Low Libido in Menopause

Losing interest in sex after menopause is common and often has several causes. Painful, dry sex, lower testosterone, antidepressants, poor sleep and relationship problems can all play a part. Treating one cause, often vaginal symptoms, may not be enough.

Why does menopause lower libido?

1. Sex hurts, or has started to. Falling estrogen thins the vaginal lining, reduces lubrication and blood flow, and slows arousal. Sex that was comfortable can become painful, and desire can fall after painful sex. Our vaginal dryness page covers this in detail; it is a common, treatable cause.

2. Hormones, including testosterone. Women make testosterone too, from the ovaries and adrenal glands, and it is the hormone most tied to desire and arousal. Levels fall gradually from the twenties and are roughly half by the fifties; women who have had their ovaries removed drop faster. Estrogen’s fall matters less for desire itself than for everything around it: comfort, sleep, mood and energy. See signs of low testosterone in women.

3. Mood, stress and sleep. Depression and anxiety suppress desire directly, and the medications most used to treat them, SSRIs and SNRIs, suppress it further. Chronic sleep loss from night sweats leaves little energy for sex. Body-image changes with weight gain can also affect desire.

4. The relationship and the life. Twenty-plus years with the same partner, teenagers or ageing parents in the house, a partner with their own erectile or health problems, or simply never having talked about what you actually want. Hormones didn’t cause these and won’t fix them, and a page about menopause that pretends otherwise isn’t being honest.

Most women have more than one cause, so treatment usually works through them in steps.

Is it a problem if I don’t mind?

Only if you mind. Low desire that doesn’t bother you or your relationship doesn’t need treating, and no clinician should push it. The medical term, hypoactive sexual desire disorder, specifically requires that the low desire causes you distress. If it does, it’s as legitimate a thing to treat as hot flashes.

Does testosterone help women’s libido?

How Golden Leaf Health prescribes it, for patients in California, is in testosterone for women: what we prescribe.

Yes, with conditions.

For postmenopausal women with distressing low desire that remains after pain, mood, sleep and medication causes have been dealt with, transdermal testosterone at physiological female doses improves desire, arousal, pleasure and satisfaction in randomised trials, with modest effects. That is the conclusion of the 2019 international consensus statement on testosterone for women, endorsed by the major menopause and endocrine societies.

The practical details matter:

• Form. Gel or cream applied to the skin, at about a tenth of a male dose. No testosterone product is FDA-approved for women in the US, so it is prescribed off-label from male products or compounded at the female dose. Golden Leaf Health prescribes testosterone for patients in California only.
• Monitoring. A baseline blood level, then a check after a few weeks to make sure the level is within the normal female range and not above it.
• What’s not recommended. Pellets, injections and high doses, which produce levels well above the female range, with acne, hair growth, voice changes and unknown long-term risks. Golden Leaf Health doesn’t offer pellets.
• Timeline. Three to six months to judge the effect; stopped if there isn’t one.
• Who it isn’t for. Women whose low desire is explained by one of the other causes above, and women with certain cancers or liver disease. It isn’t a fix for low energy or mood on its own, though some women notice both improve. Our benefits of testosterone for women post goes further.

Does HRT improve libido?

Often, indirectly. Systemic hormone therapy treats night sweats, sleep, mood and dryness, and desire may return when those were the main problems. What estrogen alone does not reliably do is restore wanting in a woman who is comfortable and sleeping well and simply isn’t interested. Then discuss testosterone, mood or the relationship.

Note that oral estrogen raises the protein that binds testosterone, which can lower free testosterone and occasionally blunt desire; transdermal estrogen doesn’t do this, and it’s one reason patches and gels are often preferred when libido is on the list.

Treat painful sex first

If sex hurts, start there. Low-dose vaginal estrogen (cream, tablet or ring), used regularly, restores the tissue in a few weeks. Very little is absorbed into the body, and it is considered safe for most women, including many who can’t take systemic hormones. Vaginal DHEA and the oral drug ospemifene are alternatives. A silicone lubricant, a vaginal moisturiser two or three times a week and more time for arousal can also help.

Medications that lower libido

If desire dropped after a prescription started, suspect it:

• SSRIs and SNRIs (most antidepressants): the commonest cause. Bupropion is the exception and sometimes the switch.
• Some blood pressure medications, especially beta-blockers
• Antihistamines and some sleep aids
• Opioid painkillers
• Hormonal contraceptives, which also raise the protein that binds testosterone
• Anti-androgens such as spironolactone

Never stop these on your own; raise it with the prescriber, who usually has an alternative.

What helps that isn’t a prescription

• Scheduling it. Spontaneous desire fades for most people in long relationships regardless of menopause; responsive desire, wanting once things have started, persists. Planning intimacy is not unromantic, it’s realistic.
• Talking. With your partner about what works now, which has changed. Most couples haven’t updated the conversation in a decade.
• Sleep and movement. Both raise energy, mood and body confidence; see sleep problems.
• Alcohol. A little lowers inhibition; more than a little blunts arousal and orgasm.
• Pelvic floor physiotherapy. For tightness, pain or weak orgasm; underused and effective.
• Sex therapy. A certified sex therapist is the right call when the problem is the relationship, past trauma, or a mismatch in desire between partners. Hormones won’t fix those; a few sessions often do.

Getting help

Low libido is a legitimate reason for care at Golden Leaf Health. A video visit reviews pain, hormonal symptoms, medications and relationship factors. Testosterone is available for patients in California only when appropriate. Book a first visit if you want help deciding what to treat first.

Sources: Mayo Clinic, Low sex drive in women; National Institute on Aging, Sex and menopause; The Menopause Society; ACOG, Your sexual health.