Female Sexual Health: A Complete Guide for Women 40+

The World Health Organization describes sexual health as physical, emotional, mental and social well-being in relation to sexuality, not merely the absence of disease, and including the possibility of pleasurable and safe experiences (WHO). For women in midlife, that definition is useful because it puts comfort, desire and satisfaction on the same footing as screening and infection prevention. All of it is legitimate health care.

What does female sexual health include?

• Desire: interest in sex, whether it shows up spontaneously or builds after touch begins.
• Arousal: the mental and physical response, including lubrication, swelling and sensitivity.
• Orgasm and satisfaction: how sex feels emotionally and physically, not just whether orgasm happens.
• Comfort: sex without pain, burning or fear of pain.
• Safety: consent, protection from sexually transmitted infections, contraception when still needed, and routine screening.

Myths and facts about women's sexual health

What are the most common sexual health concerns for women?

In the PRESIDE survey of more than 31,000 US women, 43% reported a sexual problem and about 12% reported one that caused significant distress. Low desire was the most common, and women in midlife were the most likely to be distressed by sexual problems (Shifren et al., 2008).

By the numbers

Sexual concerns among US women (PRESIDE)

43%reported a sexual problemSource: Shifren 2008

~12%reported a problem that caused significant distressSource: Shifren 2008

Low desire

Low desire becomes a medical diagnosis, hypoactive sexual desire disorder, when it persists for months and causes distress. Our guide to low libido after menopause covers causes and options in depth.

Arousal and orgasm changes

Needing more time or stimulation, reduced lubrication and weaker orgasms are frequent in midlife and are often linked with lower estrogen, blood vessel health and medications such as antidepressants.

Painful sex

ACOG notes that nearly 3 in 4 women have pain during intercourse at some point in their lives (ACOG). After menopause, the most common cause is genitourinary syndrome of menopause (GSM), the thinning and drying of vaginal and vulvar tissue that comes with lower estrogen (2020 GSM position statement). Pelvic floor muscle tension is another; see pelvic floor issues and sex.

When problems persist and cause distress, clinicians call them female sexual dysfunction. Read what is female sexual dysfunction for the four types and a symptom checklist.

What affects women's sexual health?

In the SWAN study of midlife women, sexual function was linked not only to menopause stage but also to vaginal dryness, mood, relationship satisfaction, overall health and how important sex was to each woman (Avis et al., 2018). The main influences fall into four groups:

• Hormones: estrogen, testosterone and progesterone shift through the menstrual cycle, pregnancy, breastfeeding, perimenopause and menopause. See how hormones affect sexual desire.
• Physical health: diabetes, heart disease, thyroid problems, pelvic surgery, cancer treatment, chronic pain and many medicines.
• Mind and mood: depression, anxiety, past trauma, body image and chronic stress.
• Relationship and context: communication, conflict, a partner's health, privacy, fatigue and time.

Sexual health at different life stages

After childbirth

Low estrogen while breastfeeding, healing tissue, pelvic floor changes, sleep loss and the demands of a newborn commonly lower desire and can make sex uncomfortable for months. Pelvic floor physical therapy can help with pain or leaking.

Perimenopause

Fluctuating hormones can make desire, lubrication and comfort unpredictable. Pregnancy is still possible until you have gone 12 months without a period, so contraception remains relevant.

After menopause

Vaginal and urinary symptoms tend to persist or worsen without treatment, while desire is shaped by health, mood and relationship as much as hormones. Bleeding after menopause always needs evaluation (ACOG).

Sexual safety and screening after 40

Midlife is when many women start new relationships after divorce or loss, and prevention advice written for younger women still applies:

• STIs don't stop at menopause. Thinner vaginal tissue may even tear more easily. Use condoms with new partners and ask for STI testing when a relationship begins or if you have symptoms.
• Keep up with cervical screening. For most women, routine Pap and HPV testing continues until the mid-60s, on a schedule your clinician sets based on your history.
• Contraception is still needed in perimenopause until a clinician confirms you are past menopause.
• Urinary symptoms such as burning, urgency or repeated infections after sex can be part of GSM and are worth mentioning, not just treating with antibiotics each time.

Feeling safe, including feeling free to say no, is part of sexual health too. If you feel pressured or unsafe in a relationship, a clinician can connect you with support.

Evidence-based ways to support sexual health

Everyday steps

• Use lubricant for sex and a vaginal moisturizer regularly if you have dryness.
• Prioritize sleep and treat night sweats or insomnia.
• Exercise regularly. In a trial of women taking antidepressants, exercise shortly before sexual activity improved desire, and improved overall sexual function in women who started with sexual difficulties (Lorenz and Meston, 2014).
• Limit alcohol and stop smoking, both of which affect blood flow and arousal.
• Talk with your partner about what has changed and what feels good now.

Therapy

Sex therapy, couples counseling, cognitive behavioral therapy, mindfulness-based programs and pelvic floor physical therapy each have evidence for specific problems and carry no drug risks.

Prescription treatment

Depending on the problem, a clinician may discuss vaginal estrogen or DHEA for painful sex, systemic hormone therapy for menopause symptoms, testosterone for postmenopausal women with distressing low desire, or desire medications. Addyi is FDA-approved for low desire in women under 65, and Vyleesi in premenopausal women. Compounded and off-label options also exist; our guide to female libido pills compares them.

Amie offers Blys, a compounded rapid-dissolve tablet with PT-141 (bremelanotide), oxytocin and tadalafil, taken 30–60 minutes before intimacy for low desire and arousal. It is not FDA-approved and must never be used with nitrate medicines. A licensed clinician reviews your history and medications to decide whether it is appropriate.

When to see a clinician

ACOG recommends that clinicians ask about sexual concerns and evaluate them with a full medical, sexual and psychosocial history (ACOG Practice Bulletin 213). Book a visit if a change has lasted several months and bothers you, or if sex is painful. Seek care promptly for:

• bleeding after sex or any bleeding after menopause,
• new or severe pelvic pain,
• sores, lumps, or unusual discharge or odor,
• sexual changes together with depression or thoughts of self-harm.

Not sure how to bring it up? Our guide on how to talk to your doctor about low libido includes wording you can use, and keeping a simple log of your symptoms for a few weeks gives you concrete details to share.