Reduced sexual desire

Summary

A drop in sexual desire is common during the menopause transition and rarely has a single cause. Hormones play a part; but painful sex, fatigue, sleep, mood, body image, the state of the relationship and certain medicines usually count for more. That is why the search for a "libido pill" generally starts in the wrong place. The right order is: pain and dryness first, then sleep and mood, then the relationship and the wider context; hormonal options such as testosterone are considered for a specific picture, after all of that has been addressed. Which step is right for you is something you decide with your doctor.

What is happening?

In women, sexual desire works less as a spontaneous urge than as a response to a stimulus and a context — and that becomes more marked in midlife. The menopause transition touches this system in several places:

• Falling estrogen: Vaginal dryness and thinning make sex painful; pain is the single strongest suppressor of desire.

• Testosterone: Women produce it too, and it is linked to desire; but it does not fall abruptly at menopause — it declines slowly with age. Blood levels do not track desire reliably.

• Fatigue and sleep: Broken sleep and daytime tiredness make sex the easiest activity to give up.

• Mood: Depressive symptoms lower desire; some antidepressants do the same.

• Body image and the relationship: Changes in the body, communication with a partner, the age and routine of the relationship, caring responsibilities. These are independent of hormones but at least as decisive.

• A partner's health: Erectile problems are common in male partners of the same age group and affect a couple's sex life.

What do we know?

• Treat GSM first: Relieving painful sex is usually the precondition for desire returning; vaginal estrogen and moisturizers are the first step ⁵.

• Testosterone has a limited, defined place: International consensus states that testosterone may be considered only in postmenopausal women, for hypoactive sexual desire disorder (HSDD), after other causes have been excluded. Because products licensed specifically for women exist in only a few countries (a testosterone cream for women was licensed in the UK in 2025), in most places this means off-label use of male products at low doses, with regular blood-level monitoring ¹. In meta-analysis, testosterone significantly increased the frequency of satisfying sexual events and desire compared with placebo; the skin route is preferred because oral forms adversely affect blood lipids ^{2 6}.

• Testosterone is not given for "energy" or "mood": The evidence exists only for sexual desire; it is not recommended for cognition, bone, muscle or general well-being ¹.

• Systemic HRT can improve desire indirectly: When sleep, hot flashes and vaginal symptoms improve, desire often increases; HRT's direct effect on libido is limited ³. NICE states that adding testosterone can be considered where HRT does not improve sexual function ⁴.

• Psychosexual approaches work: Sex therapy, couples therapy and mindfulness-based programs have shown efficacy in randomized trials for low desire; they are used with or without medication ⁴.

• Medication effects are often overlooked: SSRIs, some blood pressure medicines and hormonal contraceptives can lower desire; reviewing them with your doctor is a simple first step.

What does this give you?

• Get the order right: If there is pain, deal with pain first. If you are not sleeping, sleep first. If there is low mood, mood first. Expecting desire to change before those improve is not realistic.

• Talk about it: With your partner, and if possible with your doctor. Loss of desire is not something to be ashamed of; it is common and it can be addressed. Logging sexual desire as a symptom in Lumia can make it easier to raise with your doctor.

• Revisit the definition: Spontaneous desire may fade while desire that arises in response to a stimulus continues; sex does not have to run in the order "desire first, then act".

• Be realistic about testosterone: For a specific picture, under specific conditions, with monitoring. Saliva-test-based "hormone balancing" and unregulated creams are not recommended. Where no product licensed for women is available, use takes the form of off-label prescribing of male products at low doses; prescribing and access conditions change over time. Whether this option is right for you, and how to obtain it, is for your doctor to determine.

Sources

1. Davis SR, et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Clin Endocrinol Metab. 2019;104(10):4660-4666.
2. Islam RM, et al. Safety and efficacy of testosterone for women: systematic review and meta-analysis. Lancet Diabetes Endocrinol. 2019;7(10):754-766.
3. The Menopause Society. The 2022 Hormone Therapy Position Statement. Menopause. 2022;29(7):767-794.
4. NICE. Menopause: identification and management (NG23). 2015; updated November 2024.
5. The Menopause Society. The 2020 Genitourinary Syndrome of Menopause Position Statement. Menopause. 2020;27(9):976-992.
6. Panay N, et al. International Menopause Society (IMS) recommendations and key messages on women's midlife health and menopause. Climacteric. 2025;28(6):634-656.

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