Sex during menopause and beyond: how to reignite the passion

The perimenopause – the time leading up to menopause – can change the way your vagina feels, as well as how it functions. This is quite common, due to the amount of oestrogen usually present in and around our sexual organs.

In fact, it has its own name: genitourinary syndrome of menopause, or GSM. Different studies have yielded different results, but it’s thought that anywhere between 27% and 84% of menopausal women experience GSM in some form.

Symptoms include, but are not limited to, the following:  

• dryness  
• itching 
• uncomfortable or painful sex 
• repeated urinary tract or yeast infections 
• stress incontinence
• vaginal atrophy (thinning and narrowing of vaginal walls) 
• a change in the appearance of the vulva. 

Unlike a lot of menopause issues, GSM symptoms are not just experienced during menopause. They are also associated with ageing, and so may persist or even worsen over time. However, it’s important to know that there are ways to ease symptoms (more on that later), and things you can do to ensure you can enjoy a full and active sex life throughout menopause and beyond. 

Throughout our adult lives there are times when we’re in the mood for sex, and times when intimacy takes a back seat – such as when work is stressful, or you’re dealing with a house move, caring for relatives, and so on.  

But overall, sexual intimacy with a partner forms an important part of a loving relationship, and it shouldn’t have to stop due to menopause. Hormonal changes can have a profound effect on our mood, mental health and our bodies, however, meaning sex becomes the last thing on our minds. 

Miranda Christophers is a relationship and psychosexual therapist, and Issviva menopause ambassador. She works with individuals and couples on matters of sexual intimacy. Christophers says mood fluctuations during menopause can affect desire and libido.  

“You might notice that you’re not feeling as you did previously, maybe you’re feeling a bit more anxious. You might be having some mood swings, feeling lower, and experiencing volatility. You might also notice that you lose your temper more, or just don’t feel quite yourself. So that’s something to really consider.” 

She adds: “A lot of people say menopause can affect how you feel towards partners or potential partners. One of the other things to consider is the physical changes that are happening in your body as you’re going through menopause. As hormone levels fluctuate and oestrogen declines, you might notice changes in desire that you hadn’t noticed at all before.” 

If you’re experiencing physical symptoms, such as vaginal dryness or recurrent infections, you might understandably feel less in the mood for sex. Combined with mood fluctuations, this can really affect a relationship. Christophers stresses that this is more common than we may think.

“People often feel very alone with it,” she says. “I talk to individuals in the therapy room all the time about how this has affected their relationships and their sense of self. They may have had regular sexual intimacy or sexual thoughts before and may notice that’s changed. And that’s very important to people who are sexually active in terms of their sexual sense of self and feeling sexually alive. 

“We’ve got to think about how that affects somebody. How are they feeling about themselves, what does their self-esteem look like, how is it affecting their confidence? Body image is an important consideration, if you don’t feel good about yourself because of how you feel, you look, or because you’re going through a period of change.

“If all of that is affecting your relationship with your partner, then ultimately that is likely to affect your confidence and self-esteem. That can very much have an impact on desire.” 

A change to the physical makeup of the vagina can also become a barrier to sex. The vagina has a thick wall made up of rugal folds, which stretch during sexual activity (or to make room for a baby when giving birth). But as oestrogen levels fall, the walls of the vagina become thinner and flatter, preventing these folds from expanding properly. The vagina can also shorten and narrow, leading to painful sex, even if aroused.

“The reduction in elasticity and thinning of the skin can affect the vulva area too,” Christophers says. “And with that, women can find that they get tears and discomfort.  

 “Also, some women experience pelvic area prolapses. These symptoms don’t affect everybody,” she points out, “but we need to be aware of them.” 

Urinary incontinence is common for many women as they get older (especially after having children). It can be a symptom of the menopause too, because of the issues caused by GSM. 

“Regardless of whether you’ve had children or not, many people experience urinary incontinence,” Christophers tells us. “This can present in terms of leakage when you’re laughing, when you sneeze or cough, or you can feel an urgent need to get to the toilet. This can really affect confidence apart from anything else, as well as being uncomfortable and embarrassing. 

“And that’s really sad because when you’re moving into another part of your life, you want to be able to enjoy it and do the things that actually make you feel good.”

Urinary incontinence is something that can worsen over time if left untreated, but pelvic floor exercises can really make a difference (see more below), and your post-menopausal sex life doesn’t need to suffer because of it.  

Other menopause symptoms can be urinary tract infections (UTIs), or an increase in bacterial vaginosis, or thrush, due to the changes in acidity in the vagina. These can all make for discomfort when urinating, a burning sensation, or itching in and around the vulva, but can be eased with over the counter medication.  

If these become a persistent problem, please seek medical advice, as they can worsen if left untreated. 

It might seem overwhelming but remember we won’t all experience all of the above issues – and even if we do, not all these symptoms will remain as we come out the other side of menopause. However, even one of those is enough to seriously affect your sex life.  

Christophers has top tips on how to navigate these issues and improve intimacy with your partner.  

Christophers says: “The thing to remember is that lots of people are going through menopause and everybody’s situation may be different in terms of their relationship status, gender identity, individual circumstances, and where they are in that menopause transition period.

“The key thing is that they are all going through menopause and maybe experiencing differing degrees of menopause symptoms. It’s really important to remember that, regardless of your sexual identity, gender or gender identity, or relationship status, if you’re experiencing menopausal symptoms or you are affected by menopause, then you are part of the menopause community.” 

“I want people to be able to enjoy the intimacy and the sex lives that they would like to have,” she says. “What we understand in terms of relationships is that sense of closeness, understanding and communication are important. And for many people, intimacy on some level really matters to them. That can be physical intimacy, or sexual intimacy. What’s important is that people don’t feel they need to be doing a particular thing. It’s about finding the intimacy that works for them.” 

She suggests: “Think about emotional intimacy. What would you like to be doing with your partner? Is it spending more time together, going out for dinner, doing things at home that are pleasurable, taking up new interests?” 

“It can be helpful for partners to know what you’re experiencing,” says Christophers. “Make sure you’re talking to your partner, really engaging with them, so they can understand what you’re experiencing, why you’re experiencing it, and what else you would enjoy doing. It’s also helpful for you to understand what’s happening for them and for any other family members as well. You may have children in the house, and you may have work colleagues you feel you’d like to talk to about things if you notice that it’s affecting your relationship.” 

She also recommends seeking professional advice when needed. “I always say to people who are struggling with menopausal symptoms that they may want to think about having a chat with a menopause expert at their GP’s surgery. If you can’t access one through your surgery, try looking on the ACP Forum or Women’s Health Concern.” 

“If you want to be sexually intimate, focus on touch and sensation,” Christophers advises. “You might want to introduce lubricants, even if you’re on your own. You may notice it feels different or increases sensation and sensitivity. If you use sex toys, they can be used externally if you prefer, focusing on clitoral stimulation to reduce any discomfort anywhere else and really focusing on what works for you. 

“You might notice a decrease in sensation, and that it’s harder to get to that point of orgasm. Something to think about is that the orgasm does not need to be the main goal. We have emotional intimacy, physical intimacy, and sexual intimacy. And you can break those apart or combine them. It’s about finding what is right for you and what is comfortable for you.” 

Working the muscles of your pelvic floor can improve stress incontinence and prolapse as well as vaginal sensation. There are several ways to do this. The NHS has a guide to simple pelvic floor exercises you can do at home. It takes time to see results but it’s worth persevering.  

Kegel weights are another popular choice. These small weights or devices can be used internally or externally with pelvic floor exercises. There’s no evidence that pelvic floor exercises work better with or without weights, but some people may prefer the physical sensation of having something tangible to work with.  

Hormone replacement therapy (HRT), or a more holistic approach like cognitive behavioural therapy (CBT), can be useful for addressing symptoms. HRT can help restore oestrogen in the body as well as progesterone. It does carry some associated risk of certain medical conditions, but it can also reduce others, so it’s important to make an informed decision with the help of a medical professional.  

Dr Paula Briggs, from The British Menopause Society, says that urogenital atrophy (the thinning of the vagina and urinary tract) responds well to certain treatment: “It can be treated with vaginal oestrogen, which is a low dose (of HRT) and doesn’t get systemically absorbed.”  

Vaginal oestrogen is applied locally, meaning very little oestrogen is absorbed into the bloodstream. Because of this, it rarely causes any health issues to those taking it, although, as always, you would need to consult your doctor or medical professional for advice.  

If HRT isn’t for you, cognitive behavioural therapy can be very beneficial in building coping mechanisms, and enabling you to better deal with symptoms.