The way we view ourselves as sexual beings is often, perhaps subconsciously, tied up in our perception of being fertile, feminine and in our ‘sexual prime’. The end of our reproductive lives at the menopause can make women feel like they are no longer desirable and can completely alter the way they perceive their sexual self. The negative connotations around ageing in the media and its association with the menopause can also have a profound impact- we shouldn’t be talking about sex over the age of 40 right?! There is a deeply embedded view in western society that good sex is a privilege of the young and beautiful and women can experience a real grief in the overwhelming feeling that the opportunity for a healthy sex life has come to an end at the menopause.

Many factors around the Menopause can contribute to a lack of enjoyment of, and loss of drive to have sex. Women sometimes feel like if they do have sex they have to tolerate it rather than it being a pleasurable experience due to factors which may make sex less desirable. Conversations with health professionals about sex- if they happen- often focus on reducing painful sex rather than improving pleasure. Sex should be fun and enjoyable!

Having a healthy sex life has many benefits- it has been shown to be linked to a longer life, improves intimacy thereby having a positive effect on relationships, reduces heart disease and improves sleep- but to name a few.

Sex can be more liberating at the menopause- we are released from the burden of worrying about preventing pregnancy with often difficult contraceptive choices, children may have left home or are older so there may be more opportunity for time to yourself as a couple at home or even some time away to reconnect.

What affects sex at the menopause?

1.) Low Oestrogen Oestrogen keeps the vaginal tissue moist, lubricated, plump and elastic allowing for penetration during sex. As oestrogen levels drop at the menopause the vagina and vulval skin can become much thinner and less pliable thus tearing more easily during sex. More advanced changes can cause tightening of the vaginal entrance and reduction/ fusion of the labia (the outer lips of the vagina).

This can make sex painful, even causing tearing and bleeding during penetration. The skin changes can alter sensation causing issues with arousal and ability to orgasm. Is it any wonder that just the thought of sex with a sore dry vagina that might split is somewhat distressing?

The phrase ‘use it or lose it’ is sometimes said and whilst this may not be overly helpful for a woman struggling with sexual intimacy, reframing this to describe the vicious cycle of loss of lubrication, painful sex, less sex, anxiety around sex and low sex drive may go some way to explaining where this phrase come from. Regular sex- be that with a partner or through masturbation using sex toys such as vaginal vibrators- may help to prevent some of the more severe symptoms from developing.

2.) Prolapse Oestrogen helps to keep the pelvic floor tight and consequently at the menopause symptoms of a urogenital prolapse (perhaps present from childbirth) may worsen. Though women can usually physically have sex with a prolapse, the change in anatomy may make sex more uncomfortable and there is often a psychological impact to knowing that vaginal anatomy is somewhat altered if a prolapse is present.

3.) Urinary incontinence is another common symptom around the Menopause. This is again often due to reduction in oestrogen as we have many oestrogen receptors in the bladder. Issues with pelvic floor (above) can also contribute to incontinence. These symptoms can lead to feelings of embarrassment and shame and women may be afraid to let go during sex due to fear of leaking urine.

4.) Libido it’s very common to experience low sex drive at the menopause. Libido is complex and there are lots of contributing factors that drive us to want to have sex. Low oestrogen and testosterone, stress and anxiety, relationship problems, vulvovaginal symptoms and incontinence can all contribute to low libido. Not to mention that feeling physically unwell due to menopausal symptoms likely makes it difficult to feel sexy.

5.) Weight changes around the Menopause can have a really negative impact on self-esteem and body positivity which can impact on sexual confidence.

6.) Medical or surgical treatment for cancer sex after cancer can feel like a wilderness and can be very isolating for women. At the time of diagnosis and treatment there is often not much focus on sex in the life that continues when treatment has ended.

Medical or surgical treatments may plunge women into an instant Menopause causing many of the issues described above and the symptoms may be more severe.

Some treatments may lead to changes in physical appearance such as hair loss with chemotherapy which affect self esteem. Breasts are very much tied up with female sexuality and the physical changes following a mastectomy, even if reconstruction has been done, can be very distressing.

Changes to pelvic anatomy following surgery or radiotherapy can make the vagina narrow which can cause sex to be painful and the general trauma of having cancer treatment can create a real sense of fear about reigniting sex. There may be a perception that sex will not be possible after some treatments and so women may not even try to peruse an intimate relationship with a partner.

Watching a loved one go through cancer treatment can change the way a partner may approach sex in a relationship from the other side. They may stop initiating sex for fear of hurting their partner and it can be extremely difficult to for a partner to know how to approach these sensitive issues at such a vulnerable time for their loved one, resulting in nobody talking and the difficulties escalating. It may become ‘the elephant in the room’.

Women sometimes feel that talking about sex after cancer is frivolous- they should just feel lucky to be alive right? And worrying about lack of sex life can create a degree of guilt and shame. But women are as entitled to a good sex life after cancer treatment as they were before and opening a channel of regular, honest communication about sex during and after cancer is vitally important. Women should feel well informed right from the beginning and supported to be able to address any difficulties they may experience with sex around their cancer diagnosis.

Where do I start?

It can be very painful psychologically to explore the fears and traumas that may be contributing to sexual problems around the Menopause but communication is key. Talking to a healthcare professional can make chatting about sex feel more normal and can help to initiate conversations about sex as a couple.

It can be difficult to discuss sex with a partner. How do you bring that into a conversation? We tend to second guess what a partner is thinking but the outcome of being honest about feelings around sex is often that a partner is thinking a similar thing and is open to exploring ways to improve sexual intimacy and experience.

Knowledge of sexual anatomy can be really helpful and will encourage self-exploration- knowing what works for you and being able to show your partner will improve the experience! It may be that you have to re-wire the sexual script in your relationship and explore and experiment – change in vaginal sensation or structure may mean that what led to arousal and orgasm before, now doesn’t.

Pelvic floor exercises may improve symptoms of a prolapse and heighten sexual awareness and pleasure. Many women do not feel confident in doing pelvic floor exercises- seeing a pelvic floor physio to assess your pelvic floor and give a structured programme of exercises to improve it can be helpful.

Vaginal pessaries can improve symptoms caused by a prolapse and are completely safe to keep in during sex.

Look at medications that can effect libido unfortunately many medications that we commonly give for other medical conditions can affect sex drive and arousal.

Vaginal oestrogen see section on genitourinary syndrome of the menopause which will explore treatments to improve changes that may have occurred due to low oestrogen.

Lube lube lube!!! It is common to feel aroused but still not have adequate lubrication for comfortable sex. Using a good lubricant can vastly improve sexual experience and reduce discomfort during sex. Many off the shelf lubricants contain products that irritate the vagina so beware and choose carefully!

Some lubricants will have a high concentration of chemicals/ preservatives and/or a high ph. Both can cause irritation and predispose to recurrent infections such as bacterial vaginosis and thrush.

Choose a lubricant which has a low osmolality and a ph similar to the natural ph of the vagina (3.5-4.5) by checking the ingredients and if you’re not sure then a google search will be able to give you more information about what the product contains and which of those may be irritant.

Avoid lubricants which contain parabens, glycerine and gycols, all of which can lead to a sore vagina. Be cautious with coloured or flavoured, warming or cooling lubricants also. Flavoured lubricants can be fun for oral sex but washing this off before penetrative sex is advisable. Itching and burning sensations from a lubricant are frankly a bit of a passion killer!

Sylk, YES and SUTIL Luxe are all good sexual lubricants, some of which are available on prescription. Combining oil and water based lubricants can improve glide during penetration and make sex more comfortable.

Sex toys silicone dilators inserted into the vagina can improve vaginismus and can help to gently stretch the vagina over time. Introducing vibration- either with the above for penetration into the vagina- or for external stimulation to the clitoris and vulva can improve blood flow and lubrication as well as increasing elasticity and thus reducing pain. Try making this part of a sexual experience with your partner or during self-exploration as part of masturbation?

Sexual connection and intimacy a common misconception is that sex has to mean penis in vagina which can be anxiety provoking if penetration is the cause of pain. Sexual connection and intimacy is so important and can be achieved by other sexual experiences. Trying a period of time where there is an agreement not to have penetrative sex can help remove the fear of pain that may come with the assumption that all sexual contact will end in penetration. This in turn may encourage a couple to relax, explore each other’s bodies and rekindle that sexual intimacy that may have been lost.

HRT and testosterone The right HRT can help to improve libido and testosterone can be added in for hypoactive sexual desire disorder (HSDD) if libido is still not improved by taking oestrogen. Please see the section on HRT and testosterone for more information.

Psychosexual counselling some women may benefit from a course of psychosexual counselling, particularly if past trauma is a large contributing factor to sexual difficulties.

The take home message is never be afraid to ask- it might just change your sex life! It’s never too late to sexually reconnect with your partner, whatever your age and everyone is entitled to good sex. Focus on pleasure rather than performance and remember sex is meant to be fun!


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