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Vaginal Dryness and Low Libido in Menopause
What's Really Going On (And What Actually Helps)
Genito-urinary Syndrome of Menopause
If sex has started to hurt, your desire has quietly disappeared, or you’re dealing with dryness, irritation, or bladder symptoms that never used to be a problem — you are not imagining it, and you are absolutely not alone. Up to 70% of postmenopausal women experience this cluster of symptoms. Yet only around 7% ever receive treatment for it, and just a quarter of women even mention it to their doctor.
There’s a clinical name for what’s happening: genitourinary syndrome of menopause, or GSM. It’s one of the most common — and most under-treated — effects of perimenopause and menopause, and it’s directly linked to the drop in estrogen that also drives so many other menopausal changes, including low libido.
This article walks through what GSM actually is, why it affects desire and intimacy specifically, and the range of evidence-based treatments available — from simple daily habits to hormonal options that can restore comfort and desire for years to come.
What Is Genitourinary Syndrome of Menopause (GSM)?
GSM is the umbrella term for the vaginal, vulval, sexual, and urinary symptoms caused by declining estrogen levels during perimenopause and menopause. It replaced older terms like “vaginal atrophy,” which described the physical changes but completely missed how far-reaching the symptoms really are — and how much they affect quality of life, relationships, and sexual wellbeing.
Estrogen isn’t just involved in your menstrual cycle. Receptors for it are found throughout the vagina, vulva, urethra, bladder, and pelvic floor. When estrogen drops, this tissue loses collagen, elasticity, and blood supply. The result is a set of physical changes that can show up as:
- Vaginal dryness, irritation, burning, or itching
- Reduced elasticity and thinning of vaginal and vulval tissue
- Pain or discomfort during sex (dyspareunia), sometimes with light bleeding afterward
- Decreased arousal, sensation, and orgasm
- Urinary urgency, frequency, discomfort when urinating, or recurrent UTIs
Importantly, GSM isn’t limited to women who are fully through menopause. It can begin in perimenopause, and it also affects women who are breastfeeding or using progestogen-only contraception, both of which lower estrogen levels.
Why GSM Quietly Drives Low Libido
It’s easy to think of low libido and vaginal dryness as two separate problems. In reality, they’re often the same problem wearing two faces.
When sex is uncomfortable or painful, desire doesn’t just switch off out of nowhere — it switches off as a protective response. Your body and brain learn to associate intimacy with discomfort, and arousal becomes harder to access even when the desire to want to want sex is still there. Add in the physical changes to sensation and lubrication that estrogen loss causes, and you have a situation where the mechanics of arousal and the psychology of desire are both working against you at once.
This is precisely why GSM symptoms “have a very negative effect on interpersonal relationships, quality of life and daily activities” — not only during sex, but in everyday moments too, from cycling and exercising to simply sitting comfortably or choosing what to wear.
The good news: because this is a physiological process with an identifiable cause, it’s also one of the most treatable aspects of menopause. Restoring the tissue often restores comfort — and restoring comfort is frequently the first step to restoring desire.
If low libido has been the hardest part of this transition for you, our Perimenopausal Libido Program was built specifically to address the layered physical, hormonal, and emotional factors behind changes in desire — GSM included.
Why So Few Women Get Help
The statistics here are striking: around 70% of healthcare professionals rarely or never ask patients about vaginal dryness, and most women don’t bring it up either — often out of embarrassment, or because they’ve been told (incorrectly) that this is just something to live with after menopause.
It isn’t. Clinical guidance is unambiguous that GSM treatments are “usually effective, safe and cost effective,” and a normal physical examination doesn’t rule out GSM, nor is an exam required before starting treatment. If you’ve been quietly living with these symptoms, that’s a conversation worth having with your doctor — or a program built to walk you through your options.
What Actually Helps: Evidence-Based Treatment Options
Treatment for GSM isn’t one-size-fits-all, and it often works best as a combination approach. Here’s what the evidence supports, from least to most targeted:
Vaginal moisturisers are used regularly (not just before sex) to help the vaginal wall retain moisture and maintain a healthy pH. They provide ongoing relief from day-to-day dryness.
Vaginal lubricants are used at the time of intercourse to reduce friction and discomfort. They’re a helpful short-term tool but don’t address the underlying tissue changes the way moisturisers or hormonal treatments do.
Vaginal (local) estrogen — available as pessaries, creams, gels, or a vaginal ring — is one of the most effective treatments for GSM. It works directly on vaginal, vulval, and urinary tissue with minimal absorption into the rest of the body, meaning it can be used safely long-term, including alongside systemic HRT and, per current guidance, even by many women with a history of breast cancer, after a shared decision-making conversation with their care team. Clinical response is typically rapid, often improving symptoms within weeks.
DHEA (prasterone) pessaries are another local option, converting to estrogen and testosterone within the vaginal tissue itself, with improvements shown in dryness, pain, and several measures of sexual function.
Systemic hormone therapy (HRT/MHT) addresses GSM for roughly 75% of women who use it, particularly when it’s prescribed alongside other menopausal symptoms like hot flushes, mood changes, or sleep disruption. For women whose GSM symptoms persist despite systemic HRT, adding local vaginal estrogen closes that gap.
Testosterone is often overlooked, but it’s a hormone women produce in far greater quantities than estrogen before menopause. When low libido, low mood, and low stamina persist despite estrogen-based treatment, testosterone — prescribed off-license under specialist guidance — is a recognised option supported by NICE guidance for low sexual desire that hasn’t responded to HRT alone.
Ospemifene, an oral non-hormonal medication, is another option for vaginal symptoms in women who prefer to avoid hormonal treatment or for whom it isn’t suitable.
Simple lifestyle changes matter too: avoiding scented soaps, washes, and products in the genital area, choosing breathable fabrics, and using a gentle emollient instead of perfumed alternatives can reduce irritation alongside any medical treatment.
This is exactly the territory our MHT Online Program (Coming Soon) is designed to help you navigate — understanding how systemic hormone therapy, local estrogen, and testosterone fit together, and building a treatment plan with your own history, symptoms, and goals in mind.
You Don't Have to Choose Between Comfort and Desire
Vaginal dryness, discomfort, and low libido during perimenopause and menopause are common, well understood, and — most importantly — treatable. You don’t need to wait for symptoms to become severe before asking for help, and you don’t need to accept a normal exam result as the final word on how you’re feeling.
Whether your priority right now is rebuilding desire and intimacy, or understanding whether hormone therapy is right for you, the most useful next step is the same one: getting personalised, evidence-based guidance rather than trying to piece it together alone.
Explore our Perimenopausal Libido Program if low desire and disconnection from your body have been the hardest part of this transition, or our MHT Online Program (COMING SOON) if you’re ready to understand your full range of hormone therapy options with expert support at Sequence Wellness.
This article is for educational purposes and is not a substitute for individualised medical advice. Please speak with a qualified healthcare provider about your own symptoms and treatment options.
Source: Based on the British Society for Sexual Medicine (BSSM) Position Statement on Genitourinary Syndrome of Menopause.
Dr. Janna Fung, Naturopathic Doctor
Dr. Janna Fung is a licensed naturopathic doctor with a special interest in dermatology and women’s health. She has a passion for evidence based preventative medicine and strives to empower patients with the knowledge to achieve their optimal health. She understands collaborations is the only way to develop realistic sustainable health/wellness results and strives to develop individualized health goals with patients.
