Libido

Sexual libido is defined as interest in sex and in being sexual. It is usually the first phase of a sexual response. There are three elements to libido: 

• Sexual drive (biological). Sex drive can be experienced as sexual thoughts and fantasies, actively looking for sexual activity, or tingling and sensitivity in the genitals. Sex drive is variable among women, and can vary individually as well, based on activity, levels of stress, and overall health. 
• Personal attitudes (psychological). Your beliefs, values, and expectations can impact your natural sex drive. Your attitudes result from a combination of your culture, your religious beliefs, your personal history, and your family and friends. Typically, a positive attitude about sex results in greater sexual desire.
• Motivation (psychological / emotional / interpersonal). Motivation is your willingness to behave sexually with a particular partner at any particular time. Motivation is considered to be the most complex component of desire and many experts consider it to be the most important.  

Desire is known to decline with age in both men and women, however women are two to three times more likely to be affected by a reduction in their perimenopause libido and their menopause libido. The effect of aging is variable – some women experience a menopause loss of libido beginning in their midlife years, others notice no change, and a few women in menopause have increased libido. Increased interest may be a result of freedom from contraception (once they hit menopause) or by the increased privacy they experience once their children (if they have any) leave home. While hormones may reduce episodes of spontaneous desire (the mental interest in having sex before there is any stimulus), receptive desire (interest in having sex when your partner initiates it) doesn’t seem to be affected in the same way. [2]

Arousal

Arousal is the physical process that readies your body for sex. Blood flow to the genitals increases, the vaginal lining becomes lubricated, breathing and heart rate speed up, muscles tense, and nipples become erect. Sexual desire usually triggers arousal, but as women age and move through the menopausal transition, sex drive can shift from being the first phase of their sexual response and instead, it becomes the second phase, following arousal. This is commonly seen when your partner initiates sex with seduction or suggestion and then you consciously respond. 

Female arousal after menopause is affected by hormone levels. Lower levels of estrogen can lower the blood supply to the vagina and cause vaginal atrophy (atrophic vaginitis) – an awful name for a common issue. The tissues in the vagina weaken, get thinner, dryer, and may get inflamed, causing pain, burning, or discharge. In fact one of the first noticeable signs of the menopausal transition is reduced vaginal lubrication during arousal. When the vagina is dry, sex can be uncomfortable.  Lowered blood supply also reduces circulation to the vulva, clitoris and the vagina, making arousal more difficult. [2] [3]

Orgasm

Changes in hormones and to the vagina, including reduced blood flow (especially to the clitoris), can impact a woman’s ability to achieve orgasm. The clitoris has an abundance of nerve endings and is extremely sensitive, making it the anatomical source of female sexual pleasure. During the menopausal transition, the clitoris can lose its sensitivity, in part from the reduction in estrogen levels but also due to age-related changes to the circulatory and nervous systems. 

This means that sensations and pleasure felt during sex are reduced and they in turn cause changes to the experience of an orgasm in that they may take longer to achieve or be less intense. This is called female orgasmic disorder. Problems with orgasm are more common in women over the age of 45. [2]

There are two main types of orgasm problems – primary problems, where the woman has never achieved orgasm, or secondary problems where the lack of orgasm results from another sexual issue such as problems with desire or arousal. [9]

Dyspareunia or Painful Sex

The lower levels of estrogen seen during the menopausal transition may cause changes to your vaginal tissues – they get thinner, dryer, and may get inflamed, causing pain, burning, or discharge. When this happens, penetration and intercourse can become very uncomfortable or even severely painful. Sadly dyspareunia is not rare as between 17% and 45% of postmenopausal women say they find sex painful. 

Other Sexual Health Factors

Sexuality is a highly personal and complex characteristic and many different factors can affect a woman’s interest in sex. While this is true at any point during a woman’s lifetime, the menopausal transition causes many changes in a woman’s life, many of which can influence her sexual health and sexuality. Other factors may influence a woman’s level of interest in sex during the menopausal transition and after, including

• Bladder control problems
• Sleep disturbances
• Depression  or anxiety

In addition to the direct impacts of depression and anxiety, treatment options for depression include selective serotonin reuptake inhibitors (SSRI) and serotonin and norepinephrine reuptake inhibitor (SNRI) antidepressant drugs. These have well-known negative impacts on desire and they can slow sexual response. 

• Stress and feelings of being overwhelmed 
• Other health concerns 
• Normal changes associated with aging [3]

Lack of Desire / Low libido / Low Sex Drive

Although sexual problems can be hard to discuss, talk to your doctor. There are options for you to consider, such as counseling or new treatments such as a combination of estrogen and male hormones called androgens that researchers are studying to see if they effectively help boost sex drive in women.

Your doctor may refer you and your partner to a health professional who specializes in sexual dysfunction. The therapist may advise sexual counseling on an individual basis, with your partner, or in a support group. This type of counseling can be very successful, even when it’s done on a short-term basis.

Recall from the introductory section that sexual desire is usually the first sexual response and that desire triggers arousal. During the menopausal transition, sex drive can change from being the first phase of sexual response and instead, it becomes the second phase, following arousal. If you are experiencing problems with a lack of desire, it is worth experimenting with different ways to get aroused, as this may start your desire.

Arousal Problems

The clitoris, located above the opening of the vagina, is often called the primary source of female sexual pleasure due to its very high density of nerve endings. For the majority of women, arousal starts when the clitoris becomes engorged with blood. Treatment for arousal problems centers around increasing blood flow to the clitoris. 

Your doctor can prescribe a sexual aid called the EROS clitoral therapy device (EROS-CTD) to help with this. EROS is the only FDA-approved mechanical device designed specifically to help with arousal problems. The device itself is a small battery-operated suction cup that gets placed over the clitoris before sex. A battery-operated vacuum pump provides suction to the clitoral area, drawing blood into the clitoris that results in increased pressure on the clitoral nerve. Research has shown that using this device increases lubrication, sensation, and even the number of orgasms in many women who have used it. [6] [7] 

Orgasm Problems

Orgasm problems can be a primary disorder (where the woman has never achieved orgasm) or a secondary disorder (where the lack of orgasm results from another type of sexual dysfunction such as hypoactive sexual desire disorder or low sex drive). [9]

Primary orgasm problems may be genetic or may be the result of a history of trauma or abuse. It typically does not resolve without treatment. Individual and/or couples therapy may be able to help with orgasm problems if they stem from a past traumatic history. Unfortunately, there does not appear to be an effective therapy for unexplained primary orgasmic disorder in which the patient has never achieved orgasm, even through masturbation. 

Secondary orgasmic disorder often resolves when the primary issue is treated. In the meantime, education about and practice with masturbation techniques may be helpful.

Vaginal Dryness

If your vaginal dryness is caused by low estrogen levels, your healthcare provider may prescribe topical estrogen therapy. There are three methods of applying vaginal estrogen:

• Ring: You or your doctor can insert a soft, flexible ring into your vagina. It releases estrogen directly to the vaginal tissues. The ring lasts about three months so it will need to be replaced regularly. 
• Tablets: These tablets are inserted into your vagina with a disposable applicator. 
• Cream: The cream is inserted into your vagina using an applicator. 

There are over-the-counter vaginal moisturizers as well. Speak to your pharmacist or your healthcare provider to get a recommendation. Water-soluble lubricants (such as Astroglide or K-Y Jelly) can also be used on an as-needed basis. Non-water-soluble lubricants, such as Vaseline, are not recommended if you are using condoms for either contraception or for prevention of STIs because they can weaken latex and reduce the effectiveness of the condom.  [5]

Avoid using douches, bubble baths, scented soaps, and lotions around your vaginal area. These products can make any existing dryness even worse.

Don’t forget that your brain is a sexual organ – take your time during arousal and make sure that you are relaxed. This easy step can reduce the ‘performance stress’ that can occur when you start to get stressed because it is taking time to get lubricated. This stress can start a vicious cycle of stress → dryness → more stress.  

Sex Pain

The lower levels of estrogen seen during the menopausal transition can cause your vaginal tissues to get thinner, dryer, and they may get inflamed, causing pain, burning, or discharge. Some oral estrogens (estrogen therapy taken in a tablet that circulates the estrogen throughout your body to all tissues) can help vaginal tissue become thicker and less fragile, which will decrease the experience of pain. 

Note that some oral estrogen hormone therapies are known to thicken the lining of the uterus (the endometrium) causing a condition known as endometrial hyperplasia that is usually associated with too little progesterone. Talk to your healthcare provider to find the best oral estrogen for your needs. 

Understanding the Lack of Desire

The formal name for decreased or lowered desire is Hypoactive Sexual Desire Disorder. [9] Scientific studies have consistently shown that about one third of women in the US women report low sexual desire or interest. This lack of desire, however, is only troubling to about one in three of those women. [2] Midlife women, who are typically in the menopausal transition, report being troubled by their lack of desire at a higher rate (12% reporting) compared to both post-menopausal women (7% reporting) or women younger than 45 years of age (9%). [1] 

One large (31,581 participants) cross-sectional, nationally representative study in the US is called the Prevalence of Female Sexual Problems Associated with Distress and Determinants of Treatment Seeking (PRESIDE) study. [8] This study used a 42 item questionnaire to measure sexual function, sexual distress, demographic, and health-related factors. The results showed that women with low sexual desire were most likely to be distressed by their lack of desire if they:

• are currently in a relationship with a partner
• are 35 to 64 years old (in midlife vs older or postmenopausal)
• are experiencing depression

Other factors also influenced whether women were bothered by their lack of desire, including urinary incontinence, anxiety, social skills, and the experience of other problems with arousal or orgasm. Women’s satisfaction about their overall relationship with their partner also had an important effect on desire and any distress they felt because of low desire. The study concluded that the strongest correlate of women being distressed about their lack of desire was having a current partner. In other words, women without a partner may experience a lack of desire but they are not as troubled by it. [8]

Although not directly related to menopause, an age-related decrease in testosterone may also play a role in reduced desire for midlife women. Testosterone is known to play a role in women’s sex drive and experiencing sexual sensation. The direct relationship between testosterone and sexual desire needs more research as low sexual desire in women does not appear to be related to testosterone levels in scientific studies. [2] 

Understanding Arousal Problems

Difficulties with arousal are formally classified as Female Sexual Arousal Disorder. Arousal difficulties can result from changing hormone levels, and are also often seen in women experiencing other gynecologic or chronic medical conditions. Certain antidepressant medications, particularly selective serotonin reuptake inhibitors (SSRI) and serotonin and norepinephrine reuptake inhibitors (SNRI) can have a negative impact on the ability to experience sexual arousal. Arousal issues usually resolve when the underlying condition is treated or the medication is adjusted.

The Prevalence of Female Sexual Problems Associated with Distress and Determinants of Treatment Seeking (PRESIDE) study reported that arousal problems that cause distress or concern affect about 5% of US women. In that survey, the rate of bothersome arousal problems was highest  among women ages 45 to 64 (7.5%) compared to women 65 or older (6%) or women younger than 45 (3%). [8]

Additionally, this research showed that troublesome arousal problems are more common among women:

• who are married or living with their partner
• women who had experienced surgical (rather than natural) menopause. This occurs as a result of an oophorectomy, a surgery that removes the ovaries that are the main source of estrogen production in the female body. 
• women who were in worse overall health. [8]

Understanding Orgasm Problems

A persistent or recurrent delay in, or total absence of orgasm after a normal arousal phase and adequate stimulation is called Female Orgasmic Disorder. It occurs in about 5% of US women. [9] This can be a primary disorder, where the woman has never achieved orgasm or a secondary disorder,  where the lack of orgasm results from another type of sexual dysfunction such as hypoactive sexual desire disorder or low sex drive. [9]

Another large nationwide survey found that about 5% of US women have a problem achieving orgasm and that causes them concern. [1] The survey found that the rate of problems with orgasm was higher among women ages 45 to 64 and those 65 or older (6% in both groups) than among women younger than 45 (3%).

Understanding Sex Pain

A significant number (17%- 45%) of perimenopausal and post menopausal women report experiencing pain during sex. This is called dyspareunia. The most common causes for this pain in women older than 50 are vaginal dryness and thinning of the vaginal tissues, both symptoms of a condition called vaginal atrophy. Another cause of pain during sex is vulvodynia, where women experience chronic pain in the vulva (the external part of female genitals).  

Aside from the actual sensation of pain, anticipating or fearing pain during sex can cause anxiety and this in turn impacts sexual desire or the ability to become aroused. Concern about painful sex can also reduce lubrication and can cause vaginismus, which is involuntary, painful tightening of the vaginal muscles. [2] 

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Understanding Depression

Approximately 40% of women experiencing any problems with sexual desire, arousal, orgasm, or pain are also experiencing depression. It is unclear if the depression triggers the sexual problems, or if the sexual problems trigger the depression. What is clear is that any woman experiencing sexual problems in the menopausal transition should also be screened for depression. [10]