Sexual healing: How to get your mojo back around menopause

Davina McCall says her libido was so low before taking HRT that she ‘didn’t even fancy Brad Pitt’. Besides hormone replacement, experts say simple lifestyle changes can help women recover their desire

Pic: iStock

Two things can happen to sex when you reach menopause — you either stop wanting it, or it hurts when you do. 

Neither situation is ideal for anyone involved. Until the great Menopause Revolution of 2021 hit Ireland and Britain, thanks to Channel 4’s documentary presented by Davina McCall and the women who queued up to discuss the devastating impact of menopause on RTÉ’s Liveline, many of us didn’t know how to address vanishing libido and painful sex.

Not anymore. These days, we are far more proactive and powered up with information. Davina recalled how her libido dropped to the point she “didn’t even fancy Brad Pitt” until she supplemented her HRT with testosterone. 

Often, however, raising oestrogen levels will sort things out — and it’s worth remembering that libido isn’t always purely down to hormones.

“Low libido is a complex symptom with many causes and psychosocial factors,” says menopause specialist Dr Brenda Moran, joint lead of the Complex Menopause Clinic at CUHM.

“Stress, burnout, chronic pain, chronic medical conditions, how happy someone is within their relationship, are also essential components, irrespective of menopause. It can also be a side-effect of medication such as anti-depressants.”

But if you’re not affected by any of the above, are mid-life and your libido has still fallen off a cliff, it’s probably menopause. As well as thinning vaginal walls causing painful sex, loss of oestrogen can also lead to low mood and anxiety, which in turn contributes to low libido. So too can disrupted sleep.

“Hormonal changes can be a factor in poor sleep — either directly, or indirectly via night sweats and hot flushes which keep women awake,” says Moran. “Poor sleep causes daytime fatigue and low energy, which can contribute to low libido.”

Even worse is when sex physically hurts.

“The reduction in oestrogen around the time of menopause and after menopause can cause the vagina to become thin, dry, itchy, and less elastic, resulting in painful sex, which can lead to low libido and avoidance of sex,” says Moran.

“It can cause bleeding during intercourse as the vaginal walls are so thin. It can also affect the bladder. These symptoms are now known as genitourinary syndrome of the menopause (GSM). GSM is very common and estimated to affect up to 50-80% of women. Unlike the majority of other menopausal symptoms, which resolve and reduce over time, GSM is a long-term effect of menopause and will continue unless treated.”

Moran offers a range of suggestions to address reduced libido — if you want to sort it out. “Some women simply acknowledge their libido has changed or reduced significantly - it doesn’t bother them,” she says. “But for others, it can be a big worry, particularly if it has impacted their relationship.”

She recommends:

• Increasing exercise to improve mood, energy levels and endorphin release
• Maintaining a healthy diet
• Stress reduction via practices like mindfulness
• Addressing menopause directly via lifestyle, psychological therapies, complementary therapies, HRT, or prescribed alternatives to HRT
• Good communication with your partner and psychosexual counselling, if necessary
• Treating GSM (“This can be extremely effective”)
• Using lubricants
• HRT, either standard or with testosterone therapy
• Reducing alcohol intake (“Excess alcohol can cause low libido”)

Davina McCall: menopause advocate

Reduced libido

While it took Davina McCall eight months to hit the correct dose of HRT, it took me five years. I didn’t realise I could adjust it, resulting in zero libido after surgical menopause (in my late 40s, my ovaries were removed after a cancer false alarm). 

Only by going from a standard 50mg to 100mg of twice-weekly oestrogen patches, plus using intravaginal oestrogen cream, did things recover. Yet it wasn’t a doctor who advised me to up my oestrogen, but a female friend who had been through a similar experience. Today, my libido is still reduced, but thanks to increased oestrogen, at least it exists.

Vaginal oestrogen, explains Moran, leads to “a healthier and fleshier vaginal surface” and is also effective in treating GSM. It can be used by those who do not wish to take standard HRT, who can’t tolerate it, or have a contraindication.

“Vaginal oestrogen is not linked with an increased risk of breast cancer, and there is no need for progesterone cover like there is with standard HRT,” she says, adding that “standard HRT is also very effective at improving menopausal symptoms and can help libido in some women.”

But what if you don’t want to use HRT — are there other options? “Vaginal moisturisers and lubricants can help to reduce vaginal dryness, irritation, and pain on intercourse,” she says.

Other non-HRT options include transvaginal laser therapy which can help restore the vaginal wall, and vaginal dilators, which help stretch tightened tissue. Lidocaine gel is a local anaesthetic helpful for pain during sex when HRT isn’t an option.

Shalini Wiseman, chartered physiotherapist in pelvic health and continence. Pic: Gerard McCarthy

Shalini Wiseman is a Cork-based chartered physiotherapist specialising in pelvic health and continence. “We see a lot of urinogenital syndromes menopause occurring in women, which can be treated with physiotherapy,” she says.

“Many perimenopausal women go to their GP complaining of vaginal dryness, lack of libido, and sex becoming more sandpapering. The GP gives them Vagifem [oestrogen pills inserted vaginally with an applicator] or oestrogen cream. The good news is that this can help change the anatomy of the vagina — making the mucosal tissue more oestrogenised so there’s more cushioning.

“However, with some women, there can be pain on entry, and they put up with the discomfort of penetration. What’s happening is the entrance to the vagina is getting shorter and tighter because of the lack of oestrogen.”

Some women may get recurrent urinary tract infections after sex, says Wiseman. They can be treated with antibiotics or HRT, or both. “But if the UTIs are recurrent (more than three times a year), the vaginal muscles may also have a role.

“So if [women] complain of dryness, urgency and painful sex, they don’t just need oestrogen, they also need a pelvic health physiotherapist.”

For those who cannot access a physiotherapist, she has several suggestions.

“Progressive dilators stretch the internal muscles,” she says.

“In menopause, you can have a combination of tightness and weakness [in the pelvic muscles]; if you’ve been doing pelvic floor exercises and the situation hasn’t improved after a few weeks, then stop. You need to look at more lengthening-based exercises rather than strengthening-based ones.”

Lengthening exercises include deep squats, and glute and hip flexor stretchers.

 “Focused belly breathing — breathing to expand your belly and widen your waist — can help lengthen the pelvic floor muscles from the inside,” says Wiseman.

She also recommends investing in a good lubricant: “We tend to go with the cheaper supermarket variety. Use oil or silicon-based, organic. Double lubricate – both yourself and your partner. And use a good quality vaginal moisturiser. It’s really important.”

Be prepared for trial and error; there is no standard panacea and you’ll need to be proactive and flexible in your approach. But don’t let anyone tell you your sex life is over — it’s absolutely not.

CLARIFICATION: When originally published, this article incorrectly ascribed an experience of surgical menopause to Davina McCall, rather than to the author. This has now been remedied. We are happy to correct the record on this point.

• Dr Brenda Moran and Shalini Wiseman are speaking at the National Menopause Summit at City Hall, Cork, on Friday, October 20.
• Listen: Sex in long-term relationships with Dr Karen Gurney
• Read: Mind the Gap by Dr Karen Gurney