Low libido and menopause: what changes, and what estrogen can and can't do

A change in sex drive is one of the quieter parts of menopause. It is also one of the most confusing, because so many things can feed into it at once. Hormones play a part, but they are only part of a much bigger picture ^[1]. Here is how menopause can affect desire, what estrogen therapy can and cannot do about it, and what is worth raising with a clinician.

How menopause can affect desire

There is no single menopause experience here. The Menopause Society notes that some women have a significant decline in desire at midlife, some have increased interest, and others notice no change at all ^[1]. It describes hormone changes as only part of a complex set of factors that shape sexual activity at midlife and beyond ^[1].

The best long-term data come from SWAN, the Study of Women's Health Across the Nation. It enrolled 3,302 women aged 42 to 52 and followed them yearly ^[5]. After accounting for age and for social, health, and psychological factors, desire decreased and pain during sex increased by late perimenopause ^[5]. But the menopause transition was not independently linked to how important sex felt, arousal, how often women had sex, emotional satisfaction with a partner, or physical pleasure ^[5]. Overall health, emotional well-being, and how important sex was to a woman were linked to every sexual outcome measured ^[5].

An earlier look at 3,167 SWAN women found that relationship factors, attitudes toward sex and aging, vaginal dryness, and cultural background had a bigger impact on most aspects of sexual function than the shift into early perimenopause ^[6].

The direct and indirect routes

Sleep and hot flashes. Bothersome hot flashes, especially night sweats that break up sleep, can affect sexual interest, and the Menopause Society notes that not having restful sleep might reduce interest in sex ^[1].

Dryness and pain. Genitourinary syndrome of menopause can bring less lubrication and pain with sexual activity ^[2]. In SWAN, pain during sex rose across the menopause transition ^[5]. Desire and arousal problems frequently overlap ^[1].

Life and relationships. Divorce, dating, children leaving or staying home, and caring for aging parents often happen at this stage of life ^[1]. A partner's own sexual problems can affect desire, and treating them may be important to a woman's sexual satisfaction ^[1]. Changes in body image and self-esteem, and concerns about aging, can play a part too ^[1].

Health and medicines. In a national survey of 31,581 US women, distressing sexual problems were linked to poor self-rated health, depression, anxiety, thyroid conditions, and urinary incontinence ^[7]. Some medicines, including some used to treat depression, can interfere with sexual function ^[1]. MedlinePlus adds diabetes, heart disease, nerve disorders, and hormone problems to the list of possible physical causes ^[10].

Low desire versus a problem that bothers you

Wanting sex less often is not automatically a problem. The Menopause Society says there is no "normal" frequency for sex at any age ^[1]. What matters is whether it bothers you. In the same US survey, 43.1% of women reported some kind of sexual problem, but only 12.0% had a problem that also caused them personal distress ^[7]. Those distressing problems were most common in women aged 45 to 64 ^[7].

What estrogen therapy does, and does not do, for desire

This is where expectations matter. The Menopause Society's 2022 position statement says systemic hormone therapy generally does not improve sexual function, sexual interest, arousal, or orgasm independent of its effect on genitourinary symptoms ^[2]. Studies have not found a significant effect of estrogen on interest, arousal, or orgasm apart from its role in treating menopause symptoms ^[2].

What estrogen does do is treat the physical changes. Both systemic hormone therapy and low-dose vaginal estrogen increase lubrication, blood flow, and sensation in vaginal tissue ^[2]. So when desire is being dragged down by pain, dryness, or nights of broken sleep from hot flashes, treating those symptoms is the route by which estrogen may help.

What the trials found

A 2023 Cochrane review pooled 36 randomized trials with 23,299 women ^[3]. Estrogen alone probably slightly improved overall sexual function scores in women with menopause symptoms or within five years of menopause, with the clearest gains in lubrication, pain, and satisfaction ^[3]. The reviewers were uncertain whether estrogen combined with a progestogen improves sexual function scores ^[3].

The KEEPS trial compared routes head to head. It included 670 healthy women aged 42 to 58 within three years of their last period, randomized to an oral estrogen pill, estradiol through the skin (50 micrograms a day), or placebo for four years, with progesterone or placebo for 12 days a month ^[4]. Transdermal estradiol modestly improved overall sexual function scores compared with placebo, with significant gains in lubrication and less pain; the pill did not differ significantly from placebo ^[4]. The study did not measure whether women felt less distressed ^[4].

Why the route may matter

Estrogen taken by mouth raises a protein called sex hormone-binding globulin, which reduces how much testosterone is available in the body ^[2]. Estrogen through the skin has minimal effect on it ^[2]. For that reason, the Menopause Society says that if sexual function or libido is a concern in a woman with menopause symptoms, transdermal estrogen may be preferable to oral ^[2]. Transdermal options include an estradiol patch and estradiol cream. Read more in our estradiol patch guide.

Systemic estrogen is prescribed for menopause symptoms such as hot flashes, not for low desire alone. Whether it fits you depends on your symptoms and your health history, which your clinician reviews ^[2].

If pain is part of it

If sex has become uncomfortable, treating that is often the first step. Low-dose vaginal estrogen improves sexual function in postmenopausal women with genitourinary syndrome of menopause ^[2], and lubricants and moisturizers can be used alongside it ^[9]. Regular sexual stimulation, with a partner, alone, or with a device, also promotes blood flow to the vagina, and other forms of intimacy such as extended caressing and massage are a way to stay close while you treat the pain ^[9]. See our guide to painful sex after menopause for more.

Other options a clinician may discuss

Because low desire usually has more than one cause, care often covers more than one thing. The Menopause Society says an evaluation can identify underlying medical or psychological causes, that counseling can help with medical, relationship, or family issues, and that clinicians can refer you to specialists in sexual concerns ^[1].

You may have read about testosterone. A 2019 global consensus statement, endorsed by The Menopause Society and other medical groups, says the only evidence-based use of testosterone in women is for postmenopausal women diagnosed with hypoactive sexual desire disorder after a full assessment ^[8]. It says a blood testosterone level should not be used to diagnose that condition, and the panel recommended against compounded testosterone ^[8]. WarriorBabe Health does not offer testosterone. If it interests you, it is a conversation for your own clinician.

When to talk to a clinician

Occasional problems with sexual function are common, MedlinePlus says, but if they last more than a few months or cause distress for you or your partner, it recommends seeing your health care provider ^[10]. It is worth raising if:

• Low desire bothers you or is straining your relationship ^{[1, 7]}
• Sex has become painful or uncomfortable ^[2]
• Hot flashes or night sweats are breaking up your sleep ^[1]
• You started a new medicine around the time things changed ^[1]
• You have been feeling low, anxious, or not like yourself ^[7]

Getting help through WarriorBabe Health

WarriorBabe Health offers estrogen for menopause symptoms through the skin, as an estradiol patch or estradiol cream, and an estradiol vaginal cream for dryness and painful sex. Our hormone products are compounded by a licensed pharmacy and are not FDA-approved. A licensed provider reviews your health history and decides whether any of them is appropriate for you, and not everyone will be a candidate.

You can compare options on our hormone treatments page, or take the 2-minute quiz to see where to start.

This article is for general information. It is not medical advice and does not replace a visit with a licensed clinician who knows your history. Do not start, stop or change a medication without talking to your clinician. If you think you are having a medical emergency, call 911.