Menopause, Sexual Pleasure and HRT

Are you struggling with symptoms of the menopause?

Is this impacting on your relationship, your experience of sex, on your work or family life?

Please be reassured you are not alone. The good news is treatment is available which will be tailored to meet your needs.

There has been much recent publicity about the perimenopause, menopause and hormone replacement therapy. While for some women menopause can be freeing, for many women it is accompanied by difficult symptoms: hot flushes, night sweats, mood changes, sleep disturbance and brain fog to name just a few.

Many women also experience genital symptoms and sexual difficulties but often don’t seek help for them or discuss them with healthcare providers. This can be because of shame or embarrassment for both women and doctors. Most doctors and nurses haven’t had training on discussing sexual difficulties, and therefore both patients and doctors can feel uncomfortable talking about sex in medical consultations.

Research shows most patients (both men and women) want to be asked about genital and sexual symptoms. Doctors and patients often collude in ignoring sexual difficulties despite them having a big impact on people’s lives and long-term health. At the Leger Clinic, we understand how important it is to have a doctor who is comfortable and skilled in dealing with sexual difficulties.

The Menopause and Sexual Function

As women go through the perimenopause (the years in the lead up to a woman’s final period), hormone levels vary enormously. By the time of menopause, the amount of oestrogen in the body has reduced significantly. Testosterone decreases by about 25% between the ages of 30 and 50. The reduced oestrogen and testosterone leads to decrease blood flow to the vagina, vulva and breasts. The vaginal lining (mucosa) becomes significantly thinner. The clitoris shrinks and becomes less sensitive.  As well as affecting the vulva and vagina, oestrogen is also important for bladder health. As oestrogen levels fall, the bladder thins with weakening of the muscles which control the bladder.

These changes can lead to symptoms including:

  • vulval itching
  • vaginal dryness and reduced lubrication
  • reduced sensation & sensitivity from sex
  • pain during sex
  • reduced sexual desire
  • urinary problems such as needing to go to the toilet frequently, urinary incontinence and frequent urinary infections

What might be the cause of my low sex drive? Is it hormonal?

Hormones are obviously an important factor. The changes described above can mean sex is less pleasurable or even painful, which leads to an anticipation of pain and discomfort, which reduces the desire for sex.

However, hormones are not the only factor. There can be many other factors at play. Some examples include:

  • relationship difficulties & differences in sexual desire within couples
  • how we feel about our bodies as we age
  • anxiety about sex and sexual arousal
  • sex not being very rewarding, having sex which doesn’t meet our sexual needs
  • cultural and social norms about what is ‘normal’
  • our understanding of how desire and sex drive should be
  • illness including cancer and medical treatment
  • childbirth & fertility issues
  • wider mental health issues such as anxiety and stress
  • medication, including antidepressants, hormonal contraceptives, medications for bladder issues

These are just some examples. It’s important to put things into this wider context when thinking about medication as oestrogen and testosterone won’t address many of these wider factors. Working through some of these factors with a sex and relationship therapist can be helpful to untangle what might be going on for you. You can find a list of therapists on our website HERE – insert link.

Hypoactive Sexual Desire Disorder

Hypoactive sexual desire is the formal diagnosis for absent or very reduced desire or motivation to engage in sex, which has happened over a period of several months and is causing significant distress. Despite it being common, a smaller number of women are distressed by low sexual desire and only some of those seek help for it. However cultural norms around expectations, what is ‘normal’ and allowed play a big part in what we expect of our bodies and the help we’re willing to ask for.

Now for the good news – what treatment is available?

It can seem like it’s all very difficult and overwhelming but there is hope. There are lots of things which can help, getting you back to feeling yourself again as well as improve your experience of sex.

Firstly, just by noticing and asking questions such as “what’s happened to my sex drive?!” you can become more aware of what is going on in your body, mind, relationship, and sex life and find a way forward. Usually an approach which addresses different aspects of your current experience at once is the most helpful. Exploring with a psychosexual therapist, or through books, apps and websites as well as ensuring biological aspects are treated is often helpful.

Vaginal Moisturisers

Vaginal moisturisers and pH balanced vaginal lubricants can significantly improve symptoms. Examples are those made by:




Systemic HRT

For symptoms which are related to hormonal changes, hormone replacement therapy can really help. Systemic HRT which consists of a topical (skin) patch or gel or an oral tablet can replace low oestrogen. If you still have a womb, then you will also need a progesterone to protect the lining of the womb, usually in the form of a tablet or a hormonal coil. 

Topical (vulvovaginal) HRT

Topical oestrogen delivered locally to the vagina and vulva is helpful in reducing symptoms of itching, burning, pain during sex and urinary symptoms. Topical oestrogen is incredibly safe as the dose is so low and so little is absorbed into the rest of the body. Sometimes local oestrogen is needed in combination with a systemic (tablet or skin based) HRT.

Is HRT safe?

We know that HRT is incredibly safe for the vast majority of women, with no increased risk of breast cancer for the first five years or clots in the legs or lungs with the safest form of HRT. In fact, for most women the benefits of HRT outweigh any risks particularly when started within ten years of menopause. HRT has been shown to be protective for bones, brain and heart health as well as giving women their life back and relieving difficult symptoms.

What about testosterone?

Current guidelines recommend that hormone replacement therapy with oestrogen (in combination with progesterone if needed) should be used first before considering testosterone.

Some people don’t absorb hormones through the skin as well as others, and so it is always worth doing a blood test to check oestrogen levels on HRT and your natural testosterone level before considering adding testosterone replacement. For some women, adequate oestrogen replacement stops vulval & vaginal irritation which stops sex being painful. This then leads to an increase in sexual pleasure and desire.

However, if despite adequate oestrogen and if there are no obvious other psychological, social or relationship factors causing low desire, it is reasonable to have a trial of testosterone therapy to see if this helps symptoms. This is usually a testosterone gel applied to the skin each day, equivalent to an eighth of the dose for men. There are very few risks to testosterone therapy as long as it is under the supervision of an experienced doctor, with monitoring of blood testosterone levels after three weeks or so, to check levels don’t become too high.

At the Leger Clinic we have doctors who are very experienced with HRT and testosterone replacement in women. We are always happy to talk through what might be the right treatment approach for you. Sometimes a trial of 3-6 months’ of testosterone replacement therapy can be helpful to assess any response. It can always be stopped with very little risk of side effects if it has not improved symptoms.

Further sources of help and information:

You might find these books useful guides:

Come As You Are – Emily Nagoski

Mind the Gap – Karen Gurney

Becoming Cliterate – Laurie Mintz

Secret Garden – Nancy Friday

Useful apps and websites:
OMG Yes:

Ferly App:

College of Sex & Relationship Therapists (COSRT):

Leger Clinic Sex & Relationship Therapists:

The Leger Clinic