Midlife Sex Crisis: What Are My Perimenopause Options?

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You hit your 40s or 50s and all of the sudden things start spiraling: Your period is out of whack, your undergarments are damp with urine after a one mile walk with your dog, and you can no longer wear your favorite jeans because they’re irritating to your lady parts. As if that wasn’t enough to deal with, you also wake up in the middle of the night in a puddle of sweat, you have to forgo the post-dinner tiramisu because you know it’s already going to take three times as long to exercise away the two glasses of wine you’ve consumed, and you’re in bed an hour before your partner because sex is uncomfortable. Of course, these are all quite animated examples, and women that are perimenopausal may or may not experience  irregular menstrual cycles, urinary incontinence, vaginal dryness, hot flashes, interrupted sleep, weight gain, and painful intercourse. But because these symptoms are possible,  it’s important to understand the changes our bodies go through midlife so we can find ways to mitigate some of these unpleasantries.


True menopause is defined as the absence of your menstrual cycle for 12 consecutive months, however, symptoms can creep in sooner during the perimenopausal stage. So what exactly happens to our bodies during this time that funnels them into this craze? In the simplest of terms, when we reach perimenopausal age there is a natural decline of the reproductive hormones released by the ovaries. These include estrogen, progesterone, and testosterone. Rachel wrote a fantastic post highlighting the functions of these hormones. As Rachel discussed, the reproductive hormones play an integral role in maintaining healthy vulvovaginal tissue. Because these tissues are hormone-dependent, the decrease in available reproductive hormones during menopause can lead to pelvic floor muscle strength deficits, decreased elasticity of the vaginal walls, decreased lubrication, and secondary irritation of the vestibule and external genitalia atrophy. For these reasons, perimenopausal women can sometimes experience pain with intercourse, or “dyspareunia.” It is estimated that up to 40% of women hovering around menopause experience painful sex, but only half of these women seek medical assistance.1 This statistic is shocking, as dyspareunia can have negative implications on quality of life. In a cross-sectional study examining the differences in sexual function and quality of life between perimenopausal women with and without dyspareunia, those with dyspareunia reported impaired sexual function (e.g., diminishing arousal, inadequate lubrication, less frequent orgasm) and decreased quality of life.5


Fortunately, “menopause-induced” dyspareunia is not a life sentence. Let’s go ahead and debunk the myth that once you hit menopause, painful sex has to become the the new normal. Yes, menopause is part of the aging process, but by no means should it interfere with your ability to have a healthy, satisfying, and pain-free sex life. Thankfully, there are many options available to help counteract or manage some of the vulvovaginal changes with menopause and associated painful intercourse:


  • Hormone Replacement Therapy –  To some women, the words “hormone replacement therapy” sound scary.  After findings from studies such as The Million Women Study and those performed by the Women’s Health Initiative were released in the early 2000s, many perimenopausal women have been resistant to going this route because they suggested that women who participated in hormone replacement therapy had an increased risk of heart-related conditions and cancer.  However, some in the medical community have met these conclusions with resistance, stating that either the doses used in these studies were too high or that the sample groups consisted of women way past menopausal years. Read more about how to  differentiate quality studies from the not-so-great ones. Subsequent studies have since found no significant differences in these risks and have stated that hormone replacement therapy is effective in managing menopausal symptoms.  However, if you have a history of reproductive hormone cancers such as breast or ovarian, hesitancy may be warranted. But have no fear, there are many other options for you which you can find below.
  • Localized Hormones (i.e. Estrace, Vagifem, Estring) – As opposed to the systemic delivery of hormones via hormone replacement therapy, localized hormones in the form of a topical cream, insert, or ring may be a good alternative as they only target adjacent vulvovaginal tissues. These can be prescribed “off the shelf” or compounded with a base that is agreeable with you and your body. It can take weeks to months to start to see positive tissue changes with localized hormones so being patient with the process is key. A critical review of the literature suggests localized topical hormones can improve menopause-initiated vaginal tissue changes and associated symptoms.1
  • Lubricants (Water-, Petroleum-, Natural Oil-, Silicone-based) – Lubricants are a non-hormonal option that can help bring moisture back to the vulvovaginal tissues. Because they are non-hormonal, they do not exactly mimic the effects of the above hormonal options, but can be used to help manage vaginal dryness and pain during intercourse. There are many types of lubricants available, and something as simple as coconut oil or as fancy as Vital V Wild Yam Salve can be used as a lubricant. Visit Melinda’s post for more specifics about lubricants.
  • Phytoestrogens – If you prefer to go an even more natural route, phytoestrogens may be a good starting point for you. These are naturally occurring plant compounds that have estrogen-like properties and can be found in products such as soy, lentils, flaxseed and berries. The jury is still out on whether or not they directly affect the vulvovaginal tissue, but there have been some anecdotal success. Specific dietary guidelines are still being explored.2,4


If you’re approaching menopause and have noticed any vulvovaginal tissue changes or experience pain with intercourse, you may want to consult with your physician about one of the above options. In addition to addressing the tissue changes, you may also consider consulting with a pelvic floor physical therapist. In some instances, especially in the case of longstanding dyspareunia, the muscles of the pelvic floor may guard as an innate protective response to pain. When the pelvic floor muscles rest in this contracted state, they decrease the blood flow to the area and can cause more pain creating a negative feedback loop. For cases such as this, a physical therapist can perform manual techniques and teach you strategies to help relax the pelvic floor muscles and restore normal mobility. Here’s what you can expect with pelvic floor physical therapy. This in combination with treatment specific to the vulvovaginal tissues can help reset you to a pain-free and pleasurable sex life.


As an aside, it is also worth mentioning that any decline or alteration in the reproductive hormones can cause similar menopausal-like vulvovaginal tissue changes and potential dyspareunia. These include history of hysterectomy, radiation to the pelvis or use of oral birth control pills. Check out the links to read up on some of these specifically!





  1. Alina Kao, Yitzchak BM, Kapuscinski A, Khalife S.  Dyspareunia in postmenopausal women: A critical review.  Pain Research and Management. 2008;13(3):243-254.
  2. Glazier MG, Bowman MA. A review of the evidence for the use of phytoestrogens as a replacement for traditional estrogen replacement therapy. Archives of Internal Medicine Journal. 2001;161(9):1161-72.
  3. Kingsberg S, Kellogg S, Krychman M.  Treating dyspareunia caused by vaginal atrophy: a review of treatment options using vaginal estrogen therapy.  International Journal of Women’s Health. 2010; 1:105-11.
  4. Patisaul, H. B., & Jefferson, W. (2010). The pros and cons of phytoestrogens. Frontiers in Neuroendocrinology, 31(4), 400–419.
  5. Schvartzman R, Bertotto A, Schvartzman L, Wender MC. Pelvic floor muscle activity, quality of life, and sexual function in peri- and recently postmenopausal women with and without dyspareunia: a cross-sectional study. Journal of Sex and Marital Therapy. 2014;40(5):367-78.

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