Many people describe their libido as “gone” during perimenopause or menopause. Sometimes this is a true change in desire. Sometimes it is the body protecting itself because sex has started to feel dry, sore, burning or unpredictable.
If intimacy has become uncomfortable, it makes sense that your mind and body may start to avoid it. That does not mean you are broken, uninterested in your partner, or definitely low in testosterone. It means your symptoms deserve to be understood properly.
Important
Painful sex, vaginal dryness and urinary symptoms are common, but they should not be ignored. They can often be helped, and a clinician can check whether menopause, another vaginal or vulval condition, medication, infection, pelvic-floor factors or relationship stress may be contributing.
Why low libido is not always testosterone
Testosterone can play a role in sexual desire for some women and people experiencing menopause. However, libido is not controlled by one hormone alone.
Desire can be affected by comfort, arousal, sleep, mood, confidence, body image, stress, medication, relationship dynamics, caring load and whether sex has recently felt enjoyable or painful. If sex repeatedly hurts, the brain can start to associate intimacy with discomfort rather than pleasure.
That is why a careful assessment matters. If the main issue is dryness, burning, irritation, recurrent urinary symptoms or pain with penetration, testosterone is unlikely to be the first or only answer.
Vaginal and urinary symptoms that can affect desire
Genitourinary symptoms associated with menopause can affect the vulva, vagina, bladder and urinary tract. You may hear this described as genitourinary syndrome of menopause, or GSM.
Symptoms can include:
- vaginal dryness or a feeling of reduced natural lubrication
- burning, soreness, stinging or irritation around the vulva or vagina
- pain or discomfort during sex
- reduced elasticity or a feeling that tissues are more fragile
- spotting or bleeding after sex, which should be assessed
- recurrent urinary symptoms, such as needing to pass urine more often, urgency, discomfort when passing urine or repeated urinary tract infections
These symptoms can happen alongside hot flushes, sleep disruption, mood changes or wider menopause symptoms. They can also appear even when other menopause symptoms feel well controlled.
How oestrogen loss affects vaginal and vulval tissues
Oestrogen helps support the thickness, elasticity, blood flow and moisture of vaginal and vulval tissues. When oestrogen levels fluctuate and then fall through perimenopause and menopause, these tissues can become thinner, drier, more sensitive and less comfortable.
The local vaginal environment can also change. Some people become more prone to irritation, discomfort, changes in discharge, urinary symptoms or recurrent infections. This is not simply “a bit of dryness”; for some people, it can affect walking, sitting, exercise, sleep, relationships and confidence.
Menopause is one possible cause, but it is not the only one. Thrush, bacterial vaginosis, dermatological vulval conditions, pelvic-floor tension, endometriosis, bladder conditions, childbirth-related changes, some medicines and previous cancer treatments can also contribute. Persistent or unusual symptoms should be assessed.
Reduced desire or avoidance because sex hurts?
It can be helpful to separate desire from comfort.
| What you notice | What it might suggest | What may help to review |
|---|---|---|
| You still want closeness but avoid sex because it feels sore, dry or tense. | Avoidance driven by discomfort, fear of pain or repeated negative experiences. | Vaginal symptoms, lubrication, pelvic floor, local treatment and communication support. |
| You feel little or no sexual desire, even when sex is not painful. | A change in desire, which may have hormonal and non-hormonal contributors. | HRT, sleep, mood, medicines, relationship factors and testosterone suitability. |
| You can become interested, but arousal or orgasm feels harder than before. | Arousal, blood flow, sensation, comfort, mood or medication effects may be involved. | Vaginal comfort, HRT review, medication review, psychosexual support and time for arousal. |
What may help vaginal dryness, painful sex or discomfort?
Treatment depends on what is causing the symptoms, how severe they are, your medical history and what you feel comfortable using. A clinician may discuss one or more of the following.
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Lubricants
Lubricants are used during sexual activity to reduce friction. They can be helpful when dryness or discomfort is most noticeable during sex.
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Vaginal moisturisers
Moisturisers are used regularly, not only during sex, to support ongoing comfort and hydration of the vaginal area.
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Vaginal oestrogen
Local vaginal oestrogen can help relieve vaginal dryness, irritation, painful sex and urinary symptoms linked with perimenopause and menopause. It works directly where it is needed, with minimal absorption into the rest of the body, and can be used on its own or alongside systemic HRT when appropriate.
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Intrarosa
Intrarosa contains DHEA (prasterone), which is inserted into the vagina once daily. It works locally within the vaginal tissues, where it is converted into small amounts of oestrogen and testosterone to help improve vaginal dryness, painful sex and discomfort caused by menopause. It may be considered for some women following a clinical assessment.
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HRT review
If wider menopause symptoms are not controlled, reviewing systemic HRT may help sleep, mood, flushes and general wellbeing, which can indirectly affect intimacy.
If wider menopause symptoms are not controlled, reviewing systemic HRT may help sleep, mood, flushes and general wellbeing, which can indirectly affect intimacy.
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Pelvic-floor and psychosexual support
If pain has led to tension, fear, avoidance or relationship strain, pelvic-floor physiotherapy or psychosexual support may be useful alongside medical treatment.
Local treatment is not the same as a “quick fix”. Vaginal and vulval tissues may take time to feel more comfortable. Some people need ongoing treatment and review, especially if symptoms return when treatment is stopped.
Could my systemic HRT still need reviewing?
At LIVVE, low libido is not automatically treated as a testosterone problem. The assessment looks at what has changed, what sex feels like physically and emotionally, whether there is pain, dryness or urinary discomfort, what menopause treatment you already use, and whether other medicines or life factors could be contributing.
Depending on your symptoms, your clinician may discuss local vaginal treatment, systemic HRT review, pelvic-floor or psychosexual support, medication review, or testosterone assessment. The right pathway depends on the main issue for you.
When should I seek assessment?
Please seek clinical advice if you have symptoms that are new, persistent, worsening or worrying. This is especially important if you have:
- unexplained vaginal bleeding, bleeding after sex or bleeding after menopause
- persistent pelvic, vaginal or vulval pain
- vulval skin changes, sores, lumps, whitening, splitting, thickening or persistent itching
- unusual discharge, odour or symptoms that could suggest infection
- recurrent urinary symptoms or repeated UTIs
- pain that means sex is no longer possible or you feel anxious about intimacy
- symptoms after starting, stopping or changing a medicine
These symptoms do not automatically mean something serious is wrong, but they do deserve proper assessment rather than being treated as “just menopause”.
When might testosterone still be considered?
Testosterone may still be considered if low sexual desire persists after other causes have been explored and addressed where possible. For example, someone may need support for vaginal dryness and pain, but also have persistent low desire that causes personal distress.
In that situation, testosterone should be considered as part of a wider menopause and sexual wellbeing assessment, not as a treatment for pain itself. A clinician will usually review current HRT, vaginal symptoms, medicines, mood, relationship context, blood results and side-effect risk before deciding whether a monitored testosterone trial is appropriate.
For more detail, read Testosterone in Women: Symptoms, Evidence, Treatment and Who It May Help and Testosterone Not Working? What to Review Before Changing Treatment.
How LIVVE assesses the whole picture
Testosterone may still be considered if low sexual desire persists after other causes have been explored and addressed where possible. For example, someone may need support for vaginal dryness and pain, but also have persistent low desire that causes personal distress.
In that situation, testosterone should be considered as part of a wider menopause and sexual wellbeing assessment, not as a treatment for pain itself. A clinician will usually review current HRT, vaginal symptoms, medicines, mood, relationship context, blood results and side-effect risk before deciding whether a monitored testosterone trial is appropriate.
Get help with low libido, vaginal dryness or painful sex
You do not need to decide whether your symptoms are “vaginal”, “hormonal” or “testosterone-related” before asking for help. LIVVE can help you understand what may be contributing and what support may be appropriate.
