Low libido in menopause: what no one dares to explain to you
Dryness, pain, flagging desire: we finally separate the two problems that get confused (the genitourinary syndrome of menopause and low desire), and the solutions that really work, with the science. In French with English subtitles.
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What you will understand
Desire that fades, dryness, intercourse that has become uncomfortable or even painful, and that question you dare not ask anyone: "what is wrong with me?". The answer is simple: nothing. It is not in your head, it is not a fault, and it is not inevitable.
This video separates two problems that are constantly confused, even though they have neither the same causes nor the same solutions. On one side, the genitourinary syndrome of menopause: dryness, burning, pain during intercourse. It is physical, very common, and it responds well to specific treatments. On the other side, low desire, which is multifactorial: hormonal, but also linked to sleep, mood, medication, the relationship and, very often, to pain itself.
It then reviews what really works, distinguishing what relieves dryness and pain from what acts on desire. Several treatments are discussed: local estrogen, prasterone (DHEA), ospemifene, testosterone. All are prescription-only and are an individualized medical decision.
What the studies show
Let us start with the feeling of isolation, because the figures contradict it. A large American population-representative study observed that low sexual desire affects about 27% of premenopausal women and up to 52% of naturally menopausal women. An Australian study of women aged 40 to 65 found low desire in nearly seven women in ten, with distress linked to this decline in about four in ten. This experience is therefore the statistical norm, not the exception.
Hypoactive sexual desire disorder, that is, low desire associated with real distress, has also been studied on a large scale. In the international WISHeS study, its frequency increased with age and was more marked in surgically menopausal women than in those with natural menopause. This point matters: it is not menopause as a date that weighs most, but the way, abrupt or gradual, in which it occurs.
Desire is never driven by a single switch. Researchers speak of a biopsychosocial model, in which biological, psychological and relational factors influence one another. Several studies show that life factors, stress, fatigue, body image, mood, quality of the relationship, often weigh as much as or more on desire than hormonal status itself. A qualitative study in middle-aged women identified self-esteem, the ability to feel desirable and relationship history as major determinants, sometimes more explanatory than menopause.
On the physical side, the drop in estrogen dries and weakens the vaginal and vulvar tissues, which is called the genitourinary syndrome of menopause. When every act of intercourse becomes synonymous with pain, the body learns to anticipate and to close off desire, by pure protective reflex. It is a circle better broken early, because the more it settles in, the harder it becomes to undo.
On treatments, the data are more solid than people think. Before any hormonal treatment, vaginal moisturizers, to be used regularly, and lubricants, to be used during intercourse, are an accessible and well tolerated first step. Locally applied estrogen remains the best documented treatment for dryness and pain, with very low passage into the blood compared with a systemic treatment. Vaginal DHEA, or prasterone, was evaluated in a placebo-controlled phase III trial in 216 menopausal women, with significant improvement in dryness and pain from two weeks onward.
As for testosterone, a meta-analysis gathering seven randomized trials and more than 3,000 women concluded that there was a real improvement in desire and sexual satisfaction on transdermal testosterone, with an acceptable short-term safety profile, acne being the most frequent adverse effect. It is not a generalized first-line solution: it is discussed case by case, with medical follow-up, and it does not remove the need to work on the other causes.
Each of these studies is cited with its PubMed identifier in the written and sourced version of this topic.
The key points to remember
- Two distinct problems are systematically confused: the genitourinary syndrome (physical) and low desire (multifactorial).
- The genitourinary syndrome is very common, it does not improve on its own over time, and it can be treated.
- Pain is a major cause of low desire: treating the pain is often the first step.
- The causes of desire are multiple: hormones, sleep, mood, medication, relational context.
- Local treatments act where it is needed and can be discussed even with women who do not want a systemic treatment.
- Everything discussed is prescription-only: it is a conversation to have with a doctor, not self-medication.
- Up to 52% of menopausal women report low desire in large population surveys.
- Psychosocial factors often weigh as much as or more than hormones: stress, sleep, self-image, quality of the couple.
- Moisturizers and lubricants are the first step: available without a prescription and well tolerated.
- Vaginal DHEA showed, in a controlled trial in 216 women, an improvement in dryness and pain from two weeks onward.
- Desire after 50 is often more responsive than spontaneous: it needs a context, and that is not a defect.
Video chapters
The scientific sources cited
Every claim in this video rests on a verified reference. Here is the complete list, with the PubMed links.
- Portman DJ, Gass MLS. Genitourinary syndrome of menopause: new terminology (ISSWSH/NAMS). J Sex Med. 2014. PubMed 25155380
- The NAMS 2020 GSM Position Statement. Menopause. 2020. PubMed 32852449
- Kingsberg SA, et al. Vulvar and vaginal atrophy (REVIVE survey). J Sex Med. 2013. PubMed 23679050
- Avis NE, et al. Sexual functioning through menopause (SWAN). Menopause. 2009. PubMed 19212271
- Basson R. Female sexual response (circular model). Obstet Gynecol. 2001. PubMed 11506856
- Mitchell CM, et al. Vaginal estradiol vs moisturizer vs placebo (MsFLASH RCT). JAMA Intern Med. 2018. PubMed 29554173
- Lethaby A, et al. Local oestrogen for vaginal atrophy. Cochrane Database Syst Rev. 2016. PubMed 27577677
- Crandall CJ, et al. Vaginal estrogen & cancer/CV events (WHI-OS). Menopause. 2018. PubMed 28816933
- Labrie F, et al. Intravaginal DHEA (prasterone) for dyspareunia/GSM. Menopause. 2016. PubMed 26731686
- Portman DJ, et al. Ospemifene for postmenopausal dyspareunia. Menopause. 2013. PubMed 23361170
- Franco MM, et al. Pelvic floor muscle training & sexual function (RCT). J Sex Med. 2021. PubMed 34187758
- Davis SR, et al. Global Consensus Position Statement on Testosterone Therapy for Women. 2019. PubMed 31488288
Frequently asked questions
Does vaginal dryness go away on its own over time?
No, and that is what distinguishes it from hot flashes. The genitourinary syndrome of menopause tends to persist, or even worsen, if it is not managed. That is one more reason to talk about it rather than wait.
Does low desire mean there is a problem in the relationship?
Not necessarily. Desire is multifactorial: it depends on hormones, but also on sleep, mood, certain medications, fatigue and, very often, on pain during intercourse. Treating the pain is sometimes enough to change everything.
Can local estrogen be used if you refuse systemic hormone therapy?
That is a question for your doctor, but local treatments and systemic treatments are not the same thing: they have neither the same purpose nor the same profile. The decision remains individualized and requires a prescription.
Is low desire at menopause common?
Far more than people say. A large representative American survey puts low desire at about 27% of premenopausal women and up to 52% of naturally menopausal women. An Australian study conducted between 40 and 65 finds a decline in nearly seven women in ten, with associated distress in about four in ten. This experience is the statistical norm, not the exception.
Is it hormonal or psychological?
Both, and one does not exclude the other. Studies describe a biopsychosocial model in which life factors, stress, fatigue, body image, mood and quality of the relationship, often weigh as much as or more than hormonal status. Untreated dryness also maintains a circle of pain, avoidance and low desire that is better broken early.
Where do you start, concretely?
With vaginal moisturizers and lubricants. The first are used regularly, the second during intercourse. They are available without a prescription, well tolerated, and they quickly relieve discomfort, which is already enough to give desire some space again. They do not correct the underlying hormonal cause: if the discomfort persists, medical advice makes it possible to consider local treatments.
My desire no longer comes spontaneously, is that normal?
Yes, and it does not mean it has disappeared. Desire after 50 is often more responsive than spontaneous: it needs a favorable context, made of relaxation, stimulation and emotional safety, in order to switch on. It is not a defect, it is a different mechanism, just as legitimate. Comparing yourself to what you experienced at 25 mostly sustains a feeling of failure.
Is testosterone a serious option?
It has been evaluated, without being a universal answer. A meta-analysis gathering seven randomized trials and more than 3,000 women concluded that there was a real improvement in desire and sexual satisfaction on transdermal testosterone, with an acceptable short-term safety profile and acne as the most frequent adverse effect. It is not a first-line solution: it is discussed case by case, under medical follow-up.