Sex and relationships during menopause are profoundly affected by hormonal change, and yet they remain one of the most underaddressed dimensions of menopause care in the UK. Many women experience changes in desire, arousal, comfort during sex, and relationship dynamics during perimenopause and menopause, but these issues are often underreported and undertreated.
How menopause affects sexual wellbeing: the complete picture
The hormonal dimension
Oestrogen maintains the health of vaginal and vulval tissues, including thickness, elasticity, and capacity for lubrication. As oestrogen declines, the tissues thin and dry, making penetrative sex painful. Testosterone influences sexual desire at a neurological level, governing motivation, arousal, and capacity for orgasm. As testosterone declines, the biological drive towards sexual activity reduces. Oestrogen and testosterone also influence genital blood flow and sensitivity, meaning physical arousal takes longer and may feel less intense.
The cascade of secondary effects
Hot flushes and night sweats cause sleep deprivation which reduces libido, energy, and motivation. Mood changes, anxiety, and low confidence undermine sexual self-image. Joint pain and fatigue make certain activities uncomfortable. Body image concerns affect sexual confidence. Each of these secondary factors is treatable.
The relationship dimension
Partners who do not understand perimenopause may interpret reduced libido as loss of attraction or withdrawal. Mood changes can be experienced as personal rejection. Notably, the divorce rate peaks at the time of perimenopause. With information, communication, and specialist support, couples who navigate menopause together can develop a deeper, more honest intimacy.
Medical treatments for sexual difficulties during menopause
HRT and testosterone
HRT, particularly transdermal oestrogen, supports vaginal tissue health, lubrication, and physical capacity for comfortable sex. It improves sleep, mood, and energy. Oral oestrogen can raise sex hormone binding globulin and reduce testosterone bioavailability, so transdermal oestrogen is preferred for women with libido concerns. Testosterone can be considered for persistent low sexual desire causing distress when HRT alone has not helped enough, in line with specialist guidance.
Vaginal oestrogen and prasterone
Vaginal oestrogen is the most effective treatment for pain during sex caused by vaginal dryness and tissue thinning. Prasterone (Intrarosa) is a vaginal pessary containing DHEA, converted locally in vaginal tissues. NICE recommends considering vaginal prasterone for genitourinary symptoms if vaginal oestrogen or non-hormonal moisturisers or lubricants are ineffective or not tolerated.
Specialist support for sex and relationships during menopause
| Concern | Specialist who can help | What they may offer |
|---|---|---|
| Low desire causing distress | Menopause specialist or psychosexual therapist | HRT/testosterone review, sex therapy and relationship support |
| Pain during sex | GP, menopause specialist or pelvic floor physiotherapist | Vaginal oestrogen, prasterone, moisturisers, pelvic floor assessment |
| Relationship strain | Relationship therapist or couples counsellor | Communication, intimacy rebuilding and partner understanding |
| Anxiety or avoidance around sex | COSRT sex therapist | Psychosexual therapy with no sexual contact |
| Dating in midlife | Sexual health clinic or GP | STI screening, contraception advice and safer-sex support |
Sex therapists
A sex therapist is a trained psychotherapist specialising in sexual difficulties. Sex therapy involves no sexual contact. It addresses anxiety and avoidance that develop when sex becomes painful, loss of sexual confidence and body image concerns, communication difficulties between partners, and the renegotiation of sexual identity during menopause. Look for COSRT (College of Sexual and Relationship Therapists) registration, which is the most specific indicator of sex therapy training in the UK. Sessions typically cost £80 to £150.
Relationship therapists and couples counsellors
Where the primary concern is the impact of menopause on the relationship, a relationship therapist or couples counsellor registered with BACP, UKCP, or Relate can work with both partners on communication, emotional responses, rebuilding intimacy, and managing the way menopause intersects with other relationship dynamics. Relate is the UK’s largest relationship support organisation with practitioners across the UK.
Pelvic floor physiotherapists
For women whose sexual difficulty is primarily or significantly driven by pain, a pelvic floor physiotherapist is often the most immediately impactful specialist to see. The combination of vaginal oestrogen and pelvic floor physiotherapy can be very helpful where pain is driven by both tissue changes and pelvic floor muscle tension.
Menopause specialists
A menopause specialist can conduct a thorough hormonal assessment, prescribe the appropriate combination of HRT, testosterone, and vaginal oestrogen, and refer to sex therapists, pelvic floor physiotherapists, and other specialists as part of a comprehensive plan.
Same-sex relationships and menopause
Where both partners are going through perimenopause or menopause simultaneously, which is common in long-term same-sex female partnerships, the relationship may navigate two sets of hormonal changes at the same time. A therapist with experience of same-sex relationships and menopause can provide more relevant support. LGBTQ+ specialist counselling services are available across the UK for women who would prefer a practitioner with specific LGBTQ+ experience.
Contraception and STI risk: often overlooked
Pregnancy remains possible throughout perimenopause until 12 consecutive months without periods confirm menopause. UK guidelines recommend women under 50 continue contraception for two years after the last period, and women over 50 for one year. HRT is not a contraceptive.
The thinning of vaginal tissues during menopause increases susceptibility to sexually transmitted infections. Women who are dating in midlife face a genuine STI risk that is often not discussed for this age group. Regular sexual health checks are as appropriate during and after menopause as at any other stage of life.
For related support, see testosterone therapy for women, vaginal dryness treatment, contraception during perimenopause, and menopause physiotherapists.
Frequently Asked Questions
Why does menopause affect libido?
Menopause affects libido through multiple mechanisms. Declining testosterone reduces the neurobiological drive towards sexual activity. Declining oestrogen causes vaginal dryness and thinning that makes sex painful, and pain rapidly suppresses desire. Sleep deprivation reduces energy and motivation. Mood changes, anxiety, and body image concerns affect sexual confidence. Most of these factors are treatable.
What is the most effective treatment for low libido during menopause?
HRT addressing oestrogen decline, testosterone for persistent low sexual desire causing distress, and vaginal oestrogen for pain during sex are the most directly effective medical treatments. Pelvic floor physiotherapy addresses the physical aspects of dyspareunia. Sex therapy addresses the psychological, emotional, and relational dimensions. The most effective approach combines medical treatment with appropriate specialist support.
What is sex therapy and how does it help during menopause?
Sex therapy is a form of psychotherapy specialising in sexual difficulties. It involves no sexual contact. It addresses anxiety and avoidance that develop when sex becomes painful, loss of sexual confidence, communication difficulties with partners, and the renegotiation of sexual identity and expectations during menopause. Sex therapists are registered with COSRT or BACP. Sessions typically cost £80 to £150.
Can testosterone help with menopause-related low libido?
Yes. Testosterone is prescribed off-label for women with persistent low sexual desire causing distress. Research suggests improvements in desire, arousal, frequency of sex, pleasure, and ability to orgasm in women prescribed testosterone at physiological female doses.
How does menopause affect relationships?
Through mood changes and irritability that can cause conflict, reduced libido that can create distance, pain during sex leading to avoidance, sleep deprivation reducing tolerance, and identity changes affecting how women show up in relationships. Couples therapy and sex therapy provide a space for both partners to navigate this transition with professional support.
Is it normal for sex to be painful during menopause?
Pain during sex affects approximately 45 per cent of women going through menopause and is driven primarily by vaginal dryness and thinning caused by oestrogen decline. It is common but not something that simply has to be accepted. Vaginal oestrogen, prasterone, pelvic floor physiotherapy, and appropriate lubricants and moisturisers are all effective treatments.
Do I need contraception during perimenopause if I am on HRT?
Yes. HRT is not a contraceptive. Pregnancy remains possible throughout perimenopause until 12 consecutive months without periods confirm menopause. UK guidelines recommend contraception for two years after the last period for women under 50, and one year for women over 50.
What qualifications should a sex therapist have?
Look for COSRT (College of Sexual and Relationship Therapists) registration, which is the most specific indicator of sex therapy training in the UK. BACP registered therapists who list sexual difficulties as a specialism are also appropriately qualified. All legitimate sex therapists are trained psychotherapists whose work is entirely verbal with no sexual contact.
Author: The Menopause Directory
About this guide
This guide is published by The Menopause Directory editorial team to help UK readers understand menopause symptoms, support options and services. It is for general information only and should not replace advice from a GP, pharmacist or qualified menopause specialist.
Last reviewed by The Menopause Directory editorial team.