Menopause and Sexual Health: Understanding GSM, Desire Changes, and Effective Treatments
Written by Elizabeth Bird, PhDMaybe it started gradually…more discomfort, less interest, a sense that something about sex had shifted.
Or maybe menopause arrived all at once and you suddenly felt like you didn’t fully recognize your body anymore. Whether you’re approaching menopause (perimenopause), in the thick of it, or years past the transition, you deserve to understand what’s happening and know that relief and pleasure are still very much possible.
When many people think about sexual difficulties in menopause, the first thing that comes to mind is vaginal dryness. While dryness is real, it doesn’t fully capture the physical and sexual changes that occur as estrogen levels decline. Many people also assume that menopause automatically causes low sexual desire, but everyone’s experience is unique.
What Really Happens to the Vulva and Vagina During Menopause
Estrogen keeps vulvar and vaginal tissues healthy and comfortable. As hormone levels decrease, people may notice:
Less natural lubrication
Thinner, more fragile tissues
Changes in tissue sensation
Reduced elasticity
Shrinking of the labia minora (inner lips)
More susceptibility to microtears
Higher frequency of UTIs
These changes fall under Genitourinary Syndrome of Menopause (GSM) which is a commonly used term for the combined impact of hormonal changes on vulvar, vaginal, and urinary health.
Estrogen levels in menopause are similar to the extremely low hormone levels during breastfeeding, which explains why both periods can bring similar physical changes. Some medications can also cause similar vulvovaginal symptoms even outside of menopause.
GSM isn’t just about dryness. For many people, sensation shifts as well which can influence arousal and orgasm.
How Menopause Affects Sexual Desire
A key part of sexual change in menopause involves how desire shows up.
Spontaneous desire often decreases
This biologically driven, “out of the blue” desire often declines with age and hormonal shifts.
Responsive desire becomes more common
Responsive desire emerges after sexual activity begins. Many people find their body still responds but it just needs more warmup, comfort, or stimulation.
When sex feels uncomfortable, interest in sex naturally reduces so this is another reason tissue changes matter.
The Good News is that Effective, Safe Treatments Exist
One of the most important things to know is that we have treatments that really do help with GSM and menopause-related discomfort.
Topical estrogen
Applied directly to the vulva or vaginal canal, topical estrogen:
Restores tissue elasticity
Improves lubrication
Reduces discomfort
Supports healthy sensation
Lowers UTI risk
Because it works locally, topical estrogen is safe for all people (I’ve heard trusted gynecologists and urologists say that there literally isn’t anyone they wouldn’t prescribe it for) and very different from systemic estrogen where it circulates throughout your body.
The Role of Partner Communication and Flexibility
As bodies change, many people find it helpful to talk openly with partners about what feels good now, what has shifted, and what kind of pacing or stimulation is helpful.
These conversations don’t have to be heavy. Ideally you can name what’s changed and invite curiosity. This no pressure, curious, and playful exploration is not the “go to” spirit for many people when it comes to sex so this is one reason that talking to a sex therapist (as an individual or as a couple) can be very helpful. With a therapist, you can also learn about your own needs and desires whether you are redefining or reconnecting with your sexuality or exploring for the first time.
More Than Hormones: The Whole Menopause Transition Affects Sex
Even with healthy tissues, other menopause symptoms can influence interest and arousal:
Hot flashes
Sleep disruption
Mood changes
Physical discomfort
These symptoms can activate the “brakes” in the Dual Control Model. What helps:
Education and validation – It makes sense that desire dips during discomfort.
Flexibility – Slowing down, adjusting routines, and prioritizing comfort.
Redefining sex – Letting your sexual life evolve with your changing body.
Finding Support That Takes You Seriously
Even though menopause is discussed more now, many people still feel dismissed. Treatments like topical estrogen, HRT, and pelvic floor therapy, individual and couple therapy offer real relief.
Recommended Reading
The Menopause Manifesto — Jen Gunter
The New Menopause — Mary Claire Haver
The Bottom Line
Menopause can bring changes in desire, tissue comfort, and urinary health but none of this means your sexual wellbeing is over. GSM and discomfort are common and treatable. Desire often looks and feels different, sensation may change, and communication with partners becomes more important. With accurate information, supportive care, and a willingness to adapt, sexual pleasure can remain satisfying and meaningful through menopause and beyond.
