Why women struggle to orgasm in menopause – and what to do about it

Though hormonal changes can impact sensitivity and blood flow, menopause needn’t ruin your sex life

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There are two narratives about the sex lives of midlife women playing out right now. One sees fifty-something actresses such as Nicole Kidman having the best orgasms of their life in movies like A Family Affair and the upcoming Babygirl. Meanwhile Renée Zellwegger is back in the saddle as Bridget Jones in Mad About The Boy, in which our now middle-aged heroine looks set to get it on with a much younger man, played by 20-something Leo Woodall. The other, far more alarming story, however, is that menopause could be decimating the sex lives of up to a third of women in the UK – and their partners. So which is nearer the truth?
The answer is both. The hormonal changes that happen during perimenopause (a period of several years between a woman’s mid-40s and early 50s leading up to the menopause when her periods stop for good, can for many turn their libidos off) make sex painful and orgasms elusive. However, when they come out the other side, for many women there can be a new sense of freedom, self awareness and sexual re-awakening.
But how do you cope when you’re in the middle of the maelstrom? Understanding what is happening with your hormones is crucial. “The reducing levels of oestrogen from perimenopause onwards can have a significant impact on the vagina and vulva, leading to thinning of the tissues, reduced elasticity, reduced blood flow and reduced lubrication,” explains Dr Juliet Balfour, the founder and lead of the Somerset NHS Menopause Service. “The clitoral tissue and labia can shrink and the nerve endings become less sensitive.” The loss of oestrogen can also affect the bladder, leading to disruptive urinary symptoms and urinary tract infections after sex. “All these changes,” says Dr Balfour, “mean that sex can become painful and, even if not painful, can become a lot less enjoyable.”
For 45-year old Tui McClelland, her sex life with her husband Jo was derailed by perimenopause, but she is back to having orgasms once again after going on HRT (hormone replacement therapy). “I hadn’t realised I might be in perimenopause, as so much was going on in my life at the time, I didn’t join the dots until my husband suggested seeing my GP”, says Tui. “I was grieving for my mother who had died, and I just felt so low and not myself. Sex would hurt as I was very dry, I had to use lube for the first time, and orgasm was harder to reach and less intense.”
Tui missed having the endorphin rush of orgasms, which she says makes her “feel calmer, more relaxed, less anxious. If I’ve had a really tough day, an orgasm always makes it better, whether I have one by myself or with my husband.”
Dr Balfour agrees that as well as being pleasurable, orgasms “can boost mood, reduce stress, improve sleep, increase blood flow to the pelvic area and strengthen pelvic floor muscles”.
For her perimenopausal patients struggling with their sexual response among the many other symptoms of perimenopause, such as hot flushes, night sweats, joint pain and brain fog to name just a few, Dr Balfour will suggest treating the symptoms ideally with HRT, unless you need to avoid it due to health issues. It’s also important, she says, to look at any other medication that is known to reduce desire, arousal and the ability to orgasm such as some antidepressants, certain types of blood pressure medication, antihistamines, the combined oral contraceptive pill, medication for an overactive bladder and opioid painkillers. “But it is essential that women do not stop any medication without discussing alternatives with their doctor first,” she stresses.
Many women, including those on HRT, will benefit from local oestrogen, which is a very low dose inserted into the vagina via a tablet, pessary, cream, gel or ring. “The cream or gel can also be applied to the vulva to plump up the tissues and improve sensation,” says Dr Balfour. Reassuringly, she adds that “local oestrogen is safe for almost every woman to use long-term and the sooner treatment is started the better as unfortunately symptoms will only get worse without it.” In the meantime, to make sex more pleasurable with a partner or solo with a vibrator, using a skin-safe lubricant during sex will help.
Once the physical symptoms have settled after a period on HRT, if a woman is still struggling with her libido and ability to reach orgasm, a trial of testosterone can be considered. Some GPs have extra training and are allowed to prescribe it, otherwise a referral to a menopause specialist is needed. “It’s been shown to have a moderate benefit to the sexual response of about 60 per cent of women who try it, as long as other significant factors are ruled out,” says Dr Balfour. These include lifestyle (eg nutrition, exercise, weight, sleep, stress), relationship and psychological issues.
For women of any age, orgasm requires the interaction between three key elements to occur, says Dr Karen Gurney, a consultant clinical psychologist and the author of How Not To Let Kids Ruin Your Sex Life. “These are: psychological arousal (an erotic situation or dynamic with a partner), physical stimulation (pleasurable touch to our bodies) and the ability to be in the moment (as opposed to distracted).” Any one of these can impact a woman’s ability to orgasm and stop it in its tracks, so looking at each of these aspects can often reveal the area where women in midlife might be struggling beyond menopausal symptoms.
For Tui, while physical touch is important, arousal is more about what’s going on in her mind. “For my husband Jo and I, it’s really important to talk openly about sex and what we both want and need,” she says. With a lot of the physical and emotional symptoms of perimenopause relieved by HRT, she is now “able to think about sex and want it.”
An open and evolving conversation about what feels good can certainly help. “I find my husband really attractive and sexy because of the way he talks to me and treats me, he doesn’t take me for granted,” says Tui.
She sees their sex life as a journey they are on together, adapting how and when they have sex as their bodies change with age. “It definitely takes longer for me to orgasm now,” she says, “so we’ve had to adapt how we make love such as trying different positions and using a vibrator, which is exciting.”
Dr Gurney agrees that trying new things can be the key for couples in long-term monogamous relationships to stop sex feeling predictable, routine or monotonous. “Our brains,” she says, “are more geared up to difference and novelty, so if we are going to keep one variable the same (our partners), we generally need to find a way of bringing in difference somewhere else. Too many couples fall into a predictable pattern of a fumble then penetrative sex.”
Learning to reconnect – or maybe even to connect for the first time – with your sensuality and feel comfortable exploring your own body is also a big part of your ability to orgasm in midlife, according to Coco Berlin, a movement therapist, the founder of the pelvic floor integration method and the author of Pussy Yoga: Pelvic Floor Training for Radiance, Confidence, and a Fulfilling Love Life. “Most women tend to live in their heads and not feel their bodies,” she says. “When we don’t practise inhabiting and enjoying our body in our daily life we can’t expect to get turned on easily and to feel so much when we have sex.”
A former belly dancer, Berlin teaches online courses to help women to tune into their bodies and rewire the nervous system for pleasure. “Your pelvic floor is a group of muscles that supports your pelvic organs and plays a vital role in sexual sensation and function,” she says. “These muscles help control vaginal tightness and relaxation, they also contribute to the swelling of the clitoris with arousal and help make the vagina plump and elongated for pleasure.” Orgasms involve rhythmic contractions of pelvic floor muscles, so exercising them to be strong and flexible will create more intense and pleasurable sensations.
Tui agrees that all women should be much more aware and tuned into their bodies. “It’s so important to give yourself pleasure,” she says. “You should be able to orgasm every day if you want to.”
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