Beyond Vaginal Dryness and Genito-Urinary- Syndrome of Menopause (GSM)
TLDR: Two questions: do you want sex, and can you have it comfortably? If no and you’re at peace with it, done. If something’s blocking desire or causing pain, both are treatable — though progress can be slow and partial, and that’s still worth it. Your sexual life is yours to decide what to do with.
Sex after menopause is a big topic. But I often start simply, with just two questions.
Do you want to have sex?
And if you do: Are you able to have sex comfortably and enjoy it?
If the answer is no
I follow up with: are you okay with that?
If she says yes — we’re done.
There is no medically correct amount of sex you should be having, and no correct amount of desire either.
No is a complete statement. I accept it, and move on, as long as that’s what you want. Once a woman reaches menopause, she doesn’t owe anyone a performance, sexual or otherwise. She gets to say yes or no as she wants, and her reason doesn’t need defending.
If she says no, she’s not okay with it — then there’s work to do. That might mean looking at what’s going on in her mind, in her relationship(s), and in her body. Either way, we have somewhere to start.
If the answer is yes
Now say she tells me yes — she wants to have sex. I ask: is something stopping you?
If she says no, nothing’s stopping her, we’re done there too.
If she says yes, something is stopping her, it usually comes down to one of two things: desire is missing, or there’s pain and discomfort. Both are things we can work with.
First things first. Desire.
Desire isn’t as simple as it sounds
We tend to assume desire is spontaneous — you feel like having sex, so you initiate it. But desire can also be responsive: you may not be thinking about sex on a random Tuesday, but once there’s affection or touch, it shows up.
“I don’t think about sex very often” is not the same as “I don’t enjoy sex anymore.” Those are different problems, and they deserve different responses.
Your brain is a huge part of desire, and it comes to bed with you. Sleep, mood, stress, energy — all of it affects desire. As do some medications. As does depression and anxiety.
Testosterone matters for some women, and there are cases where testosterone therapy is the right call.
But I haven’t found “low libido equals low testosterone” to be a useful shortcut. I want to know what has changed in a woman’s sex life, and whether she wants anything to be different.
Desire doesn’t exist in a vacuum, either. Sometimes the problem isn’t hers — it’s a partner dealing with his own aging body, his own erectile dysfunction, his own drop in interest. Sex after menopause is often a two-body problem, not a one-woman diagnosis.
Body image plays a role too, separate from any hormone level. How a woman feels about her changing body can affect desire as much as any lab value does.
If it’s pain
Please don’t assume you have to live with it.
Some pain is clearly from tissue changes with menopause: dryness, itching, thinning, fragility, pain with penetration. This is genitourinary syndrome of menopause, or GSM, and it’s very treatable. Recurrent UTIs can be part of the same picture — another sign the tissue needs attention.
For daily comfort, vaginal moisturizers used regularly are different from lubricants used during sex — one maintains the tissue, the other reduces friction in the moment. Most women benefit from both.
Beyond that, I use local vaginal hormones often — vaginal estrogen most commonly, sometimes vaginal DHEA, and in select patients, vaginal testosterone. Some of you hear the word “estrogen” and think, I don’t want to take hormones.
But local vaginal estrogen and systemic hormone therapy aren’t the same thing. With low-dose vaginal estrogen, systemic exposure is generally very low. So if you’ve ruled out systemic hormone therapy for yourself, that doesn’t have to rule out local vaginal estrogen. They’re not the same exposure, and it’s worth a conversation before you decide it’s not for you.
Ospemifene, an oral, selective estrogen receptor modulator, or SERM, is another option for women who can’t or won’t use a vaginal hormone at all. Breast cancer survivors deserve a separate note here. The medical establishment has moved towards local vaginal hormones being ok to use but certainly non-hormonal options should be part of that conversation.
I had a perimenopausal patient who hadn’t been having sex for a while. I started her on vaginal DHEA suppository. Not long after, she told me she could actually orgasm much more easily than before.
Sometimes you get unexpected beneficial side effects.
But seriously, it’s what treating the tissue and getting it healthier can do.
The vulvovaginal region is rich in testosterone receptors and DHEA is a precursor to testosterone. So the biology makes sense to me.
Addressing GSM isn’t a fast fix
I have a patient whose tissue had changed so much it looked almost like lichen sclerosis, and sex was very painful for her. After three months of regular DHEA and estrogen, her symptoms were only 30% better. Now 8 months into treatment, we are still at only 50%. But this is a 50% improvement from a condition that had caused significant distress to my patient, and she is much happier now, so I will take it. She does too.
Fixing the pain often comes before fixing desire: if your brain has spent a year learning that sex hurts, it has no reason to start asking for it again.
I’d also rather treat this earlier than later. Waiting until symptoms are severe just means more tissue to recover and more months of discomfort in the meantime.
For women who don’t have straightforward pain but ongoing pelvic muscle tension — guarding on top of atrophy, or pain that doesn’t fully resolve with tissue treatment — pelvic floor physical therapy is worth pursuing. It’s underused and it works.
But some pain is different. Deep pelvic pain may not be menopausal atrophy. If you’re having new, changing, worsening, or severe pain deep in the pelvis during sex, I don’t want you deciding on your own that it must be menopause. That deserves a real look: a gynecologist, a physical exam, imaging if it’s called for. Not everything that happens to you in midlife is happening because of menopause.
The point of all this
If you don’t want sex and you’re at peace with that, there’s nothing to fix. If you want it and something’s in the way — pain or desire — that’s identifiable and treatable. And if you say no, that’s the end of the conversation.
Maybe you want to enjoy sex again. Maybe you want it to stop hurting. Maybe you miss wanting sex and want to understand why that changed. Maybe you want to take care of your vaginal and urinary tissues whether or not you’re having sex. Maybe you’re perfectly happy without it. You decide.
If you do want something to change and there’s a partner involved, that usually means an actual conversation with them — not just permission to feel a certain way, but saying out loud what hurts, what’s changed, and what you’d like to try differently.
Sexual health is part of your health. For some, it’s part of their identity. But your sexual life belongs to you. My job is to help you understand what’s changed, sort out what needs attention from what doesn’t, and give you real options. What you do with that is yours to decide.
And if you want sex, you’re able to have it, but you don’t have anyone to have it with — that one, you’re on your own for.
