So you’re tired of peeing a little bit when you jog or sneeze. Who wouldn’t be?! You have multiple options to help you get from “time to do something about this” to “yes, sweet relief!” but if you’re looking for a solution that will tackle those errant tinkles, teach you a lot about your body, and maybe address a few other issues along the way, consider pelvic floor physical therapy.
Pelvic floor PT might sound like something that’s only for pregnancy or postpartum discomfort. In reality, it’s a growing specialty of physical therapy that can benefit patients of all ages. Everyone has a pelvic floor, after all: that’s the network of muscle and connective tissue that holds our pelvic organs in place. It’s also an integral part of the core, helping to stabilize the pelvis and spine along with the other muscles and tissues in your torso. Given its complexity, there’s a lot that can go awry in the pelvic floor, and dysfunction is common and increases with age, especially during the menopause transition.
Sometimes called pelvic floor physiotherapy or pelvic floor rehabilitation, pelvic floor therapy focuses on the muscles and tissues between the pubic bone and tailbone in the pelvis. They make a sort of cradle to support organs like the bladder, urethra, rectum, uterus, and prostate. They’re key players in digestive, urinary, and sexual function, so when they’re not working optimally, we notice. Just like any other muscle, pelvic floor muscles can be overly weak, or prone to spasm or tightness with difficulty relaxing. Both issues can lead to all sorts of discomfort and dysfunction: urinary or stool incontinence, painful penetrative sex, organ prolapse, constipation, even sciatica, hip pain, or lower back pain.
And that’s where your pelvic floor physical therapist comes in. They specialize in assessing the muscles of the pelvic floor, diagnosing the cause of pain or dysfunction, helping patients set goals for improvement, and using therapeutic techniques like manual therapy or exercises to get the pelvic floor back to optimal function.
Anyone who needs it, really! Many blame pelvic floor issues on pregnancy, childbirth, or menopause, but disorders can also stem from injury, such as a bad fall on your tailbone, or arise after a lifetime of seemingly harmless bathroom habits, like holding it too long when you’ve gotta go, or “hovering” over public toilet seats (pelvic health experts are begging you: stop doing that!). Issues with the pelvic floor might feel a little awkward to talk about, but they are common, treatable, and nothing to be ashamed of.
The menopause transition is an ideal time to see a pelvic floor PT, as the genitals and pelvic floor tend to need extra TLC to manage the effects of hormonal changes. Your doctor or a PT can advise you about when and why you might need pelvic floor therapy, but here are some of the most common issues for which you might seek care:
The good news is, pelvic floor PTs are accustomed to treating menopause-related concerns and understand how pelvic floor dysfunction fits in with all the other changes your body goes through during this time.
If you’re unfamiliar with it, physical therapy for your most sensitive bits might sound intimidating (especially if pain is what’s driving you to get help). We asked Dr. Kerry Boysen, DPT and owner of Restore Physical Therapy, for the lowdown on what to expect from pelvic floor physical therapy to make the whole thing a little less daunting.
Intake and first appointment: Before your first appointment, you’ll fill out some intake paperwork to get your physical therapist up to speed about your medical history and your reasons for seeking PT. At your appointment, you’ll have a chance to explain your concerns and goals in more detail.
Appointment length: Appointment length varies by practice, but for pelvic floor PT, expect your first visit to last about an hour to 75 minutes to allow for a thorough intake. Follow-up visits, if you need them, can last 45 minutes to an hour based on your treatment plan.
Privacy: Your privacy is a priority! Your appointment will take place in a private room, one-on-one with the physical therapist.
The phrase “pelvic exam” conjures thoughts of breezy medical gowns (socks on or off? We never can decide), cold crinkly exam table paper, and a speculum that’s colder still, but Kerry assures us that a pelvic floor PT exam isn’t much like an in-person visit to your OBGYN.
“The physical exam for pelvic floor PT is different than a gynecological exam in a couple of ways” she says. “The PT does not use stirrups and a speculum, and the PT is evaluating the function of your pelvic floor and musculoskeletal structures, not your pelvic organs.”
Even though you’re there for your pelvic floor, Kerry says, you’ll probably get a head-to-toe sizing up as your therapist gets to know you—PTs look at the whole body as part of the musculoskeletal assessment to see what’s going on with your hips, spine, pelvis, and extremities. It’s all connected, and patients are often surprised to learn that even things like gastrointestinal complaints or deep buttock pain can sometimes be related to pelvic floor dysfunction.
“Physical therapy is typically ‘hands-on’ care,” Kerry explains. “However, if you are not comfortable having an exam, you certainly can choose not to proceed. There does not have to be an internal vaginal or rectal exam on the first visit. No exam is ever done without your written and verbal consent. Building trust and rapport with your physical therapist is critical for optimal outcomes.”
In addition to an internal exam, some treatment plans may include manual therapy to help improve muscle tone and ease tissue restrictions to help with pain. Some of these manual techniques may be done internally (gently, gloved, and with consent, of course) but external techniques can be helpful too, if indicated. Pelvic floor physical therapists often have specialized training in trauma-informed care, so are thoughtful about informing patients about what to expect from hands-on treatment and seeking consent. You should never feel unsafe or uncomfortable with the sort of physical contact involved in your appointments. If you’re nervous about this, don’t be afraid to ask questions when you book your appointment.
Kerry says her exams aren’t tailored to her patients’ age—the assessment is the same whether they’re in their twenties or mid-fifties—but she adjusts her talking points and patient education based on their life stages and related concerns. Younger and pre-menopausal patients may come in with questions about endometriosis, childbearing, or postpartum pain, while patients in or approaching menopause may need information about conditions like genitourinary syndrome of menopause or pelvic organ prolapse.
But, she says, many pelvic issues and the benefits of pelvic floor PT are age-agnostic, so that doesn’t change how she approaches her exams. “Women at all ages and stages can have bladder and bowel issues. With all exams I am looking at vulvovaginal tissue health and pelvic floor muscle function. I want to know how women are addressing their bone health and heart health. I ask about nutrition and refer out for specific needs.”
Kerry says you can wear anything you want to your PT appointment, but she always recommends comfortable clothes you can move in. For the pelvic floor exam portion of your appointment, she says, “you will be asked to undress from the waist down (your socks can stay on!) and you will use a sheet or gown to cover your lower half.”
It depends on your individual treatment plan and why you’re in physical therapy. Some patients only need a few sessions to meet their goals and start feeling better; others may need to go for a few weeks or even months to address persistent pain or a complex diagnosis. Your PT probably won’t be able to tell you up front how many visits you’ll need for relief, since this is highly variable based on each patient’s symptoms, goals, and progress, but they should be able to help you understand your treatment plan and set expectations for your course of physical therapy.
Just as in PT for sports injuries or surgery recovery, pelvic floor PT treatment plans can include exercises to address your symptoms (and no, it’s not always Kegels!). One patient may need to focus on strengthening the muscles in their pelvic floor, while others may have to practice relaxing those muscles instead, do exercises to improve mobility, or even learn new breathing techniques—seriously! Most exercises you’re prescribed are meant to be done at home, and in the clinic, you may receive manual therapy (hands-on techniques to release tense muscles, trigger points, or “stuck” connective tissues) if it’s part of your treatment plan.
As for how to know if physical therapy is working, Kerry says, look to your symptoms. “The goal of physical therapy is to optimize function, so your response to PT should result in improved function. For example, you will start to see an improved tolerance to penetrative intercourse or leak less urine when working out.”
Remember that most pelvic floor disorders don’t start overnight, so improvement won’t happen overnight either, but gradual, steady progress should feel encouraging. Here are a few things to look for:
Sticking to your treatment plan will help you reach your goals, so do prioritize any at-home exercises and follow-up sessions your physical therapist recommends.
Physical therapy is direct access in all 50 states, which means you can see a PT without a doctor’s referral (though some states have rules about the conditions or treatments that qualify for direct access and some insurance plans may require referrals, so it’s always a good idea to double-check for your situation). Kerry notes that while patients don’t need a referral to see her for physical therapy, many people first hear about pelvic floor PT from their physician. That relationship between PTs and doctors can work both ways; Kerry sometimes refers her patients to specialists if they need prescriptions for hormones or other medications, require a surgical consult, or if she spots any red flags that need evaluation by a healthcare provider in another field.
Kerry says that most pelvic floor PTs establish a background in orthopedic physical therapy and then specialize in pelvic floor PT, so they’ll have a robust foundation in other musculoskeletal issues too. Pelvic floor specialists may have years of continuing education in pelvic floor health and therapeutic techniques, and some may seek certifications in subspecialties like pregnancy and postpartum pelvic PT.
If you’re looking for a physical therapist with specific training and credentialing in pelvic floor therapy, Kerry recommends the APTA Pelvic Health PT Locator Tool, or PelvicRehab.com.
Finally, feeling comfortable and safe with your pelvic floor PT is a must, Kerry says. Getting a recommendation from your doctor or a friend can be helpful, but the important thing is that you click with your physical therapist; you should trust them, feel at ease asking questions, and have confidence in your treatment plan.
Sex in midlife can seem like a whole new game, and if you’re also dealing with menopause symptoms like low libido, fatigue, irritation, vaginal dryness, and painful intercourse, you might not even feel like playing. The good news is, there’s a lot you can do to get back in the mood: medications, hormones, and therapy can support your physical and emotional comfort during this time, which is crucial. If plain old disinterest is keeping you out of the bedroom, though, consider trying our favorite unconventional sex tip: learn about your sexual desire style.
Plenty of books, movies, and tv shows would have you believe that the ideal sexual encounter goes something like this:
It makes for steamy media, but many people find that scenario laughably far from reality, especially in midlife, as sex drives start to change for all kinds of reasons.
Hopefully you’re not losing sleep comparing your own encounters to that fantasy version, because there are plenty other realistic ways to have a healthy, satisfying sex life. But if you’ve been frustrated lately, it’s time to get acquainted with the concept of different sexual desire types.
First things first: our sex drives are not static, and libido is not just determined by hormones, though they certainly contribute. Lots of other factors influence a person’s individual desire and readiness for sex.
In the 1960s, sexuality researchers perceived sex as a straightforward sequence of events: desire occurs, arousal and stimulation follow, and the natural conclusion is orgasm and a cooling-off, or refractory, period. Basically, desire comes first, then action, then satisfaction. Simple, right?
It’s not exactly the whole story. Other researchers like Dr. Beverly Whipple and Dr. Rosemary Basson found that many people’s experiences didn’t follow this linear progression. Those folks needed to get warmed up first—that is, they didn’t feel the desire for sex until some type of physical or emotional stimulation had already taken place. Their urges kicked in as a response to pleasurable intimate contact.
What we now understand is that types of sexual desire effectively fall into a couple categories: spontaneous and responsive. It’s worth noting that some people relate most to a third category, “context-dependent desire,” in which desire fluctuates based on what’s going on in your life: sometimes your desire is more spontaneous (vacation sex, anyone?), other times, like during periods of stress or illness, it might behave more like responsive desire.
In this article, we’ll focus on the nuances between spontaneous and responsive desire types.
Think of spontaneous desire like an out-of-the blue craving: “Ooh, sex sounds good! I’m ready, let’s go!” Simply thinking about and anticipating sex is enough to get you hot and bothered, which then motivates you to seek initiation and satisfaction. This is what we’re used to seeing in many Hollywood depictions of sex, which has left plenty of people with the impression that a healthy sex drive means you’re always raring to go on short notice, and it just happens “naturally.” You don’t need to do much to get in the mood—the mood just strikes!
Spontaneous desire is a normal way to experience a desire for sex. People with spontaneous desire may initiate readily and often, but could be disappointed if their partner turns down the invitation or doesn’t reciprocate with their own initiation as frequently.
Responsive desire is less of an urge, and more of a reaction: “Sure, I’m open to this. It’s nice to be close. Hey, that feels pretty good…okay, now I’m turned on.” This form of desire revs up in response to consensual, pleasurable input: kissing, massage, even just talking and lying in bed together can activate arousal and interest in moving on to more stimulation, in the right contexts. People with responsive desire often say they have great sex, but it just takes a while to warm up.
If you’re someone who usually experiences responsive desire, you may not feel the urge to initiate sex often, which can contribute to longer-than-planned stretches without intimacy, partners feeling distant, and shame over not meeting the culturally widespread standard of what desire “should” look like.
Responsive desire is also a normal way to experience a desire for sex—and in fact, it’s a very common one for people in long-term relationships, especially women.
It’s helpful—and if you ask us, pretty important—to understand the different sexual desire types because too many people worry that that they’re flawed or broken if they don’t experience spontaneous desire. Let’s put that myth to bed.
There’s no right or wrong desire type, and one is not better or inherently sexier than the other. Understanding the nuances between responsive and spontaneous desire, as well as some of the things that can contribute to your individual sexual readiness, can be a helpful way to make sense of your sex life in midlife if you’ve been experiencing low libido.
It’s also important to talk about desire types with your partner, especially if you have mismatched sex drives (ie, one partner wants more sex than the other does). While that’s certainly possible, another possibility is that you have different desire types—you might actually both be happy to have similar amounts of sex, but one of you feels spontaneously turned on more often and the other doesn’t feel that urge until you’ve started canoodling. It’s a subtle distinction between libido and desire types, and often one that gets a little blurry, but it’s worth figuring out your patterns if you want to understand your desires better.
Your desire style can change over time, as you age, as your hormones change (especially during and after perimenopause), and as you reach different milestones or shifts in your relationship. It can also become more context dependent during various stages of life, like parenting small children, menopause, or caregiving for family members. “New relationship energy” at any age often sparks a more spontaneous desire style—excitement, hormones, attraction, and novelty can influence your interest in sex.
That’s one reason responsive desire is so common for people in long-term relationships; as you get more familiar, settle into shared rhythms, and the curiosity about intimacy with a new partner wears off, those spontaneous “can’t keep your hands off each other” urges can fade and your desire type can shift even if you still enjoy the sex you do have. This is not a bad thing, but since our society doesn’t speak frankly about this topic, it helps to understand how responsive desire works and how you or your partner experience it so you can continue to have great—maybe even better!—sex.
Once you’ve got the difference between responsive and spontaneous desire down, you might find it helpful to explore the concepts of “accelerators” vs “brakes” in the bedroom. In her book, Come As You Are, sex educator and author Dr. Emily Nagoski uses these terms for the brain’s desire enhancing or inhibiting signals to help people understand the complex factors behind libido, arousal, and how we experience pleasure.
Here are a few ways to think about sexual accelerators vs brakes:
Your individual accelerators and brakes can influence your overall sexual desire style and affect how you experience sex on a case-by-case basis. Someone with a sensitive accelerator might be very reactive to a sexy scene in a movie or a memory of an especially hot date night and be ready to bound into the bedroom from that alone, whereas someone with a less sensitive accelerator may not share that same urge. They might still enjoy the stimulus, but it won’t be that “step on the gas” impetus that makes them want to have sex.
Similarly, a partner who’s going through a prolonged period of stress, uncomfortable physical conditions, body changes, or hormone swings (*cough* menopause *cough*) might not be interested in sex for some time because those factors have put their desire brakes on in a big way. Even accelerators like foreplay may not be able to ease the brakes in this case, which doesn’t mean something is wrong with you—it usually just means you’re in a period of low desire.
Everyone’s accelerators and brakes vary, but there are a couple of inhibitors that are especially common during the menopause transition: vaginal or pelvic pain, with or without intercourse, and fatigue from lack of quality sleep. If sex hurts, your brain’s going to have an awfully tough time helping you get in the mood, and if you’re too exhausted to function thanks to night sweats and menopause insomnia, you probably won’t be interested in staying up late for extracurriculars.
If these concerns are affecting you (or your partner, if you share a bed with someone going through menopause), know that you’re not necessarily stuck with them. A menopause-trained OBGYN can identify the cause of pelvic pain, whether it’s due to vaginal atrophy or another condition, and suggest appropriate treatment, which may include medication, lubricants, or a course of pelvic floor physical therapy. Sleep issues and fatigue can be addressed too—cognitive behavioral therapy (CBT-I) is an effective, evidence-based treatment for insomnia, and menopause hormone therapy and lifestyle shifts can provide relief for other complaints, like hot flashes, that can interfere with a good night’s sleep.
Though your sexual desire style can change in response to any number of things, making that shift isn’t typically something you can do through sheer force of will. You can’t just decide to be someone with spontaneous desire if you’re usually not, or tell yourself that your desire brakes don’t exist if they really do bother you (nor should you have to).
So if you want to change your desire style because you think you should, consider a reframe: Sex doesn’t require a spontaneous start to be enjoyable, intimate, or downright erotic. The point, as many sex researchers, educators, and therapists emphasize, should be pleasure.
That said, if you want to learn more about your desire style to have more satisfying sex and have never unpacked these concepts alone, with a partner, or with a therapist, here’s some inspiration for getting started:
Try doing a “desire audit” either alone or with a partner, where you reflect on your accelerators, brakes, and desire styles. There are so many ways to do this:
Schedule sex: We know. Scheduling sex is frequently suggested and frequently resisted, since many find it hard to let go of the notion that it should happen organically, without planning or discussion. That’s a spontaneous desire mindset (which is okay), but scheduled sex can actually be a wonderful way to work with responsive desire, especially if both partners enjoy sex and want to have more of it. Planning regular sex can help you prioritize intimacy and connection, lessen emotional hangups around spontaneity (or the lack of it), and even allow for a longer, playful buildup to create the right context for a fun, pleasurable experience. It’s something to look forward to, after all.
Foreplay: If the sex you’re having in midlife feels the same as it has for decades and you’re, well, a little bored, focusing on foreplay can go a long way. Responsive desire kicks in once sexual stimulus is underway, so don’t overlook the wind-up. Foreplay is a great way to try new things to introduce a sense of novelty into a long-term relationship and can be an enjoyable way to approach some of the changes menopause introduces, like shifts in libido and reduced vaginal lubrication. Take your time and enjoy!
Medication: Low libido in women doesn’t always mean that you have responsive desire; inability to reach arousal or feel pleasure from sex can have numerous physical and psychological causes. Medication may help in these circumstances; there are FDA-approved medications like Addyi and Vyleesi designed to help boost libido for women who have not fully reached menopause yet. Menopause hormone therapy may also be an option for women dealing with decreased libido, vaginal dryness, and painful sex during and after menopause. See an OBGYN with menopause experience to find out if medication would be right for your concerns.
Sex therapy: Introducing a third party into your sex life isn’t for everyone, but there are times you might find it tremendously helpful. A licensed therapist or mental health counselor who specializes in sex and relationships can share tools for talking about intimacy with your partner, working with your individual desire types or mismatched libidos, understanding sexual trauma, and navigating the interpersonal challenges that can come along during midlife.
And finally, please talk to a healthcare professional if something doesn’t feel right; your doctor may want to evaluate your hormones, perform an exam if you’re experiencing painful sex or pelvic pain, or screen you for FSIAD (Female Sexual Interest/Arousal Disorder), a disorder characterized by persistent disinterest in sex and/or trouble with arousal that causes emotional distress. Book an appointment with a menopause-trained OBGYN.
It’s likely been a while since you had a “sex talk,” right? Has anyone sat you down to talk about the birds and the bees in your 40s? While you probably don’t need a primer for the basics anymore, sex can still be a somewhat taboo subject and women are often left in the dark about their reproductive health, especially when it comes to the menopause transition (sometimes not-so-fondly compared to a second puberty!). Along with the physical, hormonal, and emotional changes that can kick off during perimenopause, your sex drive, aka libido, can start to change as well—so let’s talk about it.
Does perimenopause affect libido?
It certainly can and often does! Up to 87% of women experience “diminished sexual desire” or loss of libido as they age, and many will notice those changes starting during the menopause transition.
But libido is highly unique from person to person and there’s not really a baseline threshold of desire everyone should be meeting, so keep in mind that “low libido” to one person could mean something wildly different to someone else. It’s normal for your interest in sex, physical levels of arousal, and satisfaction from sexual experiences to fluctuate throughout different times in your life for all kinds of reasons, but if you feel like you’ve noticed drastic changes to your sex drive in your late 30s, 40s, or 50s, it could very well be related to perimenopause.
What factors affect sex drive in midlife?
Should I be worried about low sex drive in perimenopause?
We’d never tell you to worry without cause; we’re here to educate, not scare you. If you’re not currently worried about your sex drive, there’s no need to start now. It is unlikely that low libido on its own would be the sole symptom of a more serious medical condition, especially during perimenopause, when libido changes are incredibly common thanks to fluctuating hormones. Sometimes medical conditions like PCOS (polycystic ovary syndrome), endometriosis, and thyroid disorders, to name a few, can be accompanied by low libido, but you would probably notice other symptoms in addition to low sex drive or painful sex. If that’s going on, it’s worth keeping track of your symptoms so you can bring them up with your doctor to find the root cause.
That said, it’s okay to feel bothered if you’re not as interested in sex during perimenopause, even if nothing else is wrong. Sex is an important part of intimacy for most people, may influence your body image and self-esteem, and can be great for your mood, your pelvic floor, even your immune system. If you’re used to your libido behaving a certain way, changes can be unwelcome, annoying, even upsetting.
What about FSIAD? Could I have that?
Prolonged distress over a lack of interest in sex or difficulty reaching or maintaining arousal actually has a name: Female Sexual Interest/Arousal Disorder, or FSIAD. This term encompasses two common sexual dysfunction disorders in women: Hypoactive Sexual Desire Disorder, and Female Sexual Arousal Disorder.
Crucially, your feelings are an important part of diagnosis; if you used to enjoy sex but disinterest in sexual activities, lack of sexual thoughts, and problems with physical arousal have caused you distress for six months or longer, you may meet the criteria for FSIAD, which is treatable and should be diagnosed by a physician. Depending on what’s behind your symptoms, your doctor may recommend medication adjustments, hormone therapy, and/or counseling alone or with your partner.
Should I take testosterone to boost my sex drive during menopause?
Testosterone therapy during menopause is a hot topic. It’s not uncommon to hear some say that it’s the key to helping perimenopausal women feel better, lose weight faster, build more muscle, and yes, boost libido, but supplemental testosterone comes with some major drawbacks.
A quick testosterone primer: Testosterone isn’t just a hallmark of ultra-manly men. It’s an important hormone for women, too, though it’s present at lower levels than in men. Unlike estrogen and progesterone, testosterone levels don’t wildly dip as we age—in fact, testosterone decline during perimenopause tends to be a steady, gradual process, not a steep plummet, so it’s not the primary culprit for much of the hormonal chaos of midlife. Additionally the data for testosterone, when dosed safely, shows only modest benefit, and only for some women.
Gennev’s Chief Medical Officer, Dr. Rebecca Dunsmoor-Su, cautions against thinking of testosterone as an easy fix for a few reasons:
There are no FDA-approved testosterone doses for women, so physicians must engineer proper dosage for their female patients based on products designed and dosed for men. This can be a tricky process and requires regular blood work to make sure that women really are getting physiologically suitable and safe doses of testosterone.
Because it’s an anabolic steroid, testosterone isn’t a one-and-done solution. It’s effective for a while, but you will continue to need greater doses to maintain those effects as your body adjusts to higher levels of the hormone. Those higher doses of testosterone can make women vulnerable to heart problems, which is not ideal during menopause, when women are already at increased risk of cardiovascular disease.
Too much testosterone supplementation in women comes with other side effects, too. Acne, facial hair growth (yeah, those short wiry chin hairs? They’re coming back faster and bringing friends), hair loss, voice deepening, and clitoral growth are common side effects of high testosterone use in women. Some of these changes are not reversible, even after stopping testosterone.
Finally, Dr. Dunsmoor-Su never recommends testosterone in compounded or pellet form. These unregulated formats often contain very high levels of testosterone, cause significant side effects, and have not been shown to be safe or effective with long-term use.
Wait—if testosterone is that problematic, why does anyone take it for libido at all?
There are studies showing that low doses of testosterone, carefully prescribed and monitored, can benefit postmenopausal women struggling with libido and improve sexual function, leading to a few more “sexually satisfying encounters” per month. When used and prescribed appropriately, testosterone therapy can be an effective part of a libido-management plan, but Gennev physicians feel strongly that it must be overseen by an in-person provider with menopause experience.
How do I get my libido back?
Take it one step at a time and recognize that even though your libido in your 40s, 50s, and beyond might not feel like it did when you were younger, your sex drive and sexuality can still evolve in satisfying ways.
My sex drive is higher in my 40s. That’s not what I was expecting at all; is this for real?
In Miranda July’s 2024 novel All Fours, the 45-year-old narrator is perplexed to hear that she’s in perimenopause and can expect “reduced libido”; this never comes. Instead, she finds herself, body and mind, overtaken with lust as she navigates a series of midlife epiphanies about marriage, her body, and aging.
Yes, it’s fiction, and the very idea of a sky-high libido in perimenopause might make you snort “Yeah right!” but the truth is, no two sex drives are the same. Some women do report a surprising spike in libido during perimenopause, especially if they had a high sex drive before. Even those who didn’t have a particularly high sex drive earlier in life can experience more frequent desire and more intense arousal during perimenopause. It’s not quite as common as decreased libido and usually doesn’t last throughout the entire menopause transition, but rest assured, it does happen.
What causes increased libido in perimenopause?
Physiologically, this “midlife sex surge” could come from how some women react to hormonal changes. As estrogen dips and testosterone levels stay more stable, testosterone’s effects may feel more pronounced, effectively revving up the signals that contribute to the desire for sex. Some women report a libido boost after starting hormone therapy for menopause symptoms, though this experience varies widely.
But most of the time, high libido during and after perimenopause is likely being driven by situational factors, like:
Should I do anything about my high libido?
Not unless you want to! Just like with decreased libido, feeling like your sex drive is working overtime in perimenopause probably isn’t something to worry about unless it’s causing you distress. If your renewed interest in sex is fun, feels good, and brings you closer to your partner, great! But if it becomes a source of stress, distraction, or relationship friction, know two things: the intensity will likely mellow over time, and it’s okay to bring this up with a counselor or your doctor if you’re really concerned about a high sex drive affecting your day-to-day life.
What should I expect from my libido after menopause?
It’s hard to say, since experiences vary and sex drive isn’t a static thing even before menopause. While your desire may continue to decline or stay lower than before, even after the hormonal swings of perimenopause have eased, having good sex is absolutely still possible.
If pelvic floor dysfunction or vaginal dryness after menopause prevent you from having comfortable sex, a menopause specialist physician or pelvic floor physical therapist can help you find relief (and don’t forget the lube!); if mental health or relationship challenges are affecting your libido, therapy (for individuals, couples, or specifically for sex and intimacy) can be worth a try. Even if you’re not interested in partnered or penetrative sex after menopause, pleasure’s still very much within reach: toys, masturbation, and even physical touch that doesn’t lead to intercourse can be great for your body, mind, and mood.
Struggling with painful sex or low libido in perimenopause? Gennev’s menopause specialists can help you get to the bottom of it and feel better fast. Book an appointment with one of our board-certified OBGYNs today.
When was the last time you struggled with something new? By the time many people reach midlife, it can feel like novel experiences don’t come along as often as they did in the past. If things are going well, you might feel like you’re pleasantly coasting through life, and even if you get thrown a few curveballs, you can figure it out. Best case scenario, you’re in the middle of your favorite decade yet—one of confidence, competence, purpose, and stability. New things just don’t faze you like they used to.
Then the mother of all plot twists comes along: perimenopause!
If you have a lot of conversations about menopause, like we do, you might start to notice a trend when it comes to how some people describe their experiences. Everyone phrases it differently, but the fundamental ideas are similar: I didn’t know what to expect. Nobody warned me about this. I had no idea what was going on in my body. I was totally caught off guard. Perimenopause rocked my world, and not in a good way. I didn’t feel like myself anymore.
If you had older female friends or relatives who were forthcoming about menopause, they might have given you some idea of what to expect, but when it comes to fully understanding the highs and lows, there’s nothing like living through it yourself.
So is it any wonder that perimenopause can bleed (no pun intended) into every aspect of your life and make you feel like you’ve stepped into a whole new world you’re not sure how to navigate? Of course it’s disorienting and overwhelming—you’ve never done this before!
There’s no way to lifehack your way through the menopause transition—if there were, we’d have told you by now—but fortunately, access to menopause-savvy healthcare providers is expanding every day. As for other tools and remedies, you could spend a small fortune on menopause products that might ease your symptoms to some extent, some through legitimate means and others, not so much.
But there’s one tool that costs exactly zero dollars: your mind.
No, you can’t control menopause symptoms with your mind (again, we definitely would have told you that) but mindset can be a powerful tool for navigating times of change and disruption, which perimenopause certainly is. It may sound a little woo-woo, and we’re certainly not suggesting that you just need to “think positive!” or “relax!” and you’ll sail through this transition, but we want to put forth an idea:
What if you embraced being a beginner—a perimenopause novice?
What if you could support your mental health by letting go of unreasonable standards for yourself and acknowledging that you’re in unfamiliar territory; by learning and using new knowledge about your body and mind during the menopause transition; by treating this not-exactly-optional experience as a growth opportunity, even a messy one?
That’s our pitch: learn about how to make parts of this major transition easier on yourself by practicing the principles of “beginner’s mind.”
What it is:
The concept of beginner’s mind originates in Zen Buddhism, but you certainly don’t need to practice Buddhism or even have experience with meditation or mindfulness to try the techniques.
The premise is simple on paper: to practice having a beginner’s mindset, drop any preconceived notions you’ve cultivated through experience or expectation, and regard whatever you’re facing with curiosity and an open mind.
When you approach a situation like a complete beginner, you can give yourself permission to not excel at it right away. You may notice new ways of doing things that you wouldn’t have seen if you’d defaulted to your go-to process. You may find renewed energy or appreciation for parts of your life that have grown stale. The idea is that someone with an “expert’s mind,” who knows what works, already has their own way of doing things—they’ve cultivated shortcuts, routines, and assumptions that are effective and efficient, but may also close them off to new ideas and possibilities.
This technique is useful for learning skills or solving problems in new ways, but it can also help with a mindset shift if you’re being hard on yourself for not living up to internalized expectations—like, for instance, how you “should” tackle life through the menopause transition.
What it’s not:
Beginner’s mind is not the idea that it’s better to be naive, or that you shouldn’t prepare for a new situation, or that you must throw out everything you’ve already learned and ignore prior knowledge.
It’s not realistic or helpful to suggest that you shouldn’t draw on your skills and life experience. Those things can serve you well, and probably already have many times. What beginner’s mind advocates for is to find new ways to apply what you know, and to be receptive to the idea that what worked before might not work again for every single situation in which you find yourself. We’ll talk more about how to put this idea into practice during perimenopause later on.
We’re also not suggesting that beginner’s mind is meant to be a menopause cure-all. This is not a challenge to just “grin and bear it” or to try to think your way out of very real symptoms instead of seeking medical care for relief. Without probing the idea more closely, beginner’s mind is at risk of sounding like a type of misguided magical thinking: “Approach everything with wonder like a child, and it will all get better!” Nope, no way. That’s not what any perimenopausal woman wants to hear.
Instead, think of this concept as one of many tools for meeting this time of transition; something you can use to keep from getting backed into a corner if you’re frustrated, or a way to renew your sense of purpose if you’re feeling discombobulated or stagnant during midlife.
Even if you have a reasonably smooth experience with perimenopause, it’s still a transition that you didn’t exactly sign up for, and you can’t always predict how your body’s going to change, whether you’ll struggle with hot flashes, insomnia, or unexpected itching, or what kind of hoops you might have to jump through in order to feel heard about your symptoms.
(Hot tip: with Gennev clinicians, there are no hoops. Our physicians and Registered Dietitian Nutritionists are menopause-trained and ready to help.)
Your energy and capacity for things you used to do might change—you may have to shift how you eat, exercise, and sleep in order to keep feeling like yourself. It’s a lot to deal with, particularly during a time of life when other things, like work, relationships, and family needs, are changing too.
Alongside treatments or medications you need to support your physical and mental health, practicing having a beginner’s mindset during perimenopause can help you:
In some meditation practices, you’re asked to notice the sensations that arise in your body, thoughts that drift through your mind, or sounds you hear in the background. You’re not supposed to do anything about them, just acknowledge them as a means of staying present.
When it comes to perimenopause, it’s hard not to notice your symptoms, and the idea of meditating through irritability and discomfort might sound laughably unhelpful. But if you make a habit of checking in with yourself intentionally throughout the day, it could help you identify perimenopause-related patterns or notice if something significant is changing.
You might notice things like, “Okay, my hot flashes don’t really last as long as I thought they did,” or “I seem extra short-tempered with my kids on days I don’t work out,” or “That’s interesting, I actually do sleep better if I skip that second glass of wine with dinner.”
This curiosity is a way to have more lightbulb moments instead of getting through the day on autopilot at the mercy of your hormones. You may not be able to make quick changes based on all your realizations, but the simple act of noticing patterns in your symptoms and emotions can go a long way toward helping you feel less out of control. If nothing else, this practice of noticing can be a great way to gather detailed talking points for discussing your symptoms with a healthcare provider.
Asking questions is a powerful technique for cultivating a beginner’s mindset for two reasons:
Asking questions of yourself as a thought exercise can help you get to the heart of what you really want or need and give you a way to move through situations where you feel stuck. Even if you don’t have the answers or decide not to act on them, practicing curiosity can be a creative way to tackle challenges, avoid jumping to conclusions, and tune in to your gut instincts for more clarity.
Need some inspiration? Start with these cues and tailor the questions to your own perimenopause pet peeves
Asking questions of others can help you find people going through similar struggles, learn from their experiences, or get connected to others who can help you. It’s a fantastic way to build camaraderie and trade support during a time when that’s especially important. When it comes to menopause information and visibility, sharing really is caring.
This one can be hard. If you’re someone who’s used to having it all together, who usually has everything dialed in and can juggle lots of life’s spinning plates at once, you probably have high expectations of yourself and your ability to get stuff done. For most of your life that’s probably worked just fine, but perimenopause can complicate things.
Whether it’s weight gain, brain fog, or anxiety, changes during the menopause transition can thwart your usual habits and make things that used to come naturally to you feel a lot more difficult.
It’d be completely understandable to think that you just need to work harder: wake up earlier, cut calories, exercise more intensely, work longer hours, just grind more. If all that worked when you were younger, why not now?
A beginner’s mindset would remind you that approaching the new, often frustrating, shifts of perimenopause with the assumption that you should be able to just do it is a recipe for disappointment, self-criticism, even injury, illness, or burnout.
So give this a try: next time you’re irritated by some menopause-related hurdle, let go of any I should be able to’s and why can’t I’s and this used to be easier’s in your internal monologue, even just for a few moments. That’s your expert’s mind talking, and it’s setting you up for an uphill battle.
Instead, just see what it feels like to say, “Looks like what I used to do isn’t working. I need a new system. I need more information. Maybe I don’t have to do it the way I did before. What can I try instead? Who else can help me with this?”
We’re not saying it’s easy, but if you can let go of expectations about how you should do something during perimenopause instead of turning those judgements on yourself, you might discover new solutions and coping strategies that are more effective and sustainable for this time in your life.
There aren’t many rules of menopause; it’s not like you sign a contract saying you’ll behave a certain way or suffer in polite silence until the chaos subsides. But social pressure is real, and expectations of women are perpetually demanding. What would happen if you adopted a beginner’s mindset to bypass some of the social conventions we rely on to make others more comfortable?
Being a beginner doesn’t mean constantly pushing through discomfort—sometimes it means recognizing when you need to take a break. Beginners aren’t expected to have all the answers, and they’re not expected to perform perfectly at all times. Flawed is okay. Clumsy is okay. Tapping out to reset is okay. So as someone navigating perimenopause for the first time (because really, you are!), give yourself that privilege too.
Next time you’re having a bad day, go rogue. Tell your spouse and the teens they’re on their own for dinner. Take a mental health day. Cry it out. Own the hot flash, don’t pretend it’s not happening. Confess your most unhinged perimenopausal thoughts to a friend, therapist, or your doctor. Do something that seems silly or self-indulgent, just because it feels good. This is, after all, your menopause. While you probably can’t drop everything and run off to a quiet cottage in the woods til it’s all over, you’re allowed to lose your composure sometimes while you figure out your new normal.
Perimenopause can last for a long time, and your symptoms and experiences will probably change along the way. That’ll deliver plenty of opportunities to keep practicing beginner’s mind, if you find it valuable, but may also make it easier to slip into the expert’s mindset—once you get more familiar with whatever shifts perimenopause throws your way, you may get used to them. Symptoms may not feel so disarming all the time. Physical and lifestyle changes might not feel so extreme. You’ll find routines and remedies that work to support you, just like you’ve done before. And that’s fine!
But don’t be afraid to return to a beginner’s mindset if you start to feel stuck again or run into a change that throws you off your game. Ask more questions; get curious about what’s going on with your body; be open-minded about potential solutions. Maybe you need a new med, or a different dose of hormones. Maybe it’s time to switch doctors, or invest in a personal trainer. Maybe you can take a leave of absence from work instead of miserably grinding through day after brain-foggy day.
If you’re still skeptical about how much mindset can help you get through menopause, that’s okay. While mindfulness techniques do show promise for alleviating some menopause complaints, there’s not enough data to suggest that they’ll work for every symptom or every patient, and we’d never suggest that they should replace evidence-based medicine, therapy, and healthcare tailored to your needs.
Instead, think of the beginner’s mind practice as another tool to help you persevere through perimenopause: the more you practice viewing these times as opportunities to learn something new about yourself or try an unexpected mode of problem-solving, the easier it will become to navigate transitions with greater confidence and self-compassion.
Of the many ways that the menopause transition makes itself known, some symptoms are more immediately apparent—and more, well, visceral—than others. Hot flashes, super-soaker periods that show up whenever they please, and puzzling weight gain are pretty dramatic physical signs that things are changing, and they can be hard to ignore. Physical symptoms get a lot of coverage in the current conversations about menopause, which is a good thing, since it means more women have the information they need to seek help and relief.
But alongside the uncomfortable physical symptoms, perimenopause can also stir up new or worsening mental health concerns, like anxiety, depression, brain fog, mood swings, even unexpected rage. In our fast-paced culture packed with distractions, stressors, and endless obligations, it may not occur to some women that these symptoms might be connected to the menopause transition, or that they can get help for them. Add to this the fact that menopause and mental health remain somewhat taboo topics and that many women have their mental health concerns dismissed, and it’s clear we need to be having more conversations about the psychological and emotional symptoms to be aware of during perimenopause.
Take this one, for instance: Some women notice a hard-to-put-your-finger-on-it sense of “blahness” or numbness, most profoundly marked by a loss of interest in things they used to enjoy, and a loss of pleasure from things that used to provide it, including food, hobbies, creative pastimes, sex, and social connections.
The term for this is anhedonia, and if it’s not already on your radar, it might be difficult to recognize or articulate at first. Anhedonia doesn’t necessarily rise to the top of the list of conversations about mental health in general, since it’s often considered a hallmark of depression and the neurobiological mechanisms behind it aren’t especially well understood yet.
We think it’s important to spotlight anhedonia in its own right, however, since mental health concerns can vary so widely between individuals during perimenopause, and we’re all about digging into the sometimes uncomfortable and underdiscussed topics you need to know about during this transition.
If you can relate to what we describe here, please consider bringing it up with a healthcare provider or mental health professional, especially one well-versed in menopause. Mental health concerns during menopause can be complex, distressing, and have multiple root causes, but getting help is worth it.
The word anhedonia is derived from the Greek words “an-” meaning “without” and “hedone,” meaning pleasure. It was first used by the French psychologist Théodule Ribot in the late 1800s, and while the definition has expanded over time (especially in the context of clinical depression), you’re still most likely to see it used to describe a lack of interest in formerly enjoyable activities, and/or a lack of pleasure in those activities while doing them.
To understand where anhedonia fits in among other mental health symptoms, it might help to imagine them along a sort of spectrum. Where depression might generally present as a low-energy condition, marked by feelings of sadness, hopelessness, despair, and disinterest in normal activities, and anxiety might present as a higher energy condition, characterized by racing thoughts (and heartbeat!), worry, rumination, and even panic attacks, typical descriptions of anhedonia place it closer to depression. It’s possible to have anhedonia as the sole sign of a mental health disorder (ie, you can experience episodes of anhedonia as a variant of depression without other symptoms), but it is also one of the diagnostic criteria for major depressive disorder (MDD), and several other psychological and neurological disorders, including Parkinson’s disease.
Essentially, anhedonia is responsible for the “disinterest and apathy” symptoms that can accompany depression and other disorders. It’s not associated with having strong negative emotions so much as it is a lack of emotions; it’s waking up feeling “meh,” “blah,” or “take it or leave it,” in the most passive sense, about activities you would ordinarily look forward to and enjoy.
Researchers believe that anhedonia presents when there is dysfunction in the brain’s motivation and reward centers. However, as with so many mental health disorders, it’s hard to narrow down a singular cause or predict what might trigger an episode in any given person, especially since it can be co-present with other conditions.
It’s thought that there may be a genetic component partially contributing to whether an individual is prone to anhedonia. It has also been linked to inflammation in the brain, which interferes with the function of neurotransmitters, such as the “feel-good hormone” dopamine, that play important roles in mood regulation, pleasure, and motivation.
Other contributors to anhedonia can include trauma and PTSD; burnout; substance use disorders; even chronic illness like Long Covid; this raises the question whether it’s driven by something biochemical, circumstantial, or both, in ways science doesn’t fully understand.
As for what spurs episodes of anhedonia during perimenopause, it’s difficult to say with certainty, but plummeting estrogen levels are likely partially responsible. During the menopause transition, we’re at the whims of fluctuating hormones, often for years. These wild hormone swings can bring about not just irritability but other serious mental health concerns, like depression, as we lose the (sometimes) mood-balancing effects of progesterone, and declining estrogen and progesterone interfere with dopamine function.
All these hormonal shifts can result in mood and mental health changes during midlife, and the severity can vary from person to person. Some research suggests that women who experienced depression before beginning menopause may be more prone to depressive symptoms (especially those severe enough to meet the criteria for major depressive disorder) during and after menopause, but mental health struggles can arise for all kinds of reasons, including situational ones, during this time.
Transitions during midlife involve so much more than just hormones: it’s a time when our relationships, body image, sense of identity, roles at home and at work can all go through destabilizing shifts too, sometimes with no predictable end in sight. It’s not unreasonable, then, that stress, burnout, overwhelm, anxiety, depression, and anhedonia can set in and prompt a need for more support.
We all have experiences we don’t enjoy sometimes, right? And is it so bad to lose interest in certain things, especially as you grow and change and adjust to new life phases throughout the years? Does moving on from former activities, hobbies, or social groups always mean you’re dealing with anhedonia?
Of course not—that’s just having preferences! Anhedonia isn’t simply disliking an activity or not being interested in a pastime because it’s not your cup of tea or you’ve found something new to try. It’s better described as a sense of apathy or indifference that extends into multiple areas of your life, or a pervasive numbness that leaves you not caring about much of anything, which doesn’t lift even after your favorite pick-me-ups—anything that used to reliably buoy you through a bad mood.
So how does this show up?
Women responding to discussions about anhedonia during perimenopause in various online forums use phrases like:
“faking my way through life”
“I don’t care about anything”
“everything is boring”
“life just feels gray”
“wouldn’t really care if I never saw my friends again”
“going through the motions”
“no sense of urgency”
“can’t find motivation, even for the fun stuff”
“trying to figure out how to want to want something again”
“nothing calls to me”
“I’m just existing”
“I would feel this in my bones…if I could feel feelings”
They describe abandoning hobbies and businesses, withdrawing from social and family obligations, not looking forward to plans, putting off basic tasks, and doing the bare minimum to get through the day, not because their to-do list feels challenging but because they simply can’t work up the motivation to care about following through.
It’s also not uncommon for people experiencing anhedonia to lose interest in, or fail to get satisfaction from, things they used to find enjoyable like food, sex, or engaging with music and art. Particularly with food, this can lead to changes in appetite and eating habits—some people may struggle to eat enough, while others might seek out highly palatable and less nutrient-dense foods, like salty or sweet snacks, in the hopes of finally tasting something satisfying.
If anhedonia saps your motivation, interest, and sense of satisfaction or joy, it’s fair to say that it isn’t compatible with nurturing your well-being, relationships, or self-image—particularly not during menopause, which can bring forth new challenges on these fronts anyway. Wanting relief from anhedonia is as understandable as wanting relief from hot flashes, and just as important for your menopausal quality of life.
Because it’s so often linked to other conditions and we’re still learning about what can cause it, anhedonia on its own can be difficult to treat. There are no treatments designed specifically for anhedonia yet, outside of those meant to address the other disorders it often accompanies, and frustratingly, it’s not always responsive to some of the go-to medications often used to treat depression, like SSRIs.
To offer some hope, though, it seems that anhedonia isn’t always a persistent state for all who experience it. Depending on the factors involved, its severity can ebb and flow over time, and various mental health interventions can help bring about relief for some people. Though there’s no one remedy that’s a proven anhedonia-buster, a combination of approaches may help.
Cognitive behavioral therapy
Atypical antidepressants
Menopause hormone therapy
Without a better understanding of what really causes anhedonia during perimenopause (and in other circumstances), and better data pointing toward effective treatment options, it can be challenging to treat and frustrating when it affects important aspects of your life, especially during a time of such intense change. But this doesn’t mean there’s nothing to be done. If you’re struggling during menopause—with anhedonia, depression, anxiety, or any combination of these—we encourage you to communicate it to a healthcare provider who listens to your concerns and can support you with the right combination of treatments, lifestyle changes, and other mental health interventions for your needs. You and your well-being are worth it.
If you feel you or someone you care about may be suffering from depression, there is help. You can start finding your way back from depression by talking to a doctor or mental health provider, or contacting the 988 Lifeline for immediate, 24/7 support. Gennev’s clinicians can support you through the unique physical and emotional challenges of menopause with personalized treatment plans; book an appointment to get started.