Perimenopause: how to get your sex life back on track
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My vagina just refuses to cooperate. I used to have no trouble with lubrication. Now it's dry, it's painful. Even with lube, it can be painful.

It's almost like my vagina just yawns and wants to roll over every time there's an opportunity. Without estrogen, the tissue becomes thinner, dry. The vagina can actually narrow, can shorten. The tissue in the labia can also shrink. I just wanted to feel like my old minxy self again. Ladies, picture this.

The lights are low, the candles are lit. You're freshly showered and in between some clean silky sheets, wearing nothing but your comfy bog undies and a giant oversized tee that says, My Little Pony. Your partner turns to you with that hopeful, expectant look in their eyes. They scooch up into your personal space, close enough that you can smell their breath, and you say...

Oh, honey, I'd sooner die than have sex. Plummeting estrogen can leave us wondering, what the hell happened to my libido? And will I ever see it again? And also, do I care if I never see it again? Then there's changes to the body.

Thinning skin can make things drier than a desiccated coconut, which means sex can hurt. And when sex hurts, of course you don't want to do it. It's enough to make you want to throw your boyfriend out the window and make a pact with My Little Pony to never have sex ever again.

But our sex lives don't need to be discarded and forgotten as our bodies change. Because guess what? You've just called the perimenopause hotline and there's help on the way. There's a siren. I'm arriving with some paramedics. I'm Yumi Steins. Ladies, we need to talk about sex and perimenopause. Stand clear. MUSIC

Suddenly I was having this just incredible, mind-blowing, mind-blowing sex. This is Ange. She's 42 and she started having the best sex of her life when she met her boyfriend three years ago. It's the first time she's been able to have an orgasm from partnered sex. I actually phoned my friend afterwards and I went, oh my God, what is happening? I was like, oh my God, what is happening?

We were having sex and I started having an orgasm. I was literally baffled for a second and then I went, oh my God, I'm having an orgasm. It was that surprising to me. He's just really good. He's good at it. He's good. He doesn't have an ego about it. Yeah, we just work.

This A grade, later in life, tell your girlfriends about it sex came after Ange's marriage of 15 years ended. She'd always had a high sex drive but sex with her husband was pretty dire. Starting a new relationship with her partner was like a reward for the dry years.

but Ange's body soon turned against her and her sexual rebirth. After experiencing pain during sex for the first time, she did some investigating and discovered she was in perimenopause.

I have found out that I've actually got some vaginal atrophy, which I didn't know. And so that's actually made things a bit challenging, which is really frustrating because I've waited so long to have a relationship like this because it's so much more than the sex. But, you know, the sex is such a huge part of it.

If you don't know what vaginal atrophy is, a couple of things. It's one of my least favourite gendered medical phrases that are put on women like a bad Byron Schooley tattoo, along with the words geriatric pregnancy and hostile uterus.

Thankfully, doctors now use the catchy phrase, genitourinary syndrome of menopause, instead. It's like a catch-all for vaginal atrophy. It covers the changes that can go on in a woman's vulva as hormone levels decline. These include the thinning of the skin and loss of lubrication, which leads to out. It's just, it can be absolutely heartbreaking at times. When I found out I was in perimenopause.

I was actually just fucking furious that I'd wasted so many fuckable years on my ex-husband. I was furious. Tell me about some real moments that you have where sex is on the table, but your body gets in the way. Yeah, it's just like my vagina just refuses to cooperate. I used to have no trouble with lubrication. I had no trouble with that at all. Now it's

It's just not working. It's sort of dry. It's painful. Even with lube, it can be painful.

And it's just really hard because that's one of the ways that I show my partner how much I love him. So the way it works is that you still feel horny. Yeah. So your body's like, yeah, yeah, yeah. My brain is saying, let's go. Right. Yeah. But your vagina is not, it's not getting the message. That's it. She's being a right bitch about it. Can you explain the difference between your orgasms before you had perimenopause and now? Yeah.

Yes. So before they felt quite powerful. They felt like they were going from my toes to the roots of my hair. They were amazing. And now they're comparatively they feel quite weak. They take a long time to happen. I used to be able to have five or six in a row if I was really greedy. LAUGHTER

And now it's sort of one, maybe two, if I'm lucky. I mean, I really get a picture of the orgasm being less intense and less all-encompassing now. Do you have a sense that this is just a period of your life and it will actually revert back to what it was or it's a transition period to something new? Where do you picture this in the timeline of your life?

Gosh, I hope it's something that's going to be resolved. I really hope so because the way that our sex life was when we first got together and the power of being able to have an orgasm from having sex with my partner, I really hope that this is a bit of a blip.

As we age, there are changes in nerve endings and as the tissue changes, it becomes sometimes a little bit more difficult and we need more stimulation to be able to reach orgasm. This is Dr Cheryl Kingsberg. She's a clinical psychologist and professor at the Department of Reproductive Biology at Case Western University.

She says that during perimenopause, women who have never experienced pain during sex can start to have issues.

Of all the categories of sexual problems, pain is the most common to really bump up. So think about this. In peri- and postmenopausal women, there is a loss of estrogen that occurs as the ovaries no longer are producing ovarian hormones. The vagina can actually narrow, can shorten. The tissue in the labia, so the outside of the vulva, can also shrink. The clitoris itself can shrink.

And that's all because of the loss of estrogen. You know how Ange was sharing her story of vaginal atrophy or GSM earlier? Cheryl says that studies show that at least half, but maybe more like 70 to 80% of women will develop GSM. And I just want to repeat that because I think it's important. 70 to 80% of women will develop GSM. That means likely that'll be you and I.

And too many women do not know that that is a common occurrence with menopause because they know about hot flashes, but they don't think about those changes that are actually chronic and progressive. Let's talk about desire. So there are two types of sexual desire, the spontaneous and the responsive. What do we know about how both of these might change during perimenopause?

Well, I'm glad you brought up the two kinds of desire because when we think about spontaneous desire, let's talk about that first. That really is one's appetite, right? The biologic drive for sexual activity, whether or not you act on it. We all have a certain level of drive. Some of us might think about and want to be sexual once, twice, three times a day. Some of us once a week, some of us once a month.

that tends to decline a little bit as we age. Responsive desire is really about not necessarily having your own appetite, but as you consciously choose to engage in the sexual encounter, it kind of kicks it. Responsive desire can also drop as a woman goes through perimenopause and beyond.

Dr. Kingsberg says that if sex is still important to you and you want to keep having it, then don't wait for inspiration to fall from the sky because you may be waiting a long time. The best analogy I can give you to that responsive desire is how I feel about going to the gym. I have no biologic urge to work out. I have none. If I waited for my own drive to go to the gym, I would never work out. I

I just go to the gym. I put my workout clothes on. I get on the treadmill. And only when I'm halfway through, now I've worked up a little sweat. My heart rate's up. I'm feeling good now. I'm in this rhythm. Only then does the smile come on my face and I say, oh, this feels great. I'm so glad I came to the gym. I'm going to come back tomorrow.

Changing hormones tinker with your surges and urges, but there's also the other stuff going on with your body that can change how much you actually feel like doing it. The symptoms of menopause can impact a woman's sexual function. If she is now fatigued, if she's having 10 hot flashes a day, if she has brain fog, those all can negatively impact one's sexual function.

It's almost like my vagina just yawns and wants to roll over like every time there's an opportunity. Remember the lead guitarist Siobhan from our band Ovarian Retirement, who you might have met earlier in this season? Well, she had always

also always enjoyed a high sex drive. And the deed was on high rotation between she and her husband until the big P reared its head. And I'm not talking about her husband's big P, I'm talking about this episode, perimenopause. Losing your sex mojo is such a gradual fade out that you don't really notice it's happening until...

You're at a point of reflection. I was always up for it. But then it's kind of like you hit a point and kind of go, wait, I haven't felt up for it for, well, I can't even remember. Siobhan's starting to worry about how this meh feeling is impacting her sex life. Once I'm there, it's fine. It's just, oh,

It takes me a lot more to get into the mood and it's become more of a bit of a chore added to my list of duties that needs ticking off as opposed to being this sensual thing that connects you and your partner, if that makes sense. And I love my husband. I find him hot as hell. I just...

I don't feel like my old, sexy, minx-y self. In fact, if I think about who I used to be as a person and who I am right now, I honestly don't think there's much correlation.

Look, if after listening to Siobhan and Anja's stories, you're thinking about shutting up shop and going to live in a caravan in the Blue Mountains, don't pack your bags yet. Professor Cheryl Kingsberg is here to help. Oral sex and vibrators are often very helpful. And as women age, the

The vibratory nerves are the last go. And so for women who could easily achieve orgasm in their younger years with manual stimulation or oral sex or penetrative sex may notice as they age, they need more direct stimulation and sometimes more vibratory stimulation. So it's not that women will lose their ability to reach orgasm. They may need to shift

how they achieve orgasm. And when you say vibratory stimulation, does that mean literally a vibrator? Yes, it does. Okay. Literally a vibrator. And there are thousands of them. It is a multi-million dollar industry for good reason. And if things are drying up or sex is hurting, there are several things you can try.

Just like we would use creams to moisturize our face, there are moisturizers developed for the vulva and vagina. But to restore the tissue, you really need to think about hormone therapy in the vagina and the vulva. And this is not the same as systemic hormone therapy.

What Professor Sheryl means about hormone treatments applied directly to the vagina not being systemic is that they're absorbed directly into the vaginal tissue and only a minimal amount is absorbed into the bloodstream. There's also suppositories, rings and gel caps and for women who don't want to put anything inside their vagina, there's pills you can swallow. There's a whole bag of tricks to choose from so please don't feel like it's not for you.

About three years into their relationship, Ange has started treatment to help with her pain during sex with her partner. So at the moment, I am relying on the hormonal cream, the intravaginal cream. Yep, that's the one you squirt into your vag. So much fun. Um,

So you get a little tube. Yeah. It's like a long, thin plastic tube and you put the cream on the end and you squirt it in and then you insert that into your vagina and then it goes up and that's it. Is it making a difference? It does. I do have to remember to do that and my memory's a bit shit because I have perimenopause, so...

Put it in your phone. Yeah, I know. A little alarm. I know, yeah. Go squirt your badge. Exactly. Yeah.

And do you do that before sex or is it just on a sort of schedule? You just have to do it at night before you go to bed. Okay. But then that could be before sex, that could be not. I mean, yeah, we're kind of jumping each other all the time. Are you really? We really are. Still horny for each other. Yeah. Talking about sexual problems with a partner isn't easy. It can also be tricky to open up to doctors about this stuff, let alone get them to hear you.

Ange found that even though she explained what was going on with the pain that she was experiencing during sex to a series of doctors, it took a while to find someone who did more than just say, oh, hey, that's life now. But even then, the ins and outs weren't discussed. It's been like unpacking a puzzle. When I got a new doctor and she was great and she was able to tell me that, yes, this atrophy was happening, I was able to tell her that,

It was very much about treating the symptom but not about what I could expect in my sex life. I feel like they just don't enter into that. Well, they didn't with me enter into that discourse at all. A lot of them are shy to talk about sex. Mostly she wanted to know how I bagged such hot sex in my 40s with somebody I met on Tinder. If you can't talk about the thing, then you can't get help for the thing.

Professor Kingsberg says that medical experts can be just like us in that they're shy to talk about sex stuff. I spend a lot of my career trying to teach physicians and nurse practitioners how to be comfortable addressing sexual concerns in their patients because if they look embarrassed by it,

then their patients are going to say, well, clearly I can't talk to this clinician about my sexual concerns because, you know, their hand is on the door handle and they're kind of turning away. You don't have any sexual concerns, do you? So back yourself and turn up prepared. I suggest to women that they write down their questions because when you get in front of a clinician, you get anxious and we forget what we wanted to ask. But sometimes, you know, carrying notes with you is perfectly legitimate.

Another thing that we've heard from women, Doctor, is that they feel embarrassed to talk to their partner about the changes that are going on in their bodies. What advice do you have for them? We are not taught how to or encouraged to talk about our sexual lives. And yes, it is hard to talk to one's partner, but I will tell you that from my experience,

Partners are so relieved that the woman who is bringing this conversation to them wants to have the conversation because it's often an unspoken elephant in the room. And sometimes all you need to say is, you know, I'm really struggling with my sexuality. Can we talk about it?

Ange takes on a kind of novel approach when talking to her partner about what is going on with her body. I kind of invent a character for my vagina. Yeah. Just to keep the mood light.

Because I'm like, oh, she's just being difficult. You know, I refer to her as a she. Yeah. And that sort of, for me, allows me to be playful with it, which makes it more comfortable for me, which is a bit silly, but it works. Does she have a name? Nah. She. She. And so that allows me to kind of reduce the awkwardness that I feel. Yeah.

And I think for me, it's sort of like, well, it's her problem. It's not me that doesn't want you. It's just she's being a real bitch today. It's amazing that we can communicate in the way that we do. And we also laugh a lot in bed, which is great. Like I just go to him, well, she's not cooperating this morning.

Siobhan, our increasingly less horny lead guitarist, has made some changes to her sexual routine to try to make things more comfortable. Things aren't as juicy as they used to be down there anymore and I usually find myself preferring to use lubricant. It can definitely take all the spontaneity out of things, that's for sure.

Siobhan's also started taking menopausal hormone therapy, or MHT, in the hope that it might turn up the volume on her fading desire.

I just wanted to feel like my old minxie self again, you know, and two months in and I'd say it has improved a little, but definitely not as much as I had hoped. Just to be clear, MHT is different to the localised treatments we talked about earlier. MHT might be a patch on your arm or medication you take and it goes through your whole bloodstream.

Siobhan is going back to the doctors to talk about other options. And you know what? In the meantime, she kind of got revisited by her old horny self once again. Yesterday I was driving home and I felt horny for the first time in ages. At first I was like, why am I thinking about sexing my husband when I get home? And the more I thought about it, the more I was certain I was back.

The feelings I hadn't felt uncoaxed for so long. Oh, it was so awesome. And my poor husband, he just doesn't know what's going on, but he's loving it. And she's dirty that perimenopause is getting in the way of her hot resurgent sex life is not taking things lying down.

She and her fella know the importance of the vibe. Sometimes, you know, that means that we'll use a toy and then that does help get the blood flowing and then after that it's amazing and it's like what it was before all this sort of started happening. On top of making sure there's plenty of stimulation, Ange noticed an improvement in her symptoms after she started taking the estrogen gel.

Oh, yeah. So it sort of did... I don't know if this is a crass way to put it, so forgive me if it is, but did it help kind of juice-ify? Yep. Yep. Yeah. You didn't even let me finish it. I'm sorry, I'll stop. No, I liked it. But it helped re-juice-ify your vagina. Yeah. Yeah, okay. Yeah. So a lot more lubricated, you know. Yeah. It was...

It almost was just like, sort of like when you are ovulating, when you do get that kind of quite sticky egg white sort of consistency, it felt a little bit like that. Right. And that was awesome. Yeah, okay. You felt like you were back. The first time I started taking it within, you know, about a week and a half, it felt like...

I was back to the level of before. Oh, great. Yeah. And so it's not so amazing now. So it's probably something that I have to review with my doctor. Yeah, yeah. So what would your advice be to listeners who are approaching this age about, I guess, getting information and looking after yourself? You need to take ownership of what's happening for you. And if you...

don't get the answers that you feel are right. There's something in that. And just keep pushing until you do feel that you've got what you need, because it does sometimes feel like either a process of elimination or you feel like I have got this bit sorted and then something else crops up. But I guess if your gut's telling you that whatever solution you've got isn't working, keep asking.

Look, change is scary and none of us like it, unless it's the kind of change where someone says, hey, guess what, all your enemies are dead. But Professor Kingsberg says that it's important not to lose sight of what can be a glorious future, full of My Little Pony T-shirts, no enemies and lots of hot sex.

Sex as you age can be amazing. You're no longer chasing after some youthful image of what should be, and you can settle into what you want to be.

And as you know your body better, I think that we can have better sex as we are aging. And I can speak from experience. It can get better. And I think that women should be given a different message that sexuality as they age may require change, but change can be better. Change absolutely can be better.

There's this boring cliche that as we get older, we don't want or need sex. But listening to your stories, for most women, that's simply not true. Sex will change, yes, but it can still be a source of great joy and a central part of our lives.

One of the best things about going on this perimenopause world tour with you all is that I'm learning heaps along the way too. Something that keeps coming up again and again in this mini series, and actually, you know what, whenever we talk about women's health, is the importance of finding a GP that you trust and that you feel comfortable talking to. If your doctor starts backing out the door looking alarmed at the mere mention of sex, then maybe they're not the right one for you.

Speaking of doctors, there's heaps of medical options if you are experiencing pain and discomfort associated with GSM. There's tablets, creams and rings that can be inserted into the vagina which deliver hormone therapy locally.

If your sex drive seems to be on permanent vacation, Professor Sheryl's advice is don't wait for it to show up again because it may not have booked a return ticket. If you want sex to happen, you've got to plan for it. Look, it doesn't sound that sexy, but we plan for other fun things in life, right? So why not this?

And if you're having issues, talk about it with your partner, with your girlfriends, with your doctor and find some solutions. And if you are feeling a little embarrassed, take a leaf out of Ange's book and create a character for your vulva. I think I'm going to call mine Venus. Full name, Mrs Venus Flytrap. LAUGHTER

This podcast was produced on the lands of the Gundungurra and Gadigal peoples. Ladies We Need To Talk is mixed by Anne-Marie de Bettencourt. It's produced by Elsa Silberstein. Supervising producer is Tamar Kranswick. And our executive producer is Alex Lolbach. This series was created by Claudine Ryan.