Libido and Sexuality

What You Need to Know

Introduction

Menopause marks a significant turning point in a woman’s life, characterized by the decline of sex hormones, especially estrogen, testosterone, and DHEA. These hormonal changes not only lead to physical symptoms but also have a considerable impact on sexual health and sexual desire. Many women experience changes in their libido during this stage of life – ranging from a slight decrease in sexual interest to a complete loss of sexual desire.

Sexual dysfunction during menopause is common but often goes unrecognized or is considered a taboo topic.

Prevalence

• Around 43% of women report reduced sexual desire during or after menopause (JAMA Internal Medicine).
• Studies such as VIVA or REVIVE show that up to 72% of women experience vaginal dryness during menopause, significantly impairing sexual enjoyment and spontaneity.
• Sexuality remains a central aspect of quality of life, intimacy, and relationships for many women – restrictions in this area often have a negative impact on mental health and partnerships.

Causes

The causes of libido disorders in menopause are multifactorial, involving physical, hormonal, psychological, and social components, following a biopsychosocial model:

1. Hormonal Causes

• Estrogen Deficiency: Leads to vaginal dryness, reduced blood flow, loss of elasticity, and pain during intercourse (dyspareunia).
• Testosterone Deficiency: Directly impairs sexual desire and arousal.
• DHEA Decline: Further deteriorates tissue structure and lubrication.

2. Physical Changes

• Vaginal atrophy and dryness
• Painful penetration (dyspareunia)
• Urinary tract problems
• Other physical changes such as weight gain or skin changes that negatively affect body image

3. Psychological Factors

• Depression, anxiety, and stress
• Low self-esteem and negative body image
• Loss of sexual self-confidence

4. Social and Relationship Factors

• Relationship issues or communication problems
• Sexual problems or illnesses of the partner
• Cultural and religious attitudes towards sexuality in later life

5. Positive Aspects

Some women report an improved sex life after menopause due to:

• Elimination of pregnancy fears
• More personal freedom (fewer childcare or household responsibilities)

Symptoms

Libido disorders during menopause can manifest in a variety of ways:

• Reduced sexual desire
• Decreased arousal
• Increased vaginal dryness
• Pain during intercourse
• Reduced sexual self-confidence
• Relationship and communication problems

Diagnostics

Evaluation includes:

• Detailed medical history: Assessment of libido, sexual satisfaction, relationship dynamics, and cultural influences.
• Gynecological examination: Exclusion of anatomical causes and assessment of the vaginal mucosa.
• DSM-5 criteria for female sexual dysfunction, including:
  • Female sexual interest/arousal disorder
  • Female orgasmic disorder
  • Genito-pelvic pain/penetration disorder

Treatment Options

The treatment of libido disorders requires an individualized, holistic approach that takes medical, psychological, and relationship factors into account.

1. Hormonal Therapies

• Local Estrogen Therapy: Improves vaginal health and reduces dyspareunia.
• Testosterone Therapy (transdermal gel, patch, or cream):
  • Proven effective for hypoactive sexual desire disorder (HSDD)
  • Recommended for up to 6 months, longer in cases of positive response
• DHEA (Prasterone) for local application:
  • Improves lubrication, tissue elasticity, and sexual function
• Systemic HRT:
  • May provide additional support but is not the first-line treatment for isolated libido problems
• Ospemifene (SERM):
  • Oral therapy for vaginal dryness and reduced sexual function
• Tibolone:
  • Androgen-like effects, possible improvement in libido, limited use due to safety concerns

2. Non-Hormonal Procedures

• Vaginal Laser Therapy (CO₂ or Erbium-YAG):
  • Improves vaginal structure and provides symptomatic relief, but does not directly affect libido
• PRP Injections (G-Shot):
  • Experimental treatment aimed at enhancing orgasmic function
• Hyaluronic Acid Preparations
• Lubricants and Moisturizers

3. Psychological and Psychosexual Therapy

• Cognitive Behavioral Therapy (CBT):
  • Addresses negative thought patterns related to sexuality
  • Strengthens self-confidence and body acceptance
• Sexual and Couples Therapy:
  • Improves communication, intimacy, and mutual understanding
• Sexual counseling and education
• Relaxation techniques and stress management

4. Lifestyle Interventions

• Healthy diet and regular physical activity
• Avoiding alcohol and nicotine
• Stress reduction and promotion of self-care
• Encouraging positive sexuality through mindfulness and open communication

5. Alternative Methods

• Damiana (Turnera diffusa):
  • Herbal aphrodisiac, traditionally used to promote sexual desire, limited scientific evidence
• Sex toys, vibrators, dilators:
  • Promote arousal and lubrication
• Bupropion:
  • Medication with positive effects on sexual interest (off-label use)

Important Considerations

• Not every woman experiences libido disorders – coping with them is highly individual.
• Sexuality during menopause is shaped by personal, relational, and cultural factors.
• Sexuality remains a valid and fulfilling need, even later in life.

Conclusion

Libido disorders during menopause are common, complex, and affect not only the body but also the psyche and relationships. A non-judgmental, empathetic approach to this topic is essential – both in gynecological practice and in private relationships.

The good news: Sexual health during menopause can be significantly improved through medical, therapeutic, and relational measures.