As you navigate through the menopausal transition from perimenopause to menopause to the postmenopausal years, you may notice changes that affect your sexual desire and intimacy. One common concern during this transition is low libido, which can be linked to hormonal changes that occur in your body. These changes can lead to feelings of frustration and confusion as you try to understand what is happening to your body.

There can be a variety of causes of low libido in women. The most common causes being:

1. Hormone changes
2. Medications and side effects 
3. Anatomical
4. Mental & emotional
5. Relationship & lifestyle

Low libido during the menopausal transition is a common experience for many women, driven largely by hormonal fluctuations that impact both your physical and emotional well-being. This period can be challenging, but recognizing the reasons behind these shifts can help you find ways to reconnect with your sexual self and improve intimacy.

These fluctuations can lead to a decreased interest in sex, affected by various factors including hormone levels, particularly estrogen and testosterone. 

Related to low libido is a condition called Genitourinary Syndrome of Menopause (GSM) which is an umbrella term that includes Vulvovaginal Atrophy (Vaginal Atrophy) as well as other conditions related to menopausal changes in the vagina and surrounding structures.

GSM is a common condition affecting menopausal women, characterized by symptoms such as vaginal dryness, pain with intercourse (dyspareunia), and urinary issues (such as increased urinary tract infections, increased urinary frequency, etc.) due to decreased estrogen levels.

Vaginal estrogen is the most frequently used treatment for GSM, offering a localized hormone therapy option. GSM affects up to 84% of postmenopausal women and may significantly reduce the quality of life in some.

Vaginal estrogen can support the healthy bacteria such as Lactobacillus Acidophilus that normally reside in the vaginal tissue. The presence of these healthy bacteria help to prevent "bad" bacteria that are opportunistic and look for a chance to move in such as E. Coli, and other bacteria that can increase the risk of urinary tract infections.

"Individualized treatment options for genitourinary syndrome of menopause (GSM) can provide relief from discomforts, with hormones, testosterones, and energy-based therapies being effective." (Shim, et al, 2021)

The Role of Hormones in Sexual Desire

Hormones play a crucial role in regulating your sex drive. As you enter perimenopause, levels of estrogen and testosterone may begin fluctuate and overall will start to decline. Estrogen contributes to vaginal lubrication and elasticity, which are important for comfortable sexual activity. Low levels can lead to dryness and discomfort, impacting your desire for intimacy.

Testosterone, although often considered a male hormone, is also vital for women's libido. It influences sexual arousal and mood. Changes in hormone levels during the menopausal transition can create a complex picture, leading to a decline in libido and specifically desire can decrease. 

Hypoactive Sexual Desire Disorder (HSDD)

Testosterone is prescribed to women who are post-menopausal and who have decreased desire. The indication for use is for Hypoactive Sexual Desire Disorder (HSDD) in women who have use systemic Hormone Replacement Therapy (HRT) but still have not seen improvements in their libido. HSDD is defined as persistent or recurrent deficiency or absence of sexual desire that causes significant personal distress or interpersonal difficulties. This condition is not attributable to another medical condition, medication, or other primary disorder. Speak to your primary care provider to discuss this treatment option. Testosterone is typically prescribed by your Medical Doctor (MD) or Nurse Practitioner (NP).

Lichen Sclerosis (LS)

Anyone with vaginal symptoms needs to have a proper exam to identify and rule out any other underlying conditions such as Lichen sclerosus (LS) which is a condition that affects the outer labia and surrounding tissue and perineum. It can cause a thinning and change within the surrounding tissue. LS is treated differently then just GSM usually with a topical corticosteroid ointment. However LS and GSM can also occur concurrently in some women, as they are both common in the post menopausal years. It is important to have your symptoms discussed and treated accordingly with your primary care provider.

Estrogen Levels and Sexual Health

Low estrogen levels during the menopausal transition can directly affect one's sexual health. Vaginal estrogen treats changes in and around the vagina as well as the structures outside including the outer labia. Symptoms can include vaginal dryness, irritation, itching, soreness and pain with intercourse. These changes can be frustrating and may cause feelings of inadequacy or concern about your relationships.

"Local estrogen therapy (LET) is the mainstay treatment for vaginal dryness, dyspareunia, and other urogenital symptoms in postmenopausal women, but patient-tailored studies are needed to investigate its effects on quality of life, sexual function, and genitourinary conditions." (Nappi, et al, 2024)

Hormone replacement therapy (HRT) could be beneficial in restoring balance. Options include localized vaginal estrogen creams, pessaries, rings or tablet inserts that target only vaginal tissues, giving relief without giving any systemic hormone chances. 

For symptom relief of GSM, there are several non-hormonal and hormonal vaginal products available. In Europe, vaginal estriol (E3) is the most frequently chosen estrogen for GSM treatment.

"With appropriate treatment, many postmenopausal women can experience relief from discomforts, including burning sensation or dryness of the vagina and dyspareunia. Topical lubricants and moisturizers, systemic and local estrogens, testosterones, intravaginal dehydroepiandrosterones (DHEAs), selective estrogen receptor modulators, and energy-based therapies are possible treatment modalities." (Shim, et al, 2021)

Vaginal Estradiol

Vagifem® is a very commonly recommended form of vaginal estradiol that is a prescription your ND or MD can prescribe. It is considered bio-identical or "body-identical" as it contains the 17-β-Estradiol that is the same compound our body makes.

Vagifem® comes in a 10 mcg vaginal tablet that is inserted vaginally at bedtime. The typical dosing is to insert every night for 14 days consecutively, followed by twice a week ongoing.

Vaginal Estriol Cream

Vaginal Estriol cream is a compounded product is a prescription your ND or MD can prescribe. The cream is inserted vaginally but it can also be applied to the outer structures of the labia if there is dryness as well as pain with intercourse. Estriol comes in various concentrations but the typical dosing is 0.1% Estriol vaginal cream compounded by a compounding pharmacy. I often recommend that patients who experience dryness to also have hyaluronic acid and Vitamin E added to the compounded creams. This can be a benefit in helping to prevent further dryness. The typical dosing is similar to the Vagifem, 14 days insertion followed by twice a week ongoing.

"Vaginal estriol (E3) for genitourinary syndrome of menopause treatment does not cause long-term changes in serum sex hormone levels, supporting its safety for postmenopausal women." (Kolokythas, et al, 2024)

Vaginal Moisturizers

Vaginal moisturizers are a non-hormonal option used to treat vaginal dryness and is designed to be used regularly to replace vaginal moisture and alleviate long-term dryness,. Many brands contain hyaluronic acid, which helps the vaginal tissue to retain moisture and promotes wound healing. Some brands also contain Vitamin E which is a natural antioxidant that helps relieve dryness, itching, and sensitivity.

Vaginal moisturizers can help alleviate dryness and are different then lubricants (see below). Vaginal moisturizers are used typically once a day for one week and then reduced to twice a week. Most brands come with a reusable applicator that can be washed and air dried. They are safe and effective treatments and there are many brands available over the counter.

My most recommended vaginal moisturizer brands are:

• Gynatrof Vaginal Moisturizer
• Replens Vaginal Moisturizer
• Bio-Nourish Ultra Moisturizing Vaginal Gel by Good Clean Love (good for sensitive tissue)

Vaginal Lubricants

Vaginal lubricants are different then vaginal moisturizers in that they are used just prior to intercourse. They are typically used on an "as needed" basis and not continuously, as lubricants don't change the actual cell structure but can provide temporary relief during intercourse by reducing friction.  Essentially, moisturizers are absorbed into the vaginal tissue, while lubricants sit on the surface to decrease friction.

There are various types of vaginal lubricants.

• Water-based: Safe for most situations and easy to clean up.
• Silicone-based: Longer-lasting, ideal for extended use.
• Oil-based: Not compatible with latex condoms but can be very moisturizing.

Look for options that offer long-lasting hydration and are free of fragrances and irritating chemicals. Incorporating these products into your routine can greatly enhance your comfort during intimacy.

Improving Sexual Wellness

Addressing low libido during the menopausal transition involves a multidimensional approach and while hormone replacement therapy (HRT) can be a very helpful treatment, it is also important to rule out any other causes of low libido. You can improve your sexual wellness through lifestyle changes, medical treatments, and open communication in relationship. Each of these areas plays a vital role in enhancing your overall sexual function and well-being.

Lifestyle suggestions for Healthy Libido

Making specific lifestyle changes can positively impact your libido. Regular exercise is crucial; activities like walking, swimming, or yoga can increase blood flow and reduce stress. Aim for a minimum of 150 minutes of moderate exercise each week. 

A balanced diet rich in adequate protein, whole food and nutrient dense foods (fruits, vegetables, whole grains, and healthy fats) can support healthy blood sugar.

Beets for example are a great addition to any salad and have been part of the Mediterranean diet for generations. Anecdotal evidence also has shown beets to be beneficial for libido. Beets are rich in nitrates, which can increase plasma nitrate and nitrite levels. This increase is associated with improved blood flow and reduced inflammation, which could potentially influence sexual health and libido positively in both women as well as men.

Mindfulness and Stress Management

In a 2024 study, 41 women who started attending groups, 37 (90%) attended at least 5 sessions. In the mindfulness group, 73% of women were very or extremely satisfied as well, women in the mindfulness group had significant improvements in sexual distress (mean Female Sexual Distress Scale). Mindfulness may decrease distress with low libido in post menopausal women. 

"A virtual mindfulness intervention is feasible and acceptable for midlife and older women with low libido, potentially reducing sexual distress compared to an education control." (Thomas, et al, 2024)

Open communication about sexual needs and concerns is vital. Discuss your feelings with your partner to foster understanding and support. This conversation can help both of you navigate the changes in your sexual relationship during this phase.

It's essential to recognize mental health impacts - anxiety and depression for example - are common areas of concern. They may not only lower your libido but also affect your self-esteem and body image. Finding ways to manage stress can be an important step towards improving your sexual wellness.

Prioritizing your relationship dynamics can lead to a more satisfying sexual life. Finding ways to connect and express affection outside the bedroom can also enhance your overall sexual wellness.

Pelvic Floor Physiotherapy

Consulting a healthcare provider can help you explore options like pelvic floor therapy, which identifies area of weakness or tension in the pelvic floor muscles. Techniques and exercises provided by a pelvic floor physiotherapist can help and can enhance arousal and decrease pain or tension

Counselling and Support for Sexual Issues

Seeking help through counselling or therapy can be beneficial for couples struggling with issues surrounding intimacy. Talking about your feelings with a professional can allow you to explore the emotional aspects affecting your libido. Cognitive behavioural therapy is one option that focuses on changing negative thought patterns. It can help you develop coping strategies for stress and emotional changes. Couples therapy or seeing a sex therapist, focuses specifically on sexual concerns and communication with your partner.

Navigating the menopausal transition involves understanding your body’s changes. Seeking support from your healthcare providers can provide tailored advice and strategies for you.

Interested in booking a free discovery call with Dr. Amy? Book here.

To your best health,

Dr. Amy Tung, ND

Naturopathic Doctor

References:

https://drannagarrett.com/dealing-with-loss-of-libido-in-perimenopause-and-beyond/

Cumming, G., Currie, H., Moncur, R., & Lee, A. (2009). Web-based survey on the effect of menopause on women's libido in a computer-literate population. Menopause International, 15, 12 - 8. https://doi.org/10.1258/mi.2009.009001.

Davis, S., & Jane, F. (2011). Sex and perimenopause.. Australian family physician, 40 5, 274-8.

Kolokythas, A., Betschart, C., Wunder, D., Janka, H., & Stute, P. (2024). Impact of vaginal estriol on serum hormone levels: a systematic review. Climacteric, 27, 137 - 153. https://doi.org/10.1080/13697137.2023.2287624.

Myskow, L. (2002). Perimenopausal issues in sexuality. Sexual and Relationship Therapy, 17, 253 - 260. https://doi.org/10.1080/14681990220149059.

Nappi, R., Tiranini, L., Martini, E., Bosoni, D., Cassani, C., & Cucinella, L. (2023). Different local estrogen therapies for a tailored approach to GSM. Climacteric, 26, 361 - 366. https://doi.org/10.1080/13697137.2023.2218998.

Nieman, D., Sakaguchi, C., Williams, J., Mulani, F., Suresh, P., Omar, A., & Zhang, Q. (2024). Beet supplementation mitigates post-exercise inflammation. Frontiers in Nutrition, 11. https://doi.org/10.3389/fnut.2024.1408804.

Shim, S., Park, K., Chung, Y., & Kim, M. (2021). Updates on Therapeutic Alternatives for Genitourinary Syndrome of Menopause: Hormonal and Non-Hormonal Managements. Journal of Menopausal Medicine, 27, 1 - 7. https://doi.org/10.6118/jmm.20034.

Thomas, H., Brotto, L., De Abril Cameron, F., Yabes, J., & Thurston, R. (2023). A virtual, group-based mindfulness intervention for midlife and older women with low libido lowers sexual distress in a randomized controlled pilot study.. The journal of sexual medicine. https://doi.org/10.1093/jsxmed/qdad081.

Turna, B., Apaydın, E., Semerci, B., Altay, B., Çikili, N., & Nazlı, O. (2005). Women with low libido: correlation of decreased androgen levels with female sexual function index. International Journal of Impotence Research, 17, 148-153. https://doi.org/10.1038/sj.ijir.3901294.

Disclaimer:

The information in this blog is for educational and informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the guidance of your doctor or other qualified health professional with any questions regarding a medical condition or treatment. Never disregard professional medical advice or delay seeking treatment because of something you have read in this blog.

Individual results may vary, and the strategies discussed here are not guaranteed to work for everyone. This content does not create a patient-client relationship and should not be used as a replacement for personalized medical care.