Discomfort During Sex and Loss of Desire: Why?

If sex has started to hurt and your desire has quietly disappeared, you are not broken and you are not alone — in my practice, this is one of the most common patterns I see in women over 40. Vaginal dryness and tissue changes from declining oestrogen are usually the first domino to fall, and low desire often follows as your body's protective response rather than a personal failing. Both discomfort and desire respond well to the right, layered treatment — but only once you understand why they're happening together.

What's happening in your body

Here's what the research I rely on, and twenty years of clinical work, keep confirming: pain and desire are not two separate problems in midlife — they're one interconnected system. As oestrogen declines through perimenopause and beyond, the vaginal and vulval tissues become thinner, less elastic, and less lubricated. This is genitourinary syndrome of menopause (GSM), sometimes still called vaginal atrophy, and it's the most common medical explanation for dyspareunia (painful intercourse) in women over 40. Yet a study found that 81% of women were unaware that vaginal atrophy is a recognised medical condition (source: https://www.themenopausehub.ie/menopause-blog/2019/2/18/painful-sex-and-the-menopause-or-peri-menpause), which means most women silently assume something is wrong with them, rather than recognising a well-documented hormonal shift.

What I've learned from working with hundreds of women through this transition is that GSM is rarely just a local, isolated issue. The tissue changes in your urogenital tract often mirror what's happening systemically — declining oestrogen affects collagen, blood flow, and nerve sensitivity throughout the body, not just in the vagina. If you're also dealing with high cortisol, poor sleep, or unmanaged inflammation, treating the tissue alone is only half the battle. This is why some women use vaginal oestrogen faithfully and still feel that something's missing — the local fix works, but the whole-body picture hasn't been addressed.

This is where the pain-desire feedback loop becomes so important to understand, because it's rarely discussed outside clinical settings. When intercourse has hurt even once or twice, your nervous system starts anticipating pain before it happens. I call this the Guard-Pain-Avoid cycle: chronic discomfort leads to an involuntary bracing of the pelvic floor muscles (hypertonicity), and over time, even non-penetrative touch — a hand on the thigh, a hug that lingers — can start to feel threatening rather than inviting. Your brain is doing exactly what it's designed to do: protecting you from anticipated harm. The problem is that this protective guarding shuts down desire before it even has a chance to start, which is why so many women describe losing interest in sex "out of nowhere" when actually there's a very logical, physiological explanation.

And this brings me to what I think is the most misunderstood part of low libido in midlife: the myth of the libido switch. Desire isn't binary — it's not that it's simply "on" or "off." I explain it to my clients as a gas-and-brake system. Oestrogen, testosterone, sleep, stress, and relationship connection are all pressing the gas pedal, while pain, anxiety, and exhaustion are pressing the brake — often much harder than we realise. Declining androgen (testosterone) levels specifically affect the drive aspect of libido — the cognitive spark, the initiating thought of wanting sex — which is different from the physical capacity for arousal. Effective treatment usually requires hormonal synergy: oestrogen for tissue integrity, progesterone to support sleep and reduce anxiety, and in some cases testosterone to restore that cognitive spark. Up to 87% of women report experiencing diminished sexual desire or loss of libido as they age (source: https://gennev.com/learn/libido-during-perimenopause), and in my experience, very few of them are getting a treatment plan that addresses all three hormones together.

Is it perimenopause or something else?

Most of the time, discomfort and desire loss in your 40s and 50s trace back to hormonal changes — but it's worth ruling out other contributors, especially if symptoms feel sudden or severe.

• ✦Genitourinary Syndrome of Menopause (GSM) — dryness, burning, tearing, or a "sandpaper" sensation during penetration, often worsening over months
• ✦Vaginal or urinary infections — thrush, bacterial vaginosis, or recurrent UTIs can cause similar burning or soreness and need separate treatment
• ✦Pelvic floor dysfunction — muscle tightness (hypertonicity) or scar tissue from childbirth or surgery causing deep or entry pain
• ✦Skin conditions — lichen sclerosus or lichen planus, which cause itching, thinning, or whitening of vulval skin and need a GP or dermatologist assessment
• ✦Medication side effects — certain antidepressants (SSRIs), antihistamines, and blood pressure medications are known to blunt desire or increase dryness
• ✦Low testosterone or HSDD — persistent, distressing loss of desire not explained by dryness alone may indicate hypoactive sexual desire disorder
• ✦Relationship or psychological factors — unresolved conflict, body confidence changes, or anxiety around initiating or being touched

If pain is sharp, localised, or accompanied by unusual discharge, bleeding, or skin changes, see your GP promptly rather than assuming it's "just menopause."

What you can do about it

• ✦Start using a vaginal moisturiser regularly, not just a lubricant during sex. A moisturiser is designed to be used two to three times a week to rebuild tissue hydration over time, while a lubricant is only used in the moment for friction — understanding this difference is one of the biggest gaps I see in how women approach the problem.
• ✦Check your lubricant and moisturiser ingredients for irritants. Glycerin, propylene glycol, and parabens can aggravate already-sensitive menopausal tissue and, in my clinical experience, are frequently the hidden reason a product "isn't working" — look for pH-balanced, fragrance-free, glycerin-free formulas instead.
• ✦Ask your doctor specifically about vaginal (local) oestrogen. Creams, rings, or tablets deliver oestrogen directly to the tissue with minimal systemic absorption, and I've seen this restore comfort for women who assumed painful sex was simply their new normal.
• ✦Discuss systemic HRT and testosterone as part of the conversation, not an afterthought. Oestrogen restores tissue; testosterone often restores drive — treating only one usually leaves women feeling only partially better, which is why hormonal synergy matters so much in practice.
• ✦Consider pelvic floor physiotherapy if pain persists despite tissue treatment. A pelvic floor physiotherapist can assess for the guarding and hypertonicity that chronic pain creates, and manual therapy is often the missing piece when hormone treatment alone hasn't resolved the discomfort.
• ✦Reframe desire as responsive, not spontaneous. In midlife, desire very often starts with touch, warmth, or connection rather than beginning in your head — expecting spontaneous urges the way you may have in your twenties can make you feel like something's wrong when nothing is.
• ✦Practise sensate focus with your partner. Deliberately removing the expectation of penetration and reintroducing non-goal-oriented touch is a core clinical technique for retraining a nervous system that has learned to associate closeness with pain.

Comprehensive, layered care works. 90% of women using comprehensive menopause care report symptom improvement within three months (source: https://www.evernow.com/symptoms/low-libido) — and 84% of women felt that maintaining an active sex life was important to them despite menopausal changes (source: https://pubmed.ncbi.nlm.nih.gov/19237616), which tells me that wanting this part of your life back is not vain or unrealistic — it's common, valid, and very achievable.

If you're ready to understand your own hormonal picture rather than guess, a structured assessment is a good place to start.

Take the Quick SOM Assessment — 2 minutes → Take the Full SOM Assessment — 5 minutes →

Frequently Asked Questions

Why does sex suddenly feel painful during perimenopause? Fluctuating and declining oestrogen thins and dries the vaginal tissue, reducing elasticity and natural lubrication. This can happen gradually or feel sudden if your levels drop sharply during a cycle. What I see time and again is that even mild dryness causes microtears that make subsequent attempts at sex more painful, reinforcing the cycle.

Is it normal to lose all interest in sex after 50? It's extremely common — up to 87% of women report diminished desire as they age (source: https://gennev.com/learn/libido-during-perimenopause) — but "common" doesn't mean it has to be permanent. Hormonal shifts, pain avoidance, and fatigue are usually treatable contributors, so it's worth exploring the cause rather than accepting it as inevitable.

Can vaginal dryness cause a permanent loss of libido? Not inherently — dryness typically causes a secondary, protective loss of desire because sex has become associated with discomfort. Once the underlying tissue changes are treated with moisturisers or vaginal oestrogen, most women find desire gradually returns, though the pain-avoidance pattern may need separate attention too.

How do I talk to my doctor about painful intercourse without feeling embarrassed? Try writing your symptoms down beforehand and naming them plainly: "I have pain during sex and I think it might be related to menopause." Doctors hear this regularly, and using specific terms like dyspareunia or GSM signals that you've done some reading and want a real conversation, not just reassurance.

What is the difference between a vaginal moisturiser and a lubricant? A moisturiser is used regularly, independent of sex, to rebuild tissue hydration over days and weeks. A lubricant is used only during intercourse to reduce friction in the moment. Many women use only a lubricant and wonder why dryness persists — you often need both, used differently.

Does hormone replacement therapy actually help with sex drive? Systemic HRT improves many menopause symptoms, and vaginal oestrogen specifically improves tissue comfort, but drive itself is more closely tied to testosterone. In my practice, the best results come from addressing oestrogen, progesterone, and testosterone together rather than expecting one hormone to do everything.

Related reading

• ✦Responsive vs Spontaneous Desire: What Changes at Midlife
• ✦Vaginal Moisturisers vs Lubricants: A Complete Guide
• ✦Testosterone Therapy for Women: What It Can and Can't Do

Disclaimer

This content is for educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider before making decisions about your health.