Why intimacy after menopause deserves a more open conversation
We talk openly about hot flushes, sleepless nights, mood changes and weight gain during menopause. But mention sex after menopause and, particularly in many Indian and multicultural families, the conversation falls quiet.
Why? Does intimacy have an expiry date? Does a woman stop needing affection, closeness or sexual wellbeing because her periods have stopped?
Of course not. Menopause is a natural biological transition. It marks the end of menstruation and fertility, but it does not mark the end of sexuality, intimacy or relationships.
For some women, menopause brings a sense of freedom: no periods and no concern about an unplanned pregnancy. For others, physical and emotional changes can make intimacy uncomfortable or less enjoyable.
In my clinical practice, I often hear women say, “Doctor, I love my partner, but sex has become painful,” or “I just don’t feel interested anymore.” What concerns me most is what sometimes follows: “I have never told anyone this before.”
For many women from Indian, South Asian and other multicultural backgrounds, discussing sexual health can be particularly difficult. We may have grown up in families where sex was simply not discussed. Menstruation itself was sometimes spoken about in whispers. Women were taught modesty and restraint, while female sexual wellbeing was rarely presented as part of health.
Then menopause arrives, and society can send another message: You are older now. Why should sex matter?
Some women believe they should quietly tolerate painful intercourse because their partner still wants intimacy. Others withdraw rather than explain what is happening to their body. Neither should be necessary. Pain during sex is not something a woman has to endure as part of ageing, marriage or culture.
There can also be practical barriers. Couples may live with adult children, ageing parents or extended family, making privacy difficult. Women may be juggling careers, grandchildren, elderly parents and household responsibilities while carrying much of the work of caring for everyone else. By the end of the day, intimacy may understandably be the last thing on their mind.
As women move through menopause, oestrogen levels fall. Oestrogen helps keep vulval and vaginal tissues healthy, elastic and lubricated. With less of it, these tissues can become thinner, drier and less flexible. Women may experience dryness, burning, irritation or pain during intercourse. Some also develop urinary symptoms, such as increased frequency or urgency, or recurrent urinary tract infections. These symptoms are often grouped under the term genitourinary syndrome of menopause, or GSM.
Sexual response may change too. A woman may need more time to become aroused. Orgasm may take longer or require more direct stimulation. Desire can decrease, or it may remain unchanged. Every woman is different.
Hormones are only part of the picture. Poor sleep, hot flushes, fatigue, stress, depression, chronic illness, medication, concerns about body image and relationship difficulties can all affect sexual desire.
Partners age as well. Erectile difficulties, diabetes, cardiovascular disease, medication, anxiety and stress can affect sexual function. It is often more helpful for couples to approach these changes together than to treat them as one person’s problem.
Hormones are only part of the picture. Poor sleep, hot flushes, fatigue, stress, depression, chronic illness, medication, concerns about body image and relationship difficulties can all affect sexual desire
Women sometimes assume vaginal dryness means they have an infection or are somehow “unclean”. Some repeatedly wash with strong soaps, perfumed products, antiseptic solutions or traditional remedies, which may make irritation worse.
The first steps can be straightforward. A lubricant used during sexual activity can reduce friction and discomfort. A vaginal moisturiser, used regularly rather than only during sex, can help with everyday dryness.
There should be no embarrassment about using lubricant. I sometimes tell my patients: we do not feel embarrassed wearing glasses when our eyes need help, so why should caring for another part of our body be different?
For more troublesome vaginal symptoms, low-dose vaginal oestrogen may help. Women should discuss whether it is suitable for them with their doctor, particularly if they have had breast cancer or have other medical conditions that call for individual advice. Menopausal hormone therapy may also be considered for symptoms such as troublesome hot flushes and night sweats after a discussion of its benefits and risks.
Pelvic floor muscles can become part of the problem. After intercourse has been painful several times, the body may begin to anticipate pain and tighten these muscles. Pelvic floor physiotherapy, counselling or psychosexual therapy may help.
One of the most useful conversations couples can have after menopause is about what intimacy means to them now. Sex does not have to follow the same pattern at 55 or 65 that it did at 25. Affection, touching, cuddling, massage, kissing, laughter and uninterrupted time together can all matter. Couples may need more time and communication to discover what feels comfortable and pleasurable.
There is another message: not every woman wants more sex. If she is comfortable with less sexual activity and is not distressed by it, she does not need to be “fixed”. The aim is wellbeing, comfort, choice and mutual respect, rather than somebody else’s definition of a normal sex life.
Menopause should not become another stage of life in which women silently tolerate symptoms while caring for everyone else. We need to make it easier to say, “This hurts,” “Something has changed,” or “Can you help me?” These are health questions, and they deserve answers.
Menopause changes the body. Intimacy, connection and sexual wellbeing can still be part of life.
Dr Preeti Khillan is an obstetrician and gynaecologist. This article provides general health information and does not replace individual medical advice. Anyone experiencing pain, bleeding after menopause, persistent vulval or vaginal symptoms, or concerns about sexual health should consult a healthcare professional. Bleeding after menopause should be assessed promptly.
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