Menopause and sexuality: what really changes and what is myth

“I thought there was something wrong with me. That I was simply too old for it, and that it was better not to talk about it.”

I hear this sentence, in one version or another, more often than I would have expected. It is said by a woman in her fifties who has noticed that sex, once a natural part of her relationship, now hurts, tires her or simply no longer draws her in. She says it quietly, almost apologetically, as if confessing a personal failing. She often adds that she has not told her partner, because she does not know how. And that she has not told her gynaecologist either, because it seemed to her that “nothing can be done about it anyway”.

Menopause is one of those stages of life that, in Slovenia, is still talked about in whispers rather than out loud. And when it is talked about, it is often in extremes: either sex is over at that point, or it is all in your head. Both are wrong. In this article I have tried to separate what really changes in the body and in the relationship from the myths that women — and their partners — pass on without ever checking them.

First, something clear: I am neither a doctor nor a sexologist. Physical changes, pain and treatment belong with a gynaecologist. What I can offer is a view of what happens inside a person, and between two people, when those changes arrive.

What really changes in the body

Menopause is the moment when menstruation stops for good — by convention, once a full year has passed without a period. The years before it are called perimenopause, a time when hormone levels fluctuate and slowly decline. I have written more about how this period affects mood in Depression in perimenopause; here I will focus on sexuality.

When oestrogen levels fall, the tissues of the vagina and urinary tract change. The lining becomes thinner and less elastic, lubrication during arousal is slower and scantier, and some women develop burning, itching or more frequent urinary infections. In 2014 professional societies introduced a shared name for this group of changes: genitourinary syndrome of menopause. It used to be called vaginal atrophy, which sounded more frightening than it is and also overlooked the fact that the urinary tract is involved too.

These are real physical changes, not imagination. Sex that hurts is not something a woman should “put up with” or overcome by willpower. It is information from the body that needs medical attention. At the same time, other parts of life change too, and they affect sexuality indirectly: hot flushes and night sweats steal sleep, sleeplessness steals energy, and energy is one of the quiet conditions for desire.

What studies that followed women for years show

Most of what we know about sexuality in midlife comes from long-term studies that did not ask once, but followed the same women over many years. The best known is the American SWAN study (Study of Women’s Health Across the Nation), which enrolled more than 3,000 women from different ethnic groups. Using these data, Nancy Avis and colleagues showed that sexual desire does, on average, decline somewhat in late perimenopause and after menopause, and that pain during sex becomes more common.

But the second part of the findings matters more. How a woman experienced her sexuality was influenced as much as, or even more than, by menopause itself by other factors: how satisfied she was with her relationship, her physical and mental health, whether she was under stress, what her attitude to sex had been before, and how important sex was to her in the first place. In a 2016 review, Holly Thomas and Rebecca Thurston came to a similar conclusion: sexuality in midlife has to be understood as an interweaving of body, mind and relationship, not as a simple consequence of hormones.

In other words, menopause changes sexuality, but it does not decide it. Two women with identical hormone results can experience intimacy very differently — depending on what is happening in their lives and in their relationships.

See a gynaecologist first — and don’t put it off

If sex hurts, if you notice dryness, burning or more frequent infections, your first port of call is your gynaecologist. In Slovenia you can see your chosen gynaecologist without a referral. A gynaecologist can check what is happening with the tissues, rule out other causes and talk with you about the treatment options available today. Which one is right for you is a decision the two of you make together — certainly not something a blog post could recommend.

Research on how women seek help shows a pattern I also know from conversations: many do not mention pain or dryness because they think it is a normal part of ageing, because they feel ashamed, or because they are waiting for the doctor to ask. The doctor, meanwhile, is often waiting for them to raise it. Years can pass in silence like this, while the pain becomes entrenched and the relationship adapts by avoiding intimacy.

If you feel awkward, you can write down two or three sentences before the appointment and simply read them out. “Sex has been painful for me over the past few months. I’d like to know what is going on and what I can do.” That is entirely enough. Pain during sex is a health matter like any other.

The same goes for your partner. He is ageing in these years too, his body is changing too, and he may also be taking medication or noticing changes in his erections. A couple’s sexuality in midlife is the story of two bodies, not one — and a check-up with a GP or urologist can be part of the same care.

Self-image: when the body no longer matches the picture in your head

The second layer is less visible, but often at least as powerful. A body in menopause changes on the outside too: weight settles differently, skin and hair change, the shape of the figure shifts. A woman who has been used to one reflection in the mirror for decades suddenly meets another. Often an inner voice speaks up at this point, saying she is no longer attractive, that her time has passed, that nobody could want her any more.

That voice was not born in menopause. It has been forming all her life — from remarks at home, from advertising, from a culture that ties a woman’s worth tightly to youth. In menopause it simply gets louder. I have written about how changes in our body and roles affect how we see ourselves in Self-image and ageing: when your body and roles change, and you will find a short explanation of the concept in the knowledge base under self-image.

This matters for sexuality because desire is closely linked to feeling at home in your own body. If you undress thinking about what your partner sees, wishing the light were off, your body is half somewhere else. Sex becomes a performance you judge from the outside rather than an experience you live from the inside. It is often this inner judge — not hormones — that closes the door on desire.

What happens between the two of you

The third layer is the relationship. In long relationships, sex settles over the years into a pattern: who initiates, when, how. When the body changes and the old pattern no longer works, many couples do not talk — they withdraw. She avoids it because it hurts or because she does not feel good in her skin. He withdraws because he reads her withdrawal as a rejection of him. A few months later they no longer talk about sex at all, only about who will buy the bread.

The conversation that could clear everything up is often exactly the one both of them fear most. It might sound like this (composite, not a real person):

“Lately I’ve had the feeling you’re avoiding me.”
“I’m not avoiding you. I’m avoiding the pain. And you noticing it.”
“Why didn’t you tell me?”
“Because I thought you’d say I’d got old. I’d already said it to myself.”
“And I thought you didn’t want me any more.”

In this short exchange something happens that is often a turning point in couples therapy: both discover that each had been interpreting the silence in their own way, and that the interpretation was worse than the truth. She feared his judgement. He feared he was no longer wanted. Neither fear was really about sex; both were about whether they still mattered to each other.

If you are looking for words for a conversation like this, How to talk to your partner about sex without blame may help, and in the knowledge base there are also questions for a couple’s conversation that you can use as a starting point.

Five myths worth putting down

Because there is so little open conversation about menopause, it gathers many beliefs that nobody ever checks. Some women heard them from their mothers, others from jokes, and others they formed themselves, in silence.

• “Menopause is the end of sex.” It is not. Research shows that many women stay sexually active and satisfied after menopause. Sexuality changes — its rhythm, its form, the time arousal needs — but not necessarily its value.
• “Pain is just part of getting older.” Pain is a reason to see a gynaecologist, not something to accept as fate.
• “If there’s no spontaneous desire, there’s no desire at all.” For many people, not only in menopause, desire does not come first but wakes up only in contact, with touch, in a safe atmosphere. The absence of spontaneous desire does not mean the absence of desire.
• “It’s her problem.” Both partners experience changes in a couple’s sex life, and both are part of how the relationship will respond to them.
• “This isn’t something you talk about.” Silence is often exactly what turns a physical change into a relationship crisis.

While preparing this article, I was struck by how often something else comes up, both in research and in conversations with women: some describe the years after menopause as a time when their sexuality became, in a sense, freer. There are no more worries about pregnancy or contraception, the children may have left home, and there is more room for the couple. It is not true for everyone. But the fact that it can be like this is worth saying out loud.

A new beginning: sexuality that no longer measures by the old rules

Menopause is a transition — one of those periods when the old balance breaks down and the new one has not yet formed. Transitions are uncomfortable because what worked before no longer works. At the same time, they are a chance for a couple to ask questions that years of habit never raised.

Many couples realise that for years they have measured sex by a single yardstick: whether intercourse happened, and how often. When that yardstick stops working, temporarily or permanently, because of physical changes, it can seem as if sex is over. But if the yardstick widens — to touch, tenderness, playfulness, time alone together, closeness without a goal — it often turns out there is more intimacy than they thought.

In her book on women’s sexuality, Emily Nagoski uses a simple image: desire has an accelerator and a brake. In menopause the accelerator often stays the same while the brakes pile up — pain, tiredness, shame, fear of a partner’s reaction, stress. So it is often more useful to ask what is standing in the way of desire than how to stimulate it artificially.

Exercise: a map of brakes and accelerators

You can do this exercise on your own or, if the atmosphere feels safe enough, together with your partner. Set aside half an hour when you are not tired and nobody will disturb you.

1. Divide a sheet of paper into two columns. On the left write “What holds me back”, on the right “What helps me feel closer to myself and to you”.
2. Write down the brakes without censoring them. Physical ones (pain, tiredness, hot flushes), emotional ones (shame, fear, resentment) and circumstances (children at home, stress at work, caring for parents). Don’t judge whether they are “justified”.
3. Write down the accelerators. When did you last feel good in your body? What was different then? Perhaps a walk, laughter, time without phones, touch without expectation.
4. Choose one brake you can address this month. If it is physical, that means booking an appointment with your gynaecologist. If it is about the relationship, that means one conversation. Just one.
5. Choose one accelerator and invite it into your week. Not as a task, but as a gift to the two of you. After a week, ask each other how it went — no ratings, just observations.

The exercise will not solve everything. But it will turn the fog in which “everything is wrong” into a map that shows where it is possible to begin.

Where this view falls short

I want to be honest about the limits of what I am writing, too. First, conversation and therapy do not treat physical changes. If pain is caused by changes in the tissue, no conversation with your partner, however good, will make it go away. A psychological approach without a medical examination can even deprive a woman of help that would quickly make her life easier — and send her the message that the problem is in her head.

Second, not every change in desire is a problem that needs solving. Some women and some couples find that sex is no longer so important to them at this stage, and they are content with that. If nobody is suffering, there is no reason to adjust to an outside norm about how often you “should”. The problem arises when there is a large gap between partners or when one of them suffers in silence. You can read more about how a couple approaches differences in desire in the knowledge base under differences in sexual desire.

Third, sometimes a drop in desire is not linked to menopause at all, but to depression, medication a woman is taking, or other illnesses. That is why a medical check-up matters even when there is no pain. And fourth: when sexual difficulties run deeper — for example when they are connected to past abuse or to a sexual dysfunction — it is right for the couple to turn to a doctor or a specialist in sexual medicine. In couples therapy, intimacy can be one of the topics we talk about, but it is not a substitute for specialist treatment of sexual dysfunctions.

When to seek a conversation with a therapist

So when does it make sense for a couple, or a woman on her own, to also turn to a psychotherapist? When the physical side has been checked, but there is still a feeling that something has closed between the partners. When every conversation about sex ends in reproach or silence. When shame or sadness about a changing body starts to shape other parts of life too. And when the changes of menopause open older stories: about what a woman heard at home about the body, femininity and ageing.

In relational family therapy, in which I am training, we often see that at moments like this a couple repeats what each of them brought from their own family — how the body and closeness were talked about (or not talked about) at home. That conversation is not quick, but it is often what gives a couple back the sense that they are on the same side. I work with English-speaking clients too, in person in Ljubljana. If you are not sure whether it is time for such a step, When is the right time for therapy may help.

What to remember

• Menopause really does change the body — the vaginal lining, lubrication, sleep. Pain during sex is a reason to see a gynaecologist, not something to endure in silence.
• Studies that followed women over years show that the relationship, health and stress influence midlife sexuality as much as, or more than, hormones.
• Self-image is often a stronger brake than the body: the inner judge closes the door on desire.
• Silence between partners quickly turns a physical change into a relationship crisis. Talking is often less frightening than the explanations each of you makes up alone.
• Menopause is not the end of sexuality; it is a transition — a chance for a couple to measure intimacy in a new way.