Low libido, dryness and painful sex after 40

By Shweta Arora, MD, board-certified physician · Medically reviewed by Robin Arora, MD · Updated October 2026

Sexual health is health. Yet many women never bring it up, and many clinicians never ask. If something has changed and it bothers you, it’s worth a conversation.

You’re not alone, and it’s not “just aging”

In a large U.S. survey of more than 31,000 women, about 43% reported some kind of sexual problem, but about 12% had a problem that also caused them distress. That rate was highest in women aged 45 to 64, at about 1 in 7. What matters isn’t how often you have sex; it’s whether something has changed in a way that bothers you.

Desire can change shape

Many women experience responsive desire: interest that builds after touch and closeness begin, rather than appearing out of the blue. That’s normal. Stress, poor sleep, mood, pain, relationship strain and some medicines, including certain antidepressants and hormonal birth control, can all turn desire down.

Genitourinary syndrome of menopause (GSM)

Falling estrogen thins and dries the tissues of the vagina, vulva and bladder. The Menopause Society estimates that this affects 27% to 84% of postmenopausal women. Symptoms include dryness, burning, pain with sex, urgency and repeat urinary tract infections. Unlike hot flashes, it usually doesn’t improve on its own.

A 2025 guideline from the American Urological Association and partner societies recommends:

• Vaginal moisturizers used regularly and lubricants for sex
• Low-dose vaginal estrogen for dryness, irritation and painful sex, and for women with GSM and repeat urinary tract infections
• Other prescription vaginal and oral options when estrogen isn’t preferred

The same guideline notes there’s no evidence linking low-dose vaginal estrogen to breast cancer. If you’ve had breast cancer, the decision is made together with your cancer team.

When sex hurts: at the opening or deep inside

• Pain at the opening can come from GSM, skin conditions of the vulva such as lichen sclerosus, nerve sensitivity or tight pelvic floor muscles.
• Deep pain can come from endometriosis, pelvic infection, or bladder or bowel conditions. See endometriosis.

Each has specific treatments, including pelvic floor physical therapy, so pain is worth reporting rather than pushing through.

What a sexual-health visit looks like

We start with a conversation about what’s changed, your health history, medicines and relationship. If an exam is needed, it’s gentle, explained step by step and stops whenever you ask. Hormone blood tests don’t diagnose low libido. See hormone testing.

Treatments with evidence

• Talking therapies: sex therapy, couples therapy, cognitive behavioral therapy and mindfulness are core treatments for low desire.
• Pelvic floor physical therapy and gentle dilator programs for pain.
• Vaginal hormone options for GSM.
• FDA-approved medicines for low desire in premenopausal women.
• Testosterone for postmenopausal women with distressing low desire. The 2019 global consensus says this is its only evidence-based use in women. At Serene it’s evaluated, prescribed and monitored in person only.

Everyday steps

• Use a water- or silicone-based lubricant, and skip scented products and douches.
• Make time for intimacy that isn’t rushed, and talk openly with your partner.
• Protect sleep, move regularly and manage stress. See mood, sleep & brain fog.
• Bring a list of your medicines to your visit.

Every plan is individualized, and treatment is recommended only when it’s right for you after your consultation.

Related reading: Perimenopause: symptoms, diagnosis and treatment · Endometriosis: more than a bad period · On hormone therapy but still not yourself?. Browse the full Women’s Health Library.

See us in person or by video

Visit our physician-led team at our Hudson, Ohio or Barboursville, West Virginia office, or meet Dr. Robin Arora by telehealth from anywhere in Ohio, West Virginia, Kentucky or Florida.

See a clinician promptly for any bleeding after menopause, bleeding after sex, a new vulvar sore, lump or white patch, pain with fever or unusual discharge, or new severe pelvic pain. If you feel unsafe in a relationship, call the National Domestic Violence Hotline at 1-800-799-7233.

Sources: Shifren et al., Obstetrics & Gynecology 2008 (PRESIDE); The Menopause Society 2020 GSM Position Statement; AUA/SUFU/AUGS Genitourinary Syndrome of Menopause Guideline (2025); Davis et al., Global Consensus Position Statement on Testosterone Therapy for Women, J Clin Endocrinol Metab 2019; Islam et al., Lancet Diabetes & Endocrinology 2019. This page is general education, not medical advice.