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Navigating Genitourinary and Sexual Changes in Menopause

March 30, 2025|Dr Kate Healy|Menopause

Menopause is a natural change that marks the end of a woman's ability to have children. It brings many hormonal changes that can affect a woman's health and well-being. Among the many changes experienced during this phase, genitourinary symptoms of menopause (GSM) and changes in libido are particularly common and often distressing. Knowing the causes,

Woman resting on pillows, looking pensive

The Hormonal Underpinnings

The decline in estrogen levels during perimenopause and menopause is the primary driver of genitourinary and sexual changes. Estrogen plays a vital role in maintaining the health and integrity of the female urogenital tract.

As estrogen levels drop, the tissues in the vagina and vulva become thinner and drier. They also lose elasticity. This leads to symptoms called genitourinary syndrome of menopause (GSM).

Estrogen influences sexual desire and responsiveness. The relationship between hormones and libido is complex. However, a drop in estrogen can lower sex drive.

Recognizing the Symptoms

GSM encompasses a wide array of symptoms, including:

Vaginal dryness
Burning, itching, or irritation in the vulva and vagina
Pain or discomfort during sexual intercourse (dyspareunia)
Increased urinary frequency and urgency
Recurrent urinary tract infections (UTIs)

Changes in sexual function during menopause may manifest as:

Reduced sexual desire (low libido)
Difficulty becoming aroused
Decreased vaginal lubrication
Pain or discomfort during sexual activity
Reduced sexual pleasure and fulfilment

Libido in the menopause

Receptive Libido is Normal: It’s important to understand that a “receptive libido” is normal. This means that a woman may not feel desire on her own. However, she can become aroused in the right situation with the right partner.
Media Portrayal and Societal Pressure: The media often shows an unrealistic image of constant sexual desire. This can make women feel inadequate if their experiences are different.
Underlying Causes Beyond Hormones: Other factors can contribute to low libido. Relationship dynamics, stress, fatigue, and overall health can all impact sexual desire.

Impact on Women’s Lives

The impact of GSM and sexual dysfunction can extend far beyond physical discomfort. These changes can significantly affect a woman’s:

Emotional well-being: Feelings of self-consciousness, frustration, and anxiety are common.
Relationships: GSM can strain intimate relationships because of painful intercourse and decreased libido.
Quality of life: The cumulative effects of GSM and sexual difficulties can diminish overall well-being and life satisfaction.

Empowering Choices: Management Options

Effective treatments are available to alleviate GSM and improve sexual health during menopause. The choice of therapy depends on the severity of symptoms, individual preferences, and careful consideration of risks and benefits.

Non-Hormonal Approaches

Vaginal lubricants and moisturizers are available without a prescription. They can help relieve vaginal dryness quickly. These products can also make sex more comfortable. See below for popular products- or click link for popular products.
Pelvic floor physical therapy: A trained physiotherapist can teach exercises. These exercises help strengthen pelvic floor muscles. They can also improve bladder control and enhance sexual function. Additionally, they aid in vaginal relaxation.
Cognitive-behavioral therapy (CBT): CBT can help manage the emotional distress associated with menopause and improve coping mechanisms.

Hormone Therapy

Vaginal estrogen comes in different forms and strengths, like creams, tablets, and rings. It provides targeted relief from GSM symptoms by directly increasing estrogen levels in the vaginal tissues. Importantly, many professionals consider vaginal estrogen a low-dose and safe option.
Intravaginal dehydroepiandrosterone (DHEA), also called prasterone, is a hormone. When placed in the vagina, it turns into estrogen and testosterone. This process helps improve vaginal tissue health and sexual function in postmenopausal women.
These hormones act directly in the vaginal area. They increase blood flow, improve natural lubrication, and strengthen vaginal tissues.
Systemic menopausal hormone therapy (MHT) includes estrogen and often progesterone. MHT can help manage many menopausal symptoms. These symptoms include hot flashes, night sweats, and GSM. Discussing the risks and benefits of MHT with a healthcare provider is crucial to determine if it’s appropriate.

Sexual Health

While treatment for GSM can significantly improve sexual comfort, addressing low libido may require additional strategies:

Open communication with your partner: Discussing concerns and expectations can foster understanding and intimacy.
Counseling: A therapist specializing in sexual health can help navigate emotional and relationship challenges related to menopause.

Is there a role for testosterone hormone therapy in women?

Clinical trials have demonstrated the efficacy and short-term safety of testosterone therapy in treating hypoactive sexual desire disorder (HSDD) in postmenopausal women. There is currently no Health Canada approved testosterone product specifically indicated for use in women.

Doctors may consider prescribing testosterone off-label for women experiencing persistent low libido after exploring other avenues. Consider non-hormonal options like cognitive behavioral therapy first.

Testosterone is only recommended for issues with libido. It should be prescribed only if other treatments for HSDD have not worked. Experts do not universally agree on testosterone hormone therapy for women. We need to monitor it and discuss and consider the associated risks and side effects.

Resources

Books

Emily Nagoski has two helpful books on women and sexual wellbeing: Come as you are and Come Together.

Two books to read in relation to everything menopause and vaginal are by Canadian born OBGYN, Dr Jen Gunther. Her best-selling books, Menopause Manifesto and The Vagina Bible, pack helpful information.

Local professionals

Pelvic health physiotherapists can be very helpful for the pelvic and sexual symptoms of menopause. Pelvic Health Oakville and Emma Conron at Burlington Sports and Spine have a special interest in this area.

Articles

The Canadian Menopause Society article on vaginal atrophy- when sex hurts.
The Menopause Society also has an article on vaginal dryness and discuss it in this educational type video.
CBC has an article and has interviewed Oakville based Dr Stephanie Finn about female sexual functioning.

Websites

The Menopause Society on sexual dysfunction and challenges in the menopause.

Vaginal Lubricants and Moisturizers

Lubricants are used during intimacy for immediate moisture and comfort.
People use moisturizers for longer-lasting hydration, and they often apply them daily to restore moisture to the vaginal walls.

Both types are important for managing vaginal dryness during menopause, with moisturizers addressing long-term hydration and lubricants providing temporary relief for intercourse.

Tips for Choosing the Right Lubricant:

Water-based lubricants are often the safest for women experiencing vaginal dryness during menopause.
Avoid glycerin and parabens as they can cause irritation or increase the risk of yeast infections.
Consider using vaginal moisturizers for longer-term relief, while people often use lubricants during intercourse.
For some women, silicone-based lubricants may provide longer-lasting moisture but can be harder to wash off.

If dryness keeps happening or gets worse, it’s a good idea to see a healthcare professional. They can suggest treatments like vaginal estrogen therapy.

Vaginal Lubricants (Designed for immediate relief during intimacy)

Good Clean Love Almost Naked Organic Personal Lubricant

Key Features: Organic aloe vera, free of parabens and glycerin, water based.
Why It’s Good for Menopause: Natural formulation suitable for sensitive skin.

Coconu Organic Lubricant (Also a moisturizer)

Key Features: Organic coconut oil, natural ingredients.
Why It’s Good for Menopause: Provides moisturizing relief and is gentle on sensitive skin.

Sliquid H2O Original Water-Based Lubricant

Key Features: Hypoallergenic, glycerin-free, water-based.
Why It’s Good for Menopause: Great for sensitive skin and provides smooth lubrication.

Vagisil ProHydrate Natural Feel Hydrating Gel

Key Features: Aloe vera and vitamin E, water-based, provides immediate moisture.
Why It’s Good for Menopause: Helps with dryness and provides comfort during intimacy.

Astroglide Gel

Key Features: Smooth, slippery texture, water based.
Why It’s Good for Menopause: Instant relief for vaginal dryness and comfort during intercourse.

Vaginal Moisturizers (Designed for long-term hydration, can be used daily)

Gynatrof Vaginal Moisturizer

Key Features: Water-based, contains hyaluronic acid and other natural ingredients to hydrate the vaginal tissue.
Why It’s Good for Menopause: This product is made to treat vaginal dryness. It gives long-lasting moisture and is often recommended for menopausal women.