Experiencing changes in libido, or sexual desire is common as we age. Sexual function is affected by multiple factors including hormone levels, pain, mood, age, relationship satisfaction, stress and history of sexual trauma. From mid-life to menopause, increased fatigue and joint pain in combination from changes in estrogen, testosterone and DHEA can affect sexual desire. The decline in estrogen specifically alters the vaginal tissue leading to decreased lubrication and increased irritation and pain. There are many ways in which women can address this and improve arousal and sexual experience including non-hormonal and hormonal options.

 Hormonal and vaginal changes with aging

As we age, the transition into menopause is accompanied by the natural fluctuations and declines in sex hormones. Testosterone, estrogen and DHEA have all been implicated in influencing sexual desire in women so it’s not unreasonable that the decrease in these hormones can alter and decrease sexual function.

 In a 10 year study of 3300 women aged 42 to 52 years, 58% reported having sexual desire at least once a week at baseline; ¹ Ten years later this number decreased to 35%. Hormone concentration measurements showed that over the course of the study FSH levels increased and estrogen levels decreased, while there was very little fluctuation in testosterone and DHEA levels.

 Researchers found a positive association between testosterone levels and the frequency of sexual desire, arousal, and masturbation.¹ Masturbation frequency was also positively associated with DHEA levels and negatively associated with FSH concentration.

 The decline in estrogen specifically has a negative effect on the tissues of the vagina which can drastically affect the sexual experience. The vaginal canal is lined with a thick, rugated and well-vascularized tissue, which after puberty is lubricated in most women. With normal aging and a decline in sex hormones, the vaginal tissues become thinner, less elastic, paler and drier. The vagina can also become more narrow and shortened, especially in the absence of sexual penetration. And in some cases, the clitoris can recede and become flush with the surrounding tissue.²

 Thinning of tissues with dryness is referred to as vaginal atrophy and can led to painful intercourse and enough irritation to tear the tissue. There can also be a feeling of decreased elasticity and a tightness which can led to an unsatisfying and even painful sexual encounter.²

 Another contributing factor is the change in the composition of the vaginal microbiome from altered levels of sex hormones during perimenopause.² During the reproductive years, lactobacilli bacteria produce lactic acid and hydrogen peroxide that helps protect the epithelial barrier by modulating the vaginal pH (keeping it within 3.8 to 4.5). In doing so, these bacteria help prevent vaginal infections such as urinary tract infections (UTIs), yeast infections, sexually transmitted infections (STIs) and bacterial vaginosis (BV).

 In postmenopausal women, it’s been reported that vaginal dryness is less likely when the vaginal environment is populated with a higher percentage of lactobacillus bacteria. Because these changes in hormone levels and the microbiome tend to be gradual over time (unless in the event of antibiotic use), symptoms aren’t often noticed.²

 First line of therapy vaginal dryness and atrophy are non-hormonal including the use of vaginal lubricants and moisturizers, as well as pelvic floor physiotherapy. Many women believe that the key is to do Kegel exercises as we age to strengthen the vaginal and pelvic muscles, but in fact practicing Kegels when the problem is vaginal tightness may not be the answer. A proper vaginal assessment by a pelvic floor physiotherapist should be completed to determine which areas or muscles need to be strengthened and which ones need to relax. A pelvic floor physiotherapist can also assess the vaginal structure as far as narrowing and can help gradually stretch the tissue. In some cases, women use therapy tools such as spacers as well.

 The use of lubricants can be helpful, but the safety of many types and brands of lubricants have come into question. Products that are more hyperosmolar such as Astroglide and KY Warming Jelly can have a toxic effect on epithelial cells and damage the vaginal lining.² Meanwhile, lubricants that are silicon-based or near iso-osmolar, such as Good Clean Love and Preseed, seem to be safer for tissue integrity; However, many lubricant products including Preseed, still contain solvents and preservatives such as parabens which are known to have endocrine-disrupting and even allergenic effects.

 Lubricants can also affect the vaginal microbiome and have toxic effects on lactobacilli bacteria. Petroleum jelly use was found to increase the risk of BV by 2.2x compared to controls.² Others can contain flavours and sugars that increase the risk of UTIs and yeast infections, so these should be avoided.

 Long-term stress and previous sexual trauma on sexual desire

Some studies have looked at the effects of stress on hormone regulation and libido. The hormones DHEA and cortisol are produced in the adrenal glands in response to stress, with each one balancing out the other. Long-term stress and childhood trauma can both affect the regulation of the signalling pathways from the brain to the organs that produce hormones.³ These are referred to as the hypothalamic-pituitary-adrenal (HPA) axis and the hypothalamic-pituitary-ovarian (HPO) axis.

 The normal physiologic pattern of cortisol is to peak in the morning, about 30 minutes after waking, and then a sloping decline with lowest levels at night. When under acute stress, cortisol secretion increases to help cope with the stressor, however, under these conditions chronically as with prolonged stress HPA function is disrupted and basal levels tend to drop, preventing a proper morning peak, and leading to impairment of the circadian rhythm impairment (flatter diurnal cortisol curve).

 In a study of women aged 19 to 65 years, those with hypoactive sexual desire had lower morning cortisol levels, a flatter diurnal slope and a lower cortisol awakening response (CAR).³ A lower CAR was also found in those with a history of sexual assault, regardless of current sexual desire.

 Erectile dysfunction

Having a partner who has sexual difficulties can also negatively affect the sexual experience, even with medication use. For some women, having a sexual encounter with a partner who is unable to participate via penetration due to erectile dysfunction (ED) can make sex less satisfying.

 Pharmaceutical drugs such as sildenafil are commonly used for and effective for ED, however, many women report that having a partner needing to take a pill and then waiting for its effect to kick in can take a toll on the experience. For example, in one report, some women noted that they felt pressured to participate in sex at the cost of not wanting to waste the prescription tablets.⁴ As well, when using ED drugs, sex is more or less scheduled for peak efficacy of the ED tablet. For some women this can create anticipation, excitement and the ability to prepare. However, for others, having to plan sex may decrease the element of romance and spontaneity.

 Hormone therapies in surgical and natural menopause

The hormonal transition into menopause can occur over years. The overall decline in hormones occurs but can be more gradual. When a woman undergoes surgical menopause, the abrupt removal of both ovaries leads to a complete halt to ovarian hormone production and secretion. This could lead to a more dramatic decline in libido.⁵

 Our current knowledge in this area shows the role of testosterone, DHEA and estrogen on libido, however, using these hormones as treatment doesn’t always solve the problem or improve symptoms.

 For example, in one study, estrogen use alone (vs combination hormone treatment) was shown to increase sexual desire in perimenopausal and menopausal women, but only if serum concentrations reached physiological pre-ovulatory levels.⁶ However, our current guidelines don’t support the use of systemic (oral) estrogen treatment solely for the purpose of increasing sexual desire. One form of topical estrogen, estriol, is often used vaginally to temporarily increase lubrication in patients with vaginal atrophy and dryness, which can benefit sexual desire.³

 Women who have undergone surgical menopause (removal of both ovaries) have been reported to have less sexual desire than those who experienced natural menopause.⁷ In these cases, there tends to be a greater negative effect when surgery occurs earlier in life (ages 20-49), compared to later life (ages 50-70 years).

 In a study of women who had undergone surgical menopause, sexual desire was greater when treated with either testosterone only, or with a combination of estrogen and testosterone.⁶ This effect was greater than giving estrogen alone and placebo.

 The use of DHEA as a hormonal treatment hasn’t been exclusively shown to improve sexual desire or function in menopausal women who already have normal DHEA levels. However, it might be of use in women with decreased libido from the use of oral contraceptive pills (OCPs) (synthetic estrogen and/or progestins).

 One study showed that after five cycles of OCP use there was a significant decline in sexual desire, lubrication and arousal. When given a combination of DHEA with the OCP, the same decline wasn’t found compared to placebo, and several parameters of sexual feelings and function (such as arousal and partner sex) were significantly improved with the addition of DHEA.⁸

 Improving sexual desire and function during aging

First line therapy for improving sexual function in aging is the use of non-hormonal lubricants and vaginal moisturizers and to engage in regular (using safe sex precautions if not with the same partner) sexual activity to encourage gentle stretching of the vaginal tissues. If these aren’t effective, then low-dose vaginal estrogen therapy may be used, and beyond that, transdermal (typically creams or patches) hormone therapy may be an option. Though some of these options can be messy and expensive.

 Alternative options include:

• Pelvic floor physiotherapy for proper assessment of tissues, muscles and overall pelvic health
• Address and minimize stressors before and during sex. Taking a vacation or being in a low stress environment can trigger desire
• Include the use of manual stimulation, oral stimulation or sex toys such as vibrators
• In the case of previous sexual trauma or long-term stress and anxiety, cognitive behavioural therapy (CBT) and mindfulness-based cognitive therapy (MBCT) may help.³
• With increased joint pain and body aches, try out new positions. What worked before might not work now. Some women also reported that it helped having an adjustable bed.⁴

Don’t be afraid to have an open and comfortable conversation with your sexual partner. Work through any negative thoughts or feelings beforehand and make sure you’re both on the same page. Make it fun and enjoy connecting and exploring both of your bodies and sexuality. Don’t ignore problems – they won’t magically fix themselves on their own. Try to understand how your partner is feeling emotionally, and don’t put any blame on either of you. The goal is to find solutions that work for both of you.

 References

1. Randolph Jr JF, Zheng H, Avid NE, et al. (2015). Masturbation frequency and sexual function domains are associated with serum reproductive hormone levels across the menopausal transition. J Clin Endocrinol Metab. 100(1): 258-66
2. NAMS (2013). Management of symptomatic vulvovaginal atrophy, Menopause: The Journal of The North American Menopause Society. 20(9): 888-902. doi: 10.1097/GME.0b013e3182a122c2
3. Basson R, O’Loughlin JI, Weinberg J, et al. (2019). Dehydroepiandrosterone and cortisol as markers of HPA axis dysregulation in women with low sexual desire. Psychoneuroendocrinol. 104: 259-68
4. Thomas HN, Hamm M, Hess R, et al. (2020). “I want to feel like I used to feel”: a qualitative study of causes of low libido in postmenopausal women. Menopause. 27(3): 289-94
5. Biddle AK, West SL, D’Aloisio AA, et al. (2009). Hypoactive sexual desire disorder in postmenopausal women: quality of life and health burden. Value Health 12(5): 763-72
6. Cappelletti M, Wallen K. (2016). Increasing women’s sexual desire: the comparative effectiveness of estrogens and androgens. Horm Behav. 78:178-93.
7. Bıldırcın FD, Özdeş EK, Karlı P, et al. (2020). Does Type of Menopause Affect the Sex Lives of Women? Med Sci Monit. 26:e921811. doi: 10.12659/MSM.921811.
8. Van Lunsen RHW, Zimmerman Y, Coelingh Bennink HJT et al. (2018). Maintaining physiologic testosterone levels during combined oral contraceptives by adding dehydroepiandrosterone: II. Effects on sexual function. A phase II randomized, double-blind, placebo-controlled study. Contraception. 98(1): 56-62