Vaginal Atrophy: Sexuality at Menopause

10 Ways to Keep Your Libido High During Menopause

by Christiane Northrup, M.D.

Sex & Sexuality

What we believe about sexuality at menopause has a lot to do with our sexual expectations and experience.  While it is a common misconception that sexual desire and activity inevitably decrease at menopause, this does not have to be true for you.  In fact, that “first-love” feeling of sexual desire can be experienced at any life-stage.

At midlife, the challenge for most women is to be able to access that in-love feeling in ways other than looking to another person for fulfillment and gratification. In other words, if you think of sexual energy in the largest possible context — as life force, or Source energy — then it is easy to see that the health and vitality of our sexuality is inexorably linked to the health and vitality of our lives.

Listen to Your Body

Many women at midlife are in the process of negotiating how to tap into their source energy, which is why they often notice a decrease in sexual desire. In addition, many other factors can affect sexual desire, including vaginal dryness, dyspareunia (pain during intercourse), vaginismus (painful spasms in the vaginal muscles), loss of clitoral sensation, and touch sensation impairment.

Determining the cause of sexual problems can be difficult. Sometimes, menopause-related hormone deficiency is to blame. But sexual function is a complex, integrated phenomenon that reflects the physical health of not only the ovaries and hormone balance but also the cardiovascular system, the brain, the spinal cord and the peripheral nerves. In addition, there are almost always underlying psychological, sociocultural, interpersonal and biological influences that affect individual sexual function. Interestingly, in one study where 14 percent of women reported having no sexual problems, one-third admitted they had previously had sexual problems, but that the problems had been resolved when they found new sex partners.

It is also important to note that health conditions and medications may also interfere with sexual functioning. Women suffering from gynecological problems, hypertension (high blood pressure), diabetes, chronic pain, alcoholism, drug use (including cigarette smoking), thyroid deficiency, or depression, as well as those who use anti-hypertensive medications, tranquilizers or sedatives, ulcer medications, glucocorticosteroids, antihistamines, or antidepressants may suffer some sexual dysfunction.

10 Common Midlife Sexual Function Changes

Many of the following midlife changes in sexual function have been associated with normal perimenopause:

  1. Increased sexual desire
  2. Change in sexual orientation
  3. Decreased sexual activity
  4.  Vaginal dryness and loss of vaginal elasticity
  5. Pain or burning with intercourse
  6. Decreased clitoral sensitivity
  7. Increased clitoral sensitivity
  8. Decreased responsiveness
  9. Increased responsiveness
  10. Fewer orgasms, decreased depth of orgasm, increase in orgasms, sexual awakening

As you can see from this list, change itself, and not the nature of the change, is the common theme. It’s important to remember that during the perimenopausal transition, with all of its changes, a woman’s libido may go underground for a while as she reprioritizes her life and the manner in which she uses her energy. This is perfectly normal and can yield great dividends. But, it is only temporary. There is no reason for diminished sex drive to become permanent after menopause. And, while some women truly do notice a decline in libido at menopause, others actually experience heightened sexual desire and activity after menopause.

10 Ways to Keep Your Libido High During Menopause

  1. Overcome cultural barriers. Give yourself permission to explore your sexual energy on your own terms.
  2. Update your relationship. Question what is no longer viable in your relationship and work with your partner on rekindling your passion together.
  3. Make time for yourself and your partner. It can be hard to make the transition from caring for everyone else to taking care of yourself. When you make time for yourself and allow some time to connect with your partner, your passion for each other will return.
  4. Get your hormone levels checked. Androgens are the hormones associated with libido; however, declining levels of estradiol (E2) can also affect a woman’s potential for sexual arousal. Having a baseline panel is ideal; it may help you to know what your hormone levels are when your sex drive is normal for you so that if and when you notice a change, you can test your hormones again to see if anything has changed. I recommend the DUTCH test (dried urine test for comprehensive hormones.)
  5. Try progesterone cream. A little progesterone cream is often all you need to restore your libido. As a precursor to estrogen and testosterone, progesterone is important in maintaining sufficiently high levels of the other hormones for optimal sexual pleasure. A normal balance of progesterone also acts as a mood stabilizer and supports normal thyroid function.
  6. Try phytoestrogens. Many women find that their libido gets restored when they increase their intake of the many known phytoestrogens that nature has given us. These include Pueraria Mirifica, maca, black cohosh, and vitex.
  7. Exercise. There is hardly a menopausal symptom that exercise cannot help, including low libido.
  8. Tell the truth about your sexuality. All humans are sexual by nature. How you choose to express your sexuality depends on many factors including your upbringing, your hormones levels, your general overall health, and your level of satisfaction with your current partner, if you have one.
  9. Read Hot Monogamy, by Dr. Patricia Love. Dr. Love has identified nine factors that can help sustain libido and cultivate a sensual relationship with your partner and yourself.
  10. Choose to feel pleasure. Your brain is the biggest sex organ in your body. It’s easy to allow yourself to feel sad or depressed. Your ability to choose how you think about sex and pleasure of all kinds is your most powerful ally in reinventing yourself sexually at midlife.

Do You Have Vaginal Atrophy?

It is estimated that up to 60% of post-menopausal women suffer from vaginal atrophy. And due to embarrassment, cultural taboos and the fact that many women just don’t feel comfortable speaking to their health care providers about the intimate details of their sex lives, many women suffer in silence.

What is Vaginal Atrophy

It is estimated that up to 60% of postmenopausal women suffer from vaginal atrophy. And due to embarrassment, cultural taboos, and the fact that many women just don’t feel comfortable speaking to their health care providers about the intimate details of their sex lives, many women suffer in silence.

Vaginal atrophy (also known as atrophic vaginitis) is caused when there is thinning, drying, and inflammation of the vaginal walls. This is often attributed to a decline in estrogen and occurs most often after menopause, but it can start as early as a woman’s late 30s.

Vaginal atrophy is considered to be a chronic and progressive condition that can affect quality of life.  The symptoms can include:

  • Vaginal dryness
  • Thinning of the vaginal walls
  • Pain or burning sensation, especially during intercourse
  • Decreased lubrication during intercourse
  • Spotting after intercourse
  • Shortening and tightening of the vaginal canal
  • Frequent urinary tract infections
  • Urinary incontinence

Treatment for Vaginal Atrophy

The good news is that vaginal atrophy is a common condition that is easily treated.  The two best ways to treat this condition is to use a vaginal moisturizer and have more sex! In fact, sexual activity increases blood flow to your vagina and helps to keep vaginal tissues healthy.

When it comes to choosing a vaginal moisturizer, there are many options today. 

1.     Try over-the-counter vaginal moisturizers and lubricants. These are nonhormonal products that can be a wonderful first-line defense against vaginal dryness. They are great for women who are concerned about the use of treatments that contain estrogen.

2.    Use a natural moisturizer. Some women can be sensitive to—or even allergic to—ingredients in OTC vaginal moisturizers and lubricants, especially those containing warming agents, dyes, parabens, mineral oil, and perfumes. Try vitamin E gel caps. You need to puncture the gel cap and then squeeze the gel into your vagina. (You also need to wear a panty liner because the gel can stain your clothing.) Aloe vera is another natural option. You can use it as both a moisturizer and lubricant. And it does not upset the pH balance of your vagina. You can also try coconut oil or olive oil, but don’t use these with condoms. Be sure to test any product on the inside of your arm before using internally to be sure that you don’t have a reaction.

3.    Try herbal remedies. Other solutions to vaginal dryness include herbal remedies that can be taken systemically, including Pueraria Mirifica (this can also be used vaginally), black cohosh, wild yam, Dong Quai or chasteberry.

4.    See your doctor. If you experience painful intercourse that is not resolved by using a vaginal moisturizer, you may need a low-dose estrogen preparation, such as estriol vaginal cream.

Related Audio:  Low Libido At Midlife? What You Can Do To Increase It

Last Updated: February 11, 2021

Christiane Northrup, M.D.

Christiane Northrup, M.D., is a visionary pioneer and a leading authority in the field of women’s health and wellness. Recognizing the unity of body, mind, and spirit, she empowers women to trust their inner wisdom, their connection with Source, and their ability to truly flourish.


Add comment
  1. Julie
    1 year ago

    I’m 77 years of age. I’m writing about a change in my labia minora (one side only). It’s thicken quite a bit. No pain, odor, color change. Just thicker. Any guess what’s going on with my vagina? I hope you will comment, because I won’t see a physician (biopsy).

  2. Carole heath
    2 years ago

    I was diagnosed with vaginal aprophy in 2021. After urine infections and given antibiotics. The doctor said I had thrush urine infection and fungus infection. The antibiotics helped the burning sensation when I passed urine. But the soreness was still present in the vulvar area. Eventually after more doctor’s visits vaginal aprophy was diagnosed and I was given ovestin cream. Which I am still on and that has helped the condition. I was 74 when I originally got the problem. I had no trouble before after the menopause. It maybe a coincidence but all this came on after the two vaccines for COVID last year and got worse after the buster last December 2021.

  3. Dina Wilson
    2 years ago

    I’m really surprised you didn’t mention the Estring as an amazing remedy for vaginal atrophy. I’ve been using it for over 2 years, and though I’m now 60, I have the vagina of a 30-year-old! I’m lubricated and my vaginal tissue is no longer so thin and fragile. I feel it’s a miracle cure for vaginal atrophy, and SO much better than using any creams or topical stuff. The Est-ring is a firm, silicone – like ring that you insert into your vagina and it stays in for 3 months – it gives your vagina estrogen but it isn’t systemic, so it’s not like being on hormone replacement therapy, it’s just localized to the vagina. You replace it every 3 months, and it’s easy and painless. Is there a reason you don’t mention this wonderful product?

    1. Cathy Valley
      2 years ago

      I read somewhere online that you shouldn’t use an Estring for very long, I could be mistaken….I’m confused about estradiol vs. estriol, and now I’m looking into “Neueve”, which doesn’t contain estrogen at all, but seems to get rave reviews from many women….then there’s phytoestrogens……so much to look into!!

  4. Lucy Oliver
    3 years ago

    Just a little question. I’m 43 years old with no menopausal symptoms so far. I’ve been researching different changes and read a lot of information about vagina atrophy, but see very little about clitoral atrophy. It seems that vaginal dryness and shrinkage aren’t always inevitable and can be treated. Is this true of the clitoris too, or is it unavoidable?

  5. Sharyn Harbison
    3 years ago

    Im interested in understanding Testosterone levels in woman that just hit menopause.
    What should the levels be at and should we take HT for loss of testosterone? I do know every case is different. Ive heard it can be dangerous. Im a healthy 57 year old, I’m noticing loss of muscle. Ive heard it can help rebuild muscle to stay strong?

    I hope I get an answer from Dr Northrup.


  6. Kelly Elliot
    3 years ago


  7. Coulson Duerksen
    3 years ago


  8. Dorothy
    4 years ago

    Any comments about Mona Lisa touch for vaginal atrophy? I tried it with my gynecologists advice and it helped, but considering stopping the annual treatment, after reading negative things about it.

  9. Sharon
    5 years ago

    I started with with estriol gel .05% then the main stream gyno and an endocrinogist wanted me to try estrace. then I bought online estriol I read the fda says no online purchase. I never had the gel tested either but the ocmpounder stated same reading as estriol he makes. NOw off estiol from bodylgics from the ocmpounder since Feb. 2017 started. then in 2018 switched. Now my nipples are sore. why is this. trying going back to the bioidentical hormone. I have proestron pills also adn always told to take l tyrxine with levothyrozine and dhea. tested. no gluten or dairy very little emat. grass fed. organic must. Hate the sore nipples. Coudl the estrace or mail order pharmacy fo rless be to blame?

  10. Lynne Wood
    5 years ago

    I came to these comments from the header: “Vaginal atrophy”. Intercourse is impossibly painful for me at 68 after being menopausal for 20 years. I was hoping for some answers to the comments and guidance about Pueraria Mirifica. I heard Dr. Northrup talk about it years ago on Hay House. I have used estriol cream before but have genetic issues about that and am concerned about trying it again. I had to have a hysterectomy and D &C after a bleed also. But there are no answers to these comments. Does Dr. Northrup ever respond (or someone in her office who knows the answers?)

  11. Sessa
    5 years ago

    I don’t see any responses to any of the questions….??? I was not sexually active for the last 5 years (full menopause behind me 6 years ago). I finally found a partner that really turned me on. I had no problem lubricating but… upon him (trying to) enter me, we both said at the same time, it was like hitting a wall! It was extremely painful to me and he was not able to get in at all! The second time we tried weeks later, it happened again. I went to a female general practitioner that had no idea what it was. She said to get lube (which is completely ineffective on atrophy)! I looked it up on line and found that it was vagmismus. I then went to a gyenecologist that referred me to a physical therapist but then I lost my job, my insurance. I researched again and purchased dialators that are hard, unnaturally shaped, cold and can’t be warmed. I can only get the smallest in (very uncomfortably). There should be a size between that and the next. They are useless! I heard that estrogen creams can cause cancer…? Lover one couldn’t deal. Now almost a year later, I took on a new one that is very perplexed and doesn’t understand why he can’t just jam it in to solve the problem. He is young and thinks I would bleed and I will be fine like virgins are, post entrance. I have had to nix him because he thinks pain is psychological and there is no way I can bear even the idea of more of that severe pain! Again, I do not have a lubrication problem, just an extremely tight opening that is unpenatratable by anything wider than two slim fingers. This was never the case prior to six years ago. Pleasuring myself does absolutely nothing to help the problem. Should I try to buy flexible, tiny dildos in graduating sizes…. if they even exist?

    1. Dina Wilson
      2 years ago

      Hi Sessa,

      If there’s any way you can get to a gynecological physical therapist, please go! I had terrible vaginismus for years, and I finally saw a really wonderful gyn pt who helped me heal my problem within 6 months. The most important thing I learned is how much I was clamping up my vaginal muscles with stress! I learned to breathe into my vaginal tension and release it. She also did internal pressure points and I learned to relax the muscles while she was applying pressure.

      I also had vaginal atrophy, which I dealt with before the vaginismus, by using the Est-ring. It’s an amazing product that you insert into your vagina and it lives in there for 3 months at a time, releasing estrogen to your vagina ONLY (not systemically.). It totally fixes my vaginal atrophy – it’s like my vagina has gone back to its glory days in my 20’s and 30’s! I’m lubricated, and my vaginal tissue is no longer so thin and fragile. Give it a try!

  12. Susie
    6 years ago

    Hi, just wanting to know how I can restore myself from Clitoral Atrophy Naturally? I have been under a lot of stress & unfortunately, my partner is a nice man he is not very passionate & I have after being post menopausal have found with the lack of passion & a lot of stress that I have shrunk & shutdown. Thankyou

    1. Christiane
      5 years ago

      Dear Sessa, Physical therapist who specialize in the female pelvis are obviously a very good resource. But I would also look into EMDR ( rapid eye movement therapy). EMDR and also Tapping ( emotional freedom technique) both override the intellect and help change the involuntary patterns in the body. You can even find someone on line who could work with you. This type of therapy has been successfully used to treat very severe PTSD in combat veterans. Please hear this– your problem is physical. BUT– when a muscle contracts involuntarily– anywhere in the body– you have to work with all parts of yourself– body , mind, and spirit. Of course I’ve also seen this kind of thing completely disappear with Divine Love, Check out I hope this is helpful!

    2. Christiane
      5 years ago

      Dear Susie– you absolutely can restore this on your own. I would recommend that you start a personal “self cultivation” practice on your own. Perhaps also consider using a yoni egg. The key here is to begin a love affair with YOURSELF. Perhaps read the book Pussy: A Reclamation by Regena Thomashauer. ( Don’t let the name scare you.). The female body has all kinds of ways to rejuvenate itself.

  13. Michele
    6 years ago

    Hello, I am 55 years old and went into menopause at the age of 34. It literally happened over night, I’d had a few symptoms like night sweats and irritability but put it down to stress over a marriage not working etc etc etc. I have always had a very low libido and sex has never been very high on my list of wants or priorities. Anyway I never took any HRT as I didn’t believe in them and instead opted to go the natural route. I used to take a wild yam and aloe combination which worked a treat but this was discontinued and at the time the internet was not as accessible to be able to research where I could get this. Anyway I subsequently got divorced and 2.5 years later scummed to pressure and tried hrt for a 6 month period,it made no difference and I stopped. I then travelled to another country to meet up with my now husband to see if the relationship would work as we’d been having a “long distance” relationship. In the 3 years since I’d been diagnosed with early menopause I’d never had a period. 4 months after moving to a new country and 3 years past menopause I fell pregnant and have a beautiful amazing son in my life. However my husband cheated on me when I was 8 months pregnant and I chose to stay in the marriage for my child. This is possibly the worst decision I ever made because it compromised my beliefs and I have been in a state of depression for such a long time. After my sons birth I still never regained my periods and sex has been non exsistant from a mental aspect and physically because it just hurts too much. Along the way I have also been diagnosed with an under active thyroid for which I now take thyroxine. So I am now trying to get my life together and realize that I may have many issues to deal with including my relationship with my mom. I still do not take hrt, I am physically active and regularly walk/run and go to the gym, but am thinking maybe I need to address my libido and depression and am not sure where to start with all of this. I was reading your blog on Pueraria mirifica and was wondering if this is something that I should look at taking. I do take a multi vitamin and multi mineral both Usana products, I have bone density scans that always show my density as being good. I did see an endocrinologist a while back and he had seen me a few years earlier and had tried to convince me to go on hrt, when he saw me a second time about 3 years later and I said I had not taken hrt, he said I was doing great and could therefore not see any compelling reason for me to use it. I look forward to hearing your feedback.

  14. doreen
    6 years ago

    I have to say, I have experienced the opposite of everything I have read about menopause and sex. I am 60 years old, 5 years into menopause. My sex drive has never been HIGHER. I can’t get enough! I am exhausting my husband, and in between use toys to pleasure myself. I also have no drying out issues, like I feared from everything I have read. I am more lubricated than I have ever been. I need to put a towel under me when we have sex because I soak the sheets! My husband isn’t complaining, but tell me, is this normal? I am not on any medications. Just a daily vitamin C pill.

  15. Registering Safely
    6 years ago

    I definitely have signs of vaginal atrophy, possibly pretty severe. I would like to try your Pueraria Mirifica products, but have concerns about taking any kind of estrogen due to my mother having had estrogen-receptive breast cancer. Is this a legitimate concern for me?

  16. bj
    6 years ago

    About what percentage of peri -menopause women actually have an highly increased sex drive at some point for a few weeks at a time where sexual desire just cannot be satisfied during and how long does it last? It goes up and down but up is extreme.

    1. Lisa
      6 years ago

      I am 47, mother of a teenager and young adult, have had hysterectomy (fallopian tubes left), and have always had a pretty low libido. Until the weekend of our 23rd wedding anniversary vacation! It was like my husband “flicked my libido switch!” I can’t get it enough! Forget about 3-4 times a week for a healthy relationship – we’re already at that per DAY! In the past I wasn’t interested in him “playing” with me let alone, self-pleasure was completely taboo. Now the floodgates have opened! I am more open to self pleasure (awaiting the arrival of my first sex-toy: vibrator), and free to let my husband “explore” me for as long as he wants. I am frisky all the time. I can’t stop thinking about having orgasms. My vagina is constantly swollen and wet. I’m loving my “awakening,” not to mention, my husband feels he’s with a new woman! My only fear is that it will expire as abruptly as it came. The way I look at it: use it while you can. We are in a loving monogamous relationship. This is our time to embrace it! We defiantly are riding this wave!

  17. Beverly
    6 years ago

    Dear Dr. Northrup,

    What are your thoughts about vaginal rejuvenation? I am 57, a 2x breast cancer warrior and have had a complete hysterectomy. Intercourse is very, very painful (even using OTC vag. moisturizer & lube). I miss sex. Any suggestions?

  18. Dr. Jan Hamilton
    6 years ago

    Sex with another woman is amazing. We share spiritual values, compassion, and a bond never achieved with a man!

  19. Dr. Jan Hamilton
    6 years ago

    Dear Chris, Today I am submitting my final version of Writ of Certiorari to the US Supreme Court. At age 60, after having been married to a very powerful Texas lawyer for 46 years, I moved my practice to Colorado, went to a bible class, invited by my elderly patients late in the day in February of 2001, when I walked into the door, there was Nan! I knew I had waited for her all my life. We lived closeted for 4 years, then 1st Baptist mandated “Conversion Therapy” with threat of arrest to fail to comply! We were mortified! I finished the classes, was invited back to church, but arrested for 3rd Degree Criminal Trespassing while we were preparing the refreshments for the congregation. I sought reconciliation; the case was dismissed but the homophobia has never ceased. That is my case at the US Supreme Court. QUESTION TO THE COURT: Does the refusal of others to reconcile violate my 1st Amendment beliefs that God loves all the same, gay and straight? As you know, I have followed your recommendations in Women’s Bodies Women’s Wisdom for the past 20 years and shared with my family. I am now 76, she is 77 and we hope to be married in the Honorable Ruth Bader Ginsburg’s Chambers after we win! Merry Christmas to you and all those you love, Jan

  20. Clarissa Stein
    7 years ago

    I am on Effexor and in menopause. Post-divorce and a the last few times I have had sex it has been v painful. I started estrace and if I have sex-it is helpful. However I haven’t been active and am starting a relationship that will have to be long distance for some time.
    Despite being a very sexual person until my early 50s- I am now scared about the pain and UTI’s I get from infrequent sex. I am also on Effexor 37.5 3 x daily which clearly reduced libido AND made orgasm very difficult.
    In addition to Estrace and lubricant- I am wondering if reducing the Effexor might help with my loss of sex drive and- worse- trouble reaching orgasm. I have anxiety- but depression is much less a problem.

  21. Jo
    7 years ago

    What’s all this talk about women thinking sexual desires decrease during menopause? I’m waiting for someone to tell us what to do when our husband’s interest is decreased while ours is just as healthy as ever. Begging obviously doesn’t work. How can our needs be met when hubby isn’t ‘in the mood’?

    1. Cristlee
      7 years ago

      I’ve had a lot of luck by giving him oral. I’ve enjoyed it as much as him, which is something new, and we have been married 20 years.

    2. Sue
      6 years ago

      I have the same issue.We talk about it and he has tried several different “male enhancement” supplements.
      There is one that works great for him. I would suggest giving that a try. Also, if he is taking beta-blockers or
      BP meds or diuretics, a side-effect is ED. The main thing is to communicate openly about it while not criticizing
      him. I am sure that it bothers him as much as it bothers my husband, but we are partners with them and it needs
      to be a team effort. Be patient and kind about it – and don’t give up!

    3. eljay
      6 years ago

      He may have to have his Testosterone levels checked. Men go through Andropause and low levels of Testosterone can be a health concern for them. Tell him to get it checked.

  22. Carol
    7 years ago

    Why don’t they know what is in Premarin Cream?
    Why won’t they make a generic form when they have a generic Viagra? ( I do not have prescription coverage with my catastrophic plan.)

    1. Sue
      6 years ago

      You are better off with a compounded estriol cream that is used vaginally, not a fake compound made
      from pregnant mare’s urine (PREMARIN). Please find a holistic or integrative physician that will prescribe
      this for you. I have had great results from it. I have been in menopause since I was 47 and am 62 now,
      and things are working just fine 😉

      1. veronica
        6 years ago

        is it safe to use it for that long? I stopped using mine because I was afraid of getting cancer.



  23. Ronna
    8 years ago

    Can you recommend a good natural lubricant for a new relationship?

    1. Esperança Melo
      7 years ago

      Coconut oil works wonders and it´s an edible product so it doesn´t contain all the chemicals found in specialized products, and it´s a lot cheaper!

  24. Kay
    8 years ago

    I haven’t had a period for over a year and a half. I am 55 and decided that I can’t get pregnant at my age so now my husband and I use no means of birth control.
    Is this ok?

  25. Deb Robbins-Madone
    8 years ago

    No mention of circumcision of the male partner as the primary cause of painful burning intercourse! You need to check this out–with an intact partner there is no discomfort during sex!

    1. bj
      6 years ago

      Of course it must be.

  26. Paula
    9 years ago

    I want an organic and safe herb or supplement to help with an extremely low libido. I don’t want to take any hormones as they really scare me to death. How do I research my options?

  27. Cheryl
    9 years ago

    From HayHouse radio program, I thought I heard you promote a product for male sexual health. I believe it was called Thor? Where would I find it?

  28. Susan Cook
    9 years ago

    Hello. I have been an admirer of yours for years. Thank you for sharing your knowledge. How do you pick a progesterone cream? There are SO may on the market. I want help with my libido. I am 55 years old and post-menopausal. thank you very much, Susan Cook

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