step toward finding a solution that will work for you.
If you are interested in trying hormone therapy to address low sexual responsiveness or other dysfunction, you will first need to talk to a provider to determine whether you are a good candidate.
Because HT is FDA-approved and well-studied, many women choose to try it as a first line of defense against sexual dysfunction, especially if they are also having other menopause symptoms. For women who choose to try HT to help address their low libido but do not see any changes, and who wish to additionally try testosterone, they may be able to get an off-label prescription from a provider. However, it is important to remember that testosterone has not been FDA-approved for women, so proceed with caution.
If you choose to try Evernow as your provider for hormone therapy, you will first complete an online health profile. We’ll ask about your age, blood pressure, symptoms, and other medical information relevant to your treatment. Then we’ll connect you with an Evernow OBGYN or NP who will review your answers in-depth, determine whether you are a candidate for HT, and create a detailed treatment plan for you.
Our process incorporates the guidelines of professional medical societies such as ACOG (American College of Obstetricians and Gynecologists) and NAMS (North American Menopause Society). We go above and beyond to ensure the most customized treatment plan to meet your needs with different HT options including an estradiol cream, estradiol patch, oral estradiol, and progesterone when needed.
Don’t let menopause get in the way of your and your partner’s pleasure and fulfillment. Click here to learn more about what an Evernow treatment plan can do for you.
Reviewed by: Cynthia Krause, MD