Hormonal changes during menopause affect sexual function in the same way they impact training, recovery, and overall health, yet this area remains under-recognised despite its direct link to wellbeing and performance. Changes to oestrogen, blood flow, and nervous system regulation influence desire, arousal, and comfort, positioning sexual health as an integrated indicator of broader physiological balance rather than an isolated issue.
This article is part of a series from Angela Harper exploring exercise, diet, hormones, sex, sleep, resilience, and recovery during menopause.
It’s an awkward topic, but if we want to perform at our best during menopause, we also need to talk about what happens between the sheets (and no, I’m not talking about sleep).
Just like training, diet, recovery, and sleep, sexual function is shaped by the same hormonal changes occurring in menopause, and which is a vital part of women performing at their peak.
Despite the inevitable onset of menopause, the decline in sex hormones can take many women by surprise. These hormones regulate far more than just reproduction, influencing muscle mass, bone density, insulin sensitivity, inflammation, and how the body uses fuel during exercise.
Sexual function sits within this system and, as women’s oestrogen declines, several changes occur simultaneously:
- vaginal tissues become thinner and less elastic
- reduced blood flow affects arousal
- declining testosterone can shift libido
- the nervous system becomes more stress-reactive
- vulvovaginal atrophy develops
- dyspareunia (pain before, during or after sex) becomes more common
- natural lubrication decreases.
These are not isolated symptoms; they are the result of hormonal, vascular, and neurological systems that shift as we enter pre-, during, and post –menopause phases. Sexual function, just like physical performance, relies on the coordination of these systems and impacts not just energy, recovery, and training, but desire, arousal, and wellbeing.
However, it’s not all bad news; while some women experience a drop in desire, others report the opposite as reduced stress and anxiety, fewer caregiving demands, and improved confidence can lead to increased intimacy and libido. This reflects an important point: that female sexual function is complex and is influenced as much by psychological and relationship factors as it is by hormones, according to research published on sexual dysfunction in postmenopausal women.
Despite this, sexual dysfunction is a common symptom in postmenopausal women that is frequently overlooked. Research shows that declining oestrogen levels can lead to vaginal atrophy, reduced blood flow, and a diminished capacity for arousal and orgasm.
There are however, a number of effective interventions that can help. Hormone Replacement Therapy (HRT) is a well-established treatment, particularly for oestrogen deficiency. Research has found that systemic and local oestrogen therapy can improve vaginal health and sexual function.
“Although both systemic and local estrogen therapy improve vaginal health and sexual functioning, local vaginal therapy with estrogen creams, rings, or tablets may be more appropriate for women without other indications for systemic estrogen therapy,” one study found.
“These therapies are highly effective in reversing vaginal atrophy, improving vaginal symptomatology, and reducing dyspareunia, and may have effects on other dimensions of sexual function.
“Emerging treatments, such as ultra-low-dose vaginal estradiol tablets, new selective estrogen receptor modulators (SERMs), and intravaginal dehydroepiandrosterone (DHEA) are other promising options for postmenopausal women with vaginal atrophy and sexual dysfunction.”
Hormones are only part of the equation
The nervous system plays a central role in sexual function, particularly the balance between the sympathetic (stress) and parasympathetic (rest-and-recover) systems. Chronic stress, poor sleep, and inadequate recovery—all common during menopause—can keep the body in a heightened stress state, making arousal and desire more difficult.
Dr Andrew Huberman, a neuroscientist and professor of neurobiology at Stanford University School of Medicine, has said that sexual arousal and function are strongly influenced by the autonomic nervous system, with heightened stress and elevated cortisol levels working against the body’s ability to enter the parasympathetic state required for intimacy.
“States of high stress and elevated cortisol tend to suppress reproductive and sexual behaviours,” he said in his podcast, noting that the body prioritises survival over reproduction when under strain.
This helps explain why many women experiencing menopause, often while managing careers, families, and disrupted sleep, may find that desire is not simply a matter of mindset, but biology.
Dr Mary Claire Haver, an obstetrician-gynaecologist and menopause specialist, has also said that the changes women experience are physiological, not psychological.
“This is not in your head,” Dr Haver said. “There are real, biological changes happening that affect sexual function, including vaginal tissue health, blood flow, and hormone levels.”
Importantly, sexual function is a reflection of overall system health, not just hormone levels.
Dr Stacy Sims, an exercise physiologist specialising in female performance, has said that the same factors that support physical performance, including adequate fuelling, recovery, and stress management, also underpin hormonal balance and overall wellbeing.
“When we look at performance in women, everything is interconnected,” Dr Sims has said. “If you’re under-fuelling, overtraining, and not recovering, it’s going to show up everywhere.”
This interconnectedness means that addressing sexual health during menopause is not about a single fix, but about supporting the body more broadly. When energy availability improves, stress is better managed, and recovery is prioritised, the systems that drive both performance and sexual function are better able to operate as intended.
