Introduction

Menopause occurs when a person assigned female at birth (AFAB) stops experiencing menstrual periods due to changes in hormone levels. It may also occur due to surgery (such as oophorectomy or hysterectomy), cancer treatment (chemotherapy), or genetics. Typically, it happens between the ages of 45 to 55, but may show up earlier and is diagnosed after 12 months of no vaginal bleeding, spotting or menstrual period.^1,2

Physical symptoms may arise in the transition period leading up to menopause. These include anxiety, emotional changes/mood swings, hot flashes, night sweats and/or cold flashes, insomnia (difficulty sleeping), vaginal dryness, urinary urgency, irregular periods or changes to period blood flow, dry skin, dry eyes, dry mouth, worsening premenstrual syndrome (PMS), and brain fog, breast tenderness. Headaches, changes in sex drive, joint and muscle pains, weight gain, and hair loss may also happen.^1,2,3

Pertaining to changes in sex drive, a lower libido can occur as a direct result of many of the symptoms a person experiences during menopause. However, sometimes, the sex drive can increase because there is a reduced fear of conceiving and less concern about family planning.³

Stages of menopause

Menopause, as a natural process, is gradual and involves three different phases:^1,2,3

1. Perimenopause (menopause transition) – This period can begin eight to ten years before menopause, typically in the 40s age range, as the ovaries produce hormones irregularly. It can last for months to many years, but the average time is about four years. During this stage, persons assigned female at birth (AFAB) can get pregnant during this time 
2. Menopause – this is signified by the halting of periods, where the ovaries no longer release eggs, and it’s not possible to get pregnant 
3. Postmenopause – this follows menopause and is ongoing until death. Oftentimes, the regular symptoms of menopause will stop during this time, but some people may still experience mild symptoms for years

Biological changes affecting sex drive

Hormonal shifts

• Decrease in estrogen → changes in the reproductive tract, which affect sex desire 

During menopause, estrogen hormone levels decrease, leading to a series of physical and physiological changes in the reproductive tract.⁴

• Drop in testosterone → reduced libido and sexual responsiveness

The levels of testosterone decrease over time in the postmenopausal period. About 50% of postmenopausal persons assigned female at birth (AFAB) still, however, produce noticeable amounts of testosterone (usually less than premenopausal levels), while the other half generate negligible amounts. This lowered level leads to decreased sexual desire and arousal. Studies show that postmenopausal persons receiving replacement therapy with estrogen and testosterone demonstrated improved libido compared to those on estrogen-only hormone treatment.⁴

Physical and physiological vaginal changes

Due to the hypoestrogenemia induced by menopause, numerous physical and psychological changes take place. These individually and combined affect the sex interest and arousal of postmenopausal persons.⁴

• Atrophic vaginitis – drying, thinning and inflammation of vaginal walls⁵ 
• Vaginal dryness / reduced vaginal lubrication – due to reduced or absent secretions by the Bartholin glands and cervix/vaginal canal
• Deceased blood flow – leading to gradual ischemia and diminished vaginal vasocongestion
• Painful intercourse (dyspareunia) – can lead to vaginismus
• Shrinking vaginal introitus
• Urinary incontinence or infections
• Slowed clitoral reaction time 
• Delayed or lack of orgasm
• Shortening of vaginal length and decreased transcervical width
• Painful uterine contractions – typically in individuals aged 60 to 70 

* Extragenital changes include a smaller bladder, thinning of the bladder’s and urethra’s mucous membrane lining, loss of pelvic muscle tone and reduced intraurethral pressure.

Psychological and emotional factors

Mood changes

Psychological problems, like anxiety and depression disorders, can occur due to hormonal changes, which can negatively affect libido. There are a lot of perimenopausal and postmenopausal persons assigned female at birth (AFAB) with untreated depression or anxiety, so this is highly likely.⁴ 

Sleep disruption

Symptoms like hot flashes, night sweats and sleep insomnia reduce energy and mood for sex.^4,6

Relationship and lifestyle factors

Partner dynamics

Ageing partners may face sexual problems due to the physiological changes associated with menopause and the decreasing sexual functioning and/or interest of a sexual partner. Relationship stress and any amassed anger can also contribute to intimacy issues.⁴

Communication

A lack of open dialogue can lower intimacy between partners, so it is important to communicate and discuss sex even if the conversation is difficult. This will allow people to work through any challenges.⁶

Lifestyle stressors

Daily life events and the symptoms of menopause can intertwine and severely interrupt your day-to-day life, making it difficult to be interested in sex.³

Management and support

Medical treatments

• Hormone therapy (HT) and hormone replacement therapy (HRT)

Hormone therapy is provided to those experiencing menopause at a natural age, and hormone replacement therapy is for those with premature menopause. Estrogen is used to replace or replenish hormone levels. It is most beneficial for relieving hot flashes, and also helps with other symptoms like mood swings, vaginal dryness, and to prevent/slow bone loss. For those who have a uterus, combined therapy with progesterone is necessary.^1,2,3 

• Non-hormone medicines 

Treatments without hormones can be used if people opt out of HT/HRT or can’t undergo it. For hot flushes and night sweats, clonidine, fexolinetant, and gabapentin can be used, while for mood symptoms, antidepressants can help. Oxybutynin has also demonstrated effectiveness against menopause symptoms like hot flashes. Ospemifene works on estrogen receptors and is used for dyspareunia associated with thin vaginal tissue^1,2,3 

• Vaginal estrogen, moisturisers or lubricants

Estrongen applied as a vaginal cream, tablet or ring can help with vaginal dryness, urinary symptoms and pain with intercourse. Prasterone is a human-made hormone applied intravaginally to improve dryness and painful intercourse. Other vaginal moisturisers and lubricants can also be utilised. Testosterone gel, while not licensed for people assigned female at birth (AFAB), may be recommended if it will help improve libido.^1,2,3

Therapy and counselling

• Sex therapy, relationship counselling, support groups 

Being a part of a support group focused on transitioning into menopause with other relatable individuals can be extremely helpful. Additionally, regular relationship counselling and sex therapy can restore lowered sex interest.³

• Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is a talk therapy used to treat mental health issues and can aid in the emotional changes produced by menopause, as well as some physical symptoms like joint pain and sleep irregularity.^1,3  

Lifestyle adjustments

Making lifestyle changes like exercising regularly, maintaining a healthy diet, which involves incorporating foods with phytoestrogens, avoiding triggers, and stress management, are good ways to improve menopausal symptoms and effects.³ 

Summary 

Menopause, a natural phase marking the end of menstrual cycles, usually occurs between the ages of 45 and 55 but can also result from medical treatments or genetics. It brings a variety of physical and emotional symptoms, including hot flashes, mood swings, insomnia, and changes in sex drive. While many experience a drop in libido due to hormonal shifts, particularly declines in estrogen and testosterone, some may notice an increase in sexual desire due to the absence of pregnancy concerns.

Menopause unfolds in three stages: perimenopause, menopause, and postmenopause. Each stage involves hormonal changes that can impact sexual function. Reduced estrogen leads to vaginal dryness, atrophy, and discomfort during sex, while lower testosterone levels can cause decreased sexual desire and responsiveness. These physical changes may also contribute to delayed or absent orgasms and reduced clitoral sensitivity.

Psychological factors such as anxiety, depression, and disrupted sleep further affect libido. Relationship dynamics, lack of communication, and everyday stressors can also reduce sexual interest. Fortunately, several management options exist. Hormone therapy, non-hormonal medications, vaginal treatments, and testosterone gels can alleviate symptoms. Additionally, therapy, support groups, and cognitive behavioural therapy help address emotional impacts. Lifestyle changes—such as regular exercise, stress reduction, and a healthy diet—can also improve overall sexual well-being during and after menopause.