It has been well documented that sexual desire, orgasmic response, and sexual activity frequency decreases with age. But clearly, the changes that occur in midlife women are poorly understood. Libido is a complex symptom. It can be a factor of reduced hormone levels (testosterone, DHEA, oestrogen) or it may be impacted by psychological factors. From a psychological perspective, often what is missing in a relationship is a closeness brought about by poor communication or disagreements, causing disharmony.

The most commonly reported symptoms associated with low libido include vaginal dryness, itching, burning, inadequate lubrication during sexual activity and dyspareunia. In clinical practice almost 50% of women in menopause experience a lack of libido associated with vaginal symptoms. The dryness and atrophy can increase the likelihood of trauma during sexual activity. This in turn can reduce a women’s subjective sexual response or desire to have intercourse.

Decreased oestrogen can result in an increased vaginal pH. The lack of oestrogen reduces the release of glycogen in the vagina. As a result, vaginal flora produces less lactic acid. The pH of the vagina increases thus increasing colonization by bacteria that cause inflammation and infection. This can undermine a woman’s defence against vaginal and urinary tract infections. Vaginal atrophy symptoms can affect sexual function and quality of life.

Female sexual physiology can be complex, but if it is a factor of a hormonal deficiency, supplementation of this deficiency may be sufficient to improve libido. The most effective hormones that will improve libido are oestrogen and testosterone. Oestrogen taken systemically can have a positive effect on brain function and mood factors that affect the sexual response. When used vaginally, it can increase blood flow to the vagina and increase lubrication. This can help improve desire by alleviating vaginal dryness and painful penetration.

Testosterone also plays a vital role in female sexual function. It can help improve libido by reducing fatigue and improving moods. This can be applied either as an injection periodically or as a cream to the skin, or more effectively, directly to the clitoris. When used locally, it increases sexual stimulation.

Libido is a complex symptom. It is important to recognise that there is no magic love potion that will fix all. The urogenital system is quite sensitive to oestrogen deficiency, especially because of the presence of oestrogen receptors in the vagina, vulva, urethra and bladder. The reduced oestrogen in a menopausal woman can result in significant cellular and structural changes in the vagina that can promote sexual and urinary symptoms. This can be quite traumatic for a woman, affecting her quality of life. Vaginal symptoms are often progressive and do not resolve without treatment.