Sex After 45: How to Rekindle Intimacy and Comfort in Menopause

When the topic of menopause surfaces, symptoms like hot flashes and night sweats get most of the attention. But there’s one topic that frequently gets overlooked—our sex lives. If you’ve felt a dip in desire or noticed that sex is becoming physically uncomfortable, you’re not alone. But reaching 45 shouldn’t mean the end of a vibrant sex life. By understanding the hormonal changes happening in your body and using the right tools, you can rekindle intimacy and feel comfortable in your skin again.

Understanding the Physical Changes

Significant physical changes are happening in our bodies as we transition into menopause. These physical changes can affect our desire and comfort during sex, but understanding what’s happening is the first step to addressing it. 

1. Vaginal Dryness

One of the most common things our patients tell us is that sex has simply become physically uncomfortable, primarily because of vaginal dryness. Estrogen is the hormone responsible for keeping your vaginal tissues thick, elastic, and lubricated. As your body’s production of estrogen begins to decline in perimenopause, the vaginal tissues can become thinner, drier, and fragile. Experts once described these changes as “vaginal atrophy,” though now they’re considered a part of genitourinary syndrome of menopause (GSM). In short, GSM is an umbrella term used to describe a group of symptoms and conditions associated with genital and urinary systems that occur as a result of declining estrogen levels in menopause.1,2 

2. Changes in Odor and Anatomy

It’s not just about dryness, though. Many women are surprised to find that the very look and scent of their body changes. For example, patients often ask us about a change in vaginal odor. This happens because as estrogen levels shift, the pH balance of the vagina changes. This can alter the natural “microbiome” in the area, leading to a different scent or a higher risk of urinary tract infections (UTIs).3 You may also notice changes in the physical appearance of the vulva. These are also due to declining estrogen levels.4 You may notice changes like the labia appearing flatter, more wrinkled, or saggy. Your clitoris and vaginal opening may also get smaller over time.5 Seeing these changes can be jarring, but they are treatable.

3. Body Image Changes

Many women in perimenopause find that they start to carry more weight around the abdomen, even if their diet and exercise routines haven’t changed. Like the changes discussed above, this shift is linked to hormonal fluctuations and metabolic changes.6 Changes in body composition can significantly impact a woman’s self-esteem and “sexual self-schema,” or how she perceives herself as a sexual being.7 In other words, not feeling like your “best self” can make it hard to feel open to intimacy.

How Changing Hormones Affect Libido

Are hormones to blame for your low libido? They’re part of it, but it’s a bit more complex than that. There are three main hormones that can affect sexual desire:

• Estrogen: Estrogen affects lubrication and tissue health. Without it, sex hurts, and when sex hurts, the brain naturally starts to avoid it.
• Progesterone: Often called the “calming hormone,” a drop in progesterone can lead to anxiety and poor sleep, both of which drain the energy needed for intimacy.8
• Testosterone: While often thought of as a male hormone, women need it too. It plays a key role in sexual desire and arousal.9

All three of these hormones can contribute to a decreased sex drive.

Is It Normal to Have No Desire?

It’s very common to have no desire for sex, but that doesn’t mean you have to accept it if you want more. Low desire can be the result of a combination of biological, psychological, and emotional factors.10 You might wonder if there are health consequences to being “sexually inactive.” While your body will be okay, there is a “use it or lose it” element to your sexual function, just like there is for your muscles and many other systems in your body. Research shows that women who continue to be sexually active show less vaginal atrophy and have slower transitions to menopause.11 Regular sexual activity – whether with a partner or alone – increases blood flow to the pelvic region. This helps keep the tissues healthier and more resilient over time.

Interventions: Finding Your Path to Comfort

If menopause has disrupted your intimacy or physical comfort, know this — there are effective solutions. In fact, this phase of life can be an opportunity to prioritize your sexual health, explore what feels good, and advocate for the care you deserve. As women’s hormone health and functional medicine specialists, we look at both hormonal and non-hormonal options to find a plan that best fits your lifestyle and health history.

1. Hormonal Options

To address vaginal atrophy and dryness, we can use estrogen in several ways. Localized vaginal preparations (creams, rings, or small tablets) can be very effective, as they deliver estrogen directly to the tissue with very low systemic absorption. If you need broader support, skin creams or oral “troches” (small lozenges that dissolve in the mouth) can help balance overall levels of estrogen and progesterone. Research has shown that these low-dose vaginal estrogen therapies can be highly effective for these symptoms, with some reports showing up to 80% improvement in symptom severity.12,13,14

2. Non-Hormonal Options

If you prefer to avoid hormonal therapies, here are some excellent alternatives:

• Vitamin E: Research shows that compound vitamin E suppositories may help with vaginal dryness. That’s because vitamin E plays a key role in maintaining estrogen levels and can help improve menopause symptoms, such as vaginal dryness.15 It also helps with blood circulation, which may help enhance the moisture and flexibility of vaginal walls.16,17
• Silicone-based lubricants: Not all lubricants are created equal. We often recommend silicone-based lubricants over water-based “jellies,” as the silicone-based ones last longer on the skin, provide more comfort, and are less likely to contain preservatives that may irritate sensitive skin. 
• Odor management: Douching or using scented products to address vaginal odor can actually make the problem worse by disrupting the vaginal ecosystem.18 Instead, we address this issue at the root by focusing on restoring your body’s hormonal balance.

3. Lifestyle Modifications for a Healthy Libido

Intimacy isn’t just about hormones; we have to look at your entire lifestyle. Here is how we address several common “obstacles” to a healthy libido.

Exercise

If the blood isn’t moving, your libido isn’t either. And poor blood circulation due to inactivity or low hormone levels can negatively impact your sexual arousal and ability to achieve an orgasm. Exercise isn’t just about losing or maintaining weight; it also improves blood flow throughout your entire body, including your genitals. Physical activity can also help increase endurance and energy for sexual activity.

Diet

What you eat affects how you feel, and that includes how you feel in the bedroom. A highly processed diet contributes to increased inflammation in the body, which is linked to lower moods and metabolic diseases.19 Some experts also believe that inflammation increases disgust sensitivity and avoidance reactions, both of which interfere with sexual arousal.20 Try to follow a healthy, whole-food based diet high in protein and fiber to keep your mood stable and your energy high. 

Stress

Stress is one of the top libido killers. It triggers the release of cortisol, which pushes your body into “survival mode” and dampens sexual arousal and creative urges. Try to find ways to schedule downtime. It’s not just about resting your busy brain – it’s about creating time and space to feel present and connected. Whether it’s going out for a date night or creating other special moments, make intimacy a priority. 

Sleep and Fatigue

Poor sleep and chronic fatigue can drain both your energy and libido.21 Support your adrenal health and prioritize quality sleep and downtime. Herbal remedies can be powerful allies in boosting energy and libido. Here are some of our favorites:

• Maca (Lepidium meyenii): An Andean plant of the brassica family, maca root has been used for centuries to enhance fertility. Studies also show that maca may help reduce psychological symptoms (such as anxiety and depression) and improve sexual dysfunction in postmenopausal women.22,23
• Shatavari (Asparagus racemosus): Used in Ayurvedic medicine, shatavari is known as a “female tonic” that helps the body cope with stress and supports reproductive health.
• Eleuthero (Eleutherococcus senticosus): Eleuthero, also known as Siberian ginseng, is an adaptogenic herb that enhances your body’s resilience to stress. 
• Rhodiola (Rhodiola rosea): Another herbal adaptogen, rhodiola may help your body manage stress and fight fatigue, helping you feel more vibrant. 

4. Don’t Wait for Your Libido, Schedule Sex

While it may sound unromantic, scheduling sex is one of the most important pieces of advice we give to our patients. That’s because the changes in our bodies that occur with menopause lead to less spontaneous desire, or the sudden desire before the initiation of intimacy.  However, responsive desire – the desire in response to initiation like kissing or touch – is still very much alive. In other words, arousal often follows physical intimacy, not the other way around. So don’t wait for your libido to get you in the mood; create it intentionally. By scheduling sex, you’ll ensure that intimacy doesn’t get pushed down to the bottom of your to-do list. 

5. Pelvic Floor Physical Therapy

Sometimes your discomfort isn’t about dryness; it’s about muscle tension. So if you have pain that isn’t solved by the use of lubricants, consider pelvic floor physical therapy. The tissues surrounding your pelvic floor can become tight or weak, and a therapist can help you release tension, improve blood flow, and make sex feel good again—not painful.

6. The UTI Connection

Some women avoid sex because it increases the risk of developing UTIs. This is often linked to GSM (genitourinary syndrome of menopause). As the vaginal pH changes, your vaginal flora can also change, increasing the risk of recurrent UTIs.24 GSM is progressive without treatment. Addressing the hormone balance in the tissue can significantly reduce these infections. The Urology Care Foundation notes that vaginal estrogen is a key tool in preventing recurrent UTIs in women during perimenopause or postmenopause.25

Sex Can Be Great in Menopause

The transition into menopause can cause significant changes, but it doesn’t mean you have to lose your sexual connection to your body or your partner. By addressing physical comfort, balancing your hormones, and making small changes to your lifestyle, you can continue to enjoy a vibrant and fulfilling sex life well into your 40s and beyond. Ready to experience comfortable, pleasurable intimacy again? We invite you to book a 15-minute complimentary consultation with us. We can discuss your specific concerns and see if a personalized, functional medicine approach can help you feel like yourself again.