Low Libido in Perimenopause and Menopause: The 4 Biochemical Pathways Behind Low Sex Drive (and How to Rebuild Intimacy)

So what happens when you've lost that loving feeling? All right. This is an intimate conversation today about the loss of sexual desire in women in that perimenopause and menopause transition. It's not just a sex talk. It's about the biochemistry, really. And it's also about preserving marriage and preserving couples and partnership. And, you know, it's a— you're not broken talk. Right. I'm going to borrow those words from Dr. Kelly Casperson in her fabulous book, You're Not Broken. We're going to talk about today is, is what's really happening in your body. And because the reality is most women experience a loss of sexual desire during the perimenopause and menopause transition, and they often think something's wrong with them and the relationship. And even more importantly, their partners may not understand what they're going through. And, you know, if they have a good partner that is aware, that helps. But a lot of, a lot of partners, particularly if you're in a heterosexual relationship, they just don't understand. And, you know, Kelly Casperson says this all the time, but I would say this is true, too. You know, what was the golden moment for her is she's a urologist and she was prescribing testosterone for men all the time. And there was a woman that showed up in her office and her husband had just been given testosterone therapy. And she's like, what am I supposed to do? My husband has the desire of an 18-year-old. And she's crying, right? She's crying. So here's the thing. Kelly Casper— Casperson experienced that. All of our practitioners for the last 21 years have experienced that. All of our practitioners online. For a lot of women, this is the quiet thing we say in the room. Right before we walk out the door. It's when we put our hand on the, on the handle, and we're like, oh, and I need to say this. And so we have to understand that it's not just about you. It's not your relationship. You're not broken. All of that chemistry is changing in your body. And the other things that are going on in your world also just exacerbate that. And this is a shift in your biochemical pathways. It's not willpower. It's not emotional. It's not— it's of it. It's hormonal, it's vascular, it's neurological. And understanding this helps us reframe it, understand it, get a handle on it, and get a sex life back and an intimacy life back that you and your partner desire. You know, here's the other thing too. I want to say this because I'm talking about women, but men have a slow decline in testosterone and, and may also experience a lack of desire at different times. You know what, they also sometimes feel like their body is changing and they don't understand it. Or maybe they're starting to experience things with erectile dysfunction and other physiological changes because of changes in blood flow and nitric oxide that also affect them. But I think really, once we understand our own body and our biochemistry, it makes it easier to have these conversations because sometimes they can be really confronting. Because it's not something that we're often taught how to talk about. So here's the other thing is this, this episode is going to have some very frank discussions about sexual health, orgasm, intimacy, your sexual anatomy that's medically informed, not explicit. But I just wanted to be aware that we're going to have kind of an adult conversation here for a few minutes. And so, you know, again, let's, let's look at it this way. So let's talk specifically now about the The Biochemistry of Desire, and there's 4 pathways that really matter. So, sex— sexual desire is not just one thing. It's not just about being in the mood. It's a complex orchestration of hormones, neurotransmitters, blood flow, and neurological activation. And, in perimenopause and menopause, the 4 pathways shift simultaneously and often a little bit off sync. Right. So let's talk about pathway 1. This is the one most people talk about. It's the one most clinicians attach to, and it's the one that everybody sort of thinks about. And that's testosterone and sexual motivation. So testosterone is the hormone of sexual desire in men and women, not estrogen. Right. Estrogen plays a role, but it's much less, much less than testosterone. Women, we have less testosterone than men. And, we're talking about 15 to 70 nanograms to up to about 82 nanograms per deciliter while men have 300 to 1,000. So, I just need you to put some math to that. So, if our high end is under 100 and men's low end is 300, put that to perspective, right? We never have the same sexual desire because one of the things I hear all the time too is men will say if I'm— you know, talking to a partner or whatever, they'll say, you know, she just never initiates it. And I'm like, our sexual motivation is like a tenth of yours. You know, so we have to remember that. But the main driver of motivation is testosterone. And it drives this impulse to initiate sexual activity. Now, the other thing I like to talk about here is sexual impulse and intimacy and motivation is also what is experienced between the ears. And so, your lifestyle situations, which we're going to talk about in a minute, and all those other things play a role, but testosterone's action is primarily in the brain. And, it creates this sexual incentive salience, right? That's the scientific term for it, the ability to notice and be attracted to sexual stimuli, right? So, when it's not working in the brain, you're like, "Eh." don't really care, right? Now, here's the problem. Our testosterone starts declining in our 20s. It doesn't have the wild ride like perimenopause and menopause, but it does decline. And so, by the time you get into perimenopause, that starts to accelerate, and women lose about 30 to 40% of their baseline testosterone during this transition. Now, relative to your estrogen in menopause, you have more testosterone, but both are basically low. Right? So, that argument that testosterone is higher than estrogen, well, pardon me, no shit. It's because the ovaries aren't making estrogen, but your overall levels of testosterone and estrogen are both low at that point. Alright. So, testosterone, sexual motivation. Now, estrogen and vaginal health and the physical foundation. So, estrogen doesn't create desire directly, but it creates the physical capacity for pleasure. It maintains healthy elasticity of the vaginal tissue and vaginal blood flow. It helps with mucus production and the thickness of the vaginal lining. It also regulates the pH and lubrication. That's why vaginal estrogen is so important to women in reducing the risk of UTIs and yeast infections. Radically important. Every woman should be on vaginal estrogen all the time. All the time if you're in menopause. Now, here's what happens to a woman. A woman tries to have sex. It's uncomfortable, so she avoids it. Sandpaper is usually the word and the term that's used, and the partner feels rejected. Who wouldn't? You know, I'm trying to be intimate. I'm probably being very, very, very vulnerable because probably sexual interest and, and intimacy in any level is the greatest form of vulnerability that we can have with another human being. She feels guilty and pressured. He, if it's a heterosexual relationship, now feels jilted and doesn't quite understand. And sexual desire, which was already dampened by low testosterone, gets completely extinguished by this experience of discomfort and pain. Right. And so this becomes a sort of toxic soup of people kind of going, well, you know, it's been 6 months, a year, 2, 3, 4 years since the last time I had sexual activity with a partner that I love. Right? Now, let's talk about dopamine and sexual reward. So, dopamine is a neurotransmitter of motivation and specifically reward. It's the anticipation of reward that motivates with dopamine. And, it makes you want something because it makes you feel good when you get it. And, estrogen regulates dopamine signaling and testosterone does too, particularly around sexual desire and pleasure. So, when your testosterone drops, dopamine signaling gets disrupted. When your estrogen drops, dopamine signaling gets disrupted. Sex stops feeling rewarding. And then when you do engage in it, the pleasure is kind of like, eh, like I always say, it's kind of like watching paint dry, right? Like, you know, if you're talking to a woman, she's like, eh, you take it or leave it, right? It's because all of that biochemistry is being dampened. Your brain isn't getting the same neurochemical signal that it got before.. And so, you're less motivated to seek it out, and especially if you have to initiate it, oh, hell no, right? Now, pathway number 4 is also really important here, and this is often showing up before you get into perimenopause, right? I have a lot of women that I've met in their late 20s, early 30s, mid-30s, even early 40s, everything seems pretty normal, but they're just not interested. And, it's cortisol and the stress override. This one gets overlooked. And, when your cortisol is elevated, right, just because you're living your life like an American, right, we have a screwed-up lifestyle here, our cortisol dysregulation becomes common and consistent. And, the body is basically perceiving a threat. Your body cannot tell the difference between you running across the Serengeti trying to save yourself or starving to death or the fact that you're on the 15th Zoom that day. It does not know the difference from that chemistry. Your parasympathetic, your rest and restore nervous system is the one that's responsible for sex, sexual desire, sexual arousal. That— it took a nosedive. It's history, right? You can't be aroused when your nervous system is in this constant state of activation and maybe fight or flight, but most of the time, it's this kind of chronicity of activation. And you physically cannot. The body's in survival mode. And it's not pleasurable, and it's— you're not sleeping well, you're not enjoying it. And all of those things become very true in perimenopause and menopause because you're losing the hormones that help drive sleep, relaxation, and restore. So sleep helps you raise your androgen levels and recover. Your androgens help recover from your excess cortisol, and your androgens are DHEA sulfate, testosterone, and the other androgens.. And if they're already nosediving, you're kind of shit outta luck, right? So we have to also understand that those 4 mechanisms are all at play, some of which are at play earlier, but they all show up dysregulated in perimenopause and menopause. All right. So let's talk a little bit about that neurobiology of desire, because this is your brain. And we have to understand that the brain is kind of on an off switch at the moment. So sexual desire happens in the brain. Before anywhere else, right? In perimenopause and menopause, multiple brain regions have been affected. The prefrontal cortex, so if you've heard me talk before, that's the little executive function in the front of the brain. It's the part that initiates sexual interest. You know, you look over and you're like, "Hey, hey, hey, how you doing?" Right? And it thinks, "Eh, that sounds nice." That's the plan for intimacy, right? It loses power when estrogen declines. And the amygdala— this is the, the threat detector— it becomes hyperactive. Right now, here's something else you need to understand, moms out there. If you had a baby, your brain rewires to the amygdala while you're pregnant. And the reason why is you need to be ready for fight or flight, and you need to save that baby. So a lot of, a lot of moms are like, I have baby brain, and then I seem like I sleep lightly. I'm constantly on surveillance. So our brain actually starts to do that. So the amygdala gets fired up, but in perimenopause and menopause, it does too. So your threat environment goes higher. You're more reactive to your stressors. You're more prone to anxiety, and you're less able to slip into a pleasurable mode. The hypothalamus, which regulates sexual function and sexual response and stress response, is flooded. It's hugely packed with estrogen receptors. And so, when that estrogen starts to decline, that region gets disrupted and your thermostat goes haywire, right? So, the hypothalamus is your thermostat, right? So, all of a sudden, you're hot all the time, right? You're sweaty. You're having hot flashes. Your arousal system goes haywire with it. And then, the other hormone that doesn't really get talked about a lot, it's oxytocin. It's our bonding hormone. Oxytocin makes you feel close and connected to your partner. It relies on healthy estrogen levels. With low estrogen, oxytocin signaling gets dampened and you feel less connected, less inclined towards physical affection, less driven to intimacy. And oxytocin is often low in our partners if we're in a heterosexual environment. So if you're with somebody who is male, right, they often have blunting of their oxytocin as well. So you're both basically like, oh, we can sit next to each other and hang out and we're cool right here, just sort of hanging out. I love you. I love you. But never do the two meet. Right. So that those are the places in the bio— biochemistry of desire. The oxytocin, the prefrontal cortex, the amygdala, and the hypothalamus are the main ones that go haywire here. Now, physical changes. Right. So I talked a little bit about sandpaper sex, but let's talk about what's really happening here. Okay, so estrogen maintains these, what they call stratified squamous epithelium. That's this thick, heavy tissue that lines the vagina, right? Makes it protected. When our estrogen drops, it gets super thin, like paper thin. So, here's the way I think about it. You remember— okay, I'm gonna talk about my hands for a minute. Remember when you were young and the skin on your hands was super soft and it was kind of spongy? Like it had a fatty layer underneath. There was no wrinkles.. It was just always like really pretty and pristine. And then think to maybe an older woman in her 80s, and you look at their hand and their skin is paper thin. Like if you bump them, they bruise. All right. That's happening inside your vagina, right? Without estrogen, that plump, healthy tissue gets really, really thin and it atrophies and it becomes easy to rip and tear and loses all of its, all of its lubrication. So it's also dry. So any activity there causes tearing and fragile skin or fragile epithelium, and it loses even glycogen, which makes the bacteria, the lactobacilli that are supposed to hang out there, and the pH of the vagina change. So all of a sudden, you're more prone to yeast infections and bladder infections, right? And the bacteria take over, and so it becomes more common. The blood flow to the vulva, which is the area outside, right, the parts that you can see, and the vagina, which is the part inside, that you can't really see unless you're like using a mirror. All of that, the blood flow goes down, right? Those are all sexual desire areas, right? The clitoris is part of that too. But, but all the entire area, erogenous zones are all part of sexual desire and sexual experience. And when it loses blood flow, we don't get as much experience, right? And we get less of the swelling of the genital tissues, which is what sort of helps lubrication and helps the intensity of activity. And the vaginal opening becomes less elastic, right? So, things like deep penetration and, and more rigorous sexual activity can become quite painful. And here's something that no one talks about. The nerves in the genital tissue are sensitive to estrogen. And when that estrogen levels drop, we have less nerve signaling, and some women report that even touch that used to be pleasurable before, before is not. And it may feel numb or uncomfortable, or the sensation's gone. It's that it's really changed, right? It's not gone, but it's changed. And it's often the way that makes sex less pleasurable. And if we can get those sensations back together and get the physiology of the tissue back together, it helps make everything better. Now, Let's talk about stress and sleep connection and the rest of your life skills for your sex life, right? So here's, here's the important thing. So I love talking to men. I tell them all the time, I can do dude, right? I can talk dude with you. And so one of the jokes I always make with them, but it's not really a joke, I mean it, is I'm like, look, man, if you sit down next to your wife at 10 o'clock at night and you're like, bam, and you start reaching over and you do kind of the titty massage, or you kind of rub up against their arm. That late at night, we have zero interest. We're exhausted. We're— all we want to do is sleep, right? And but the reality is, is you have a hard time removing sexual desire and sleep and stress. All those things are together. And most of the time, we're in the dark, and we can be a little bit vulnerable. And that's when we feel vulnerable. For a man, that's often where the desire shows up. And for a woman, they're like, please, God, let this day end. Right? We're in these two different things. So, when you're stressed and in perimenopause and your hormones are all over the place, or you're in menopause and they're now flat, stress is almost universal. And, our sympathetic nervous system is activated. And, that's that fight or flight or that chronicity of your stress response. Sexual arousal is almost physically impossible and your body is kind of in threat mode, you know, and you're like, "I just want to pass out," right? So, sleep, Good deep sleep is foundational to sexual desire. When we have poor sleep, it deprives our body of testosterone production, right? Remember, testosterone is really important to sexual activation, right? And it elevates cortisol. So, poor sleep, cortisol up, testosterone nosedive, growth hormones also nosediving, and it disrupts your dopamine signaling. So, all of these things come together as a sort of chronic kind of activation, and it changes everything. And then that changes the blood flow to the genitals, and it literally impairs your body to become aroused. So your man, if you're in a heterosexual relationship, is over there like really wanting to be intimate, and you're like, damn, damn, you know? And it's true right now. In perimenopause, we don't sleep well often because all the things going on, and hot flashes and night sweats could be part of it. And so, when we're chronically sleep deprived, that makes it worse. But, here's a little biochemistry for you, and this is why I continue this conversation with the men. Alright, women who get a chance particularly to sleep in, if you ever see that, if it's one of those unique days where you get to sleep in a little bit or just get good quality sleep, our testosterone is highest in the morning. Our testosterone is highest in the morning. So, our most likely time for arousal is actually in the morning. Now, I wouldn't say it's in the morning when you have a meeting at 8:00 AM and you have to get the kids school by 7:30 and you have to drop off the dry cleaning, you know what I mean? Like, it can't be, I gotta fit that in in between meetings and getting the kids to school, right? We have to be legitimate about this. But the reality is women are more likely to be aroused and be open to it when they're in a relaxed, comfortable environment, when they might have a few minutes. Now, the other thing I gotta say is depending on where your kids are in this world— now, many people my age, you know, they're empty nesters, you can do whatever you want whenever you want— but other people might have kids that they have to take to school or parents or whatever. You might have to plan this thing like a lunch date, right? Right before the day gets crazy, before somebody takes your time away from you. You have to make it work. But chances are the kind of ways that we sort of fell together in our 20s is harder to do today because our lives are not the same as what it was when we just met each other and our hormones were raging and we would have touched each other everywhere and anywhere all the time because life was a lot easier back then, let's face it. Right? This is where all of these things come together. And often, if we don't have the language, right? We don't have the language, we don't have the physiology, we don't have the explanation of the chemistry. And it's such a highly charged conversation. It's an emotional and vulnerable conversation. This is often where partners start to feel rejected and misunderstood and communication starts to break down. Even in the most open and friendly and loving of partners, because we have to get really vulnerable and talk about things that we've never talked about before. I don't know about you, but my parents didn't talk about sex. I remember my mom said she started bringing up the birds and the bees, and I had already learned about it. Older brother, also thank God for health class. And I asked her what she wanted to know. Right? I was like, at that point, I already knew it all because I'd heard it through like the grapevine and everything else. We don't have good conversations. Around it. And it's not just about not getting pregnant. And, you know, all the things that we sort of do, we need to have conversations about how to have good sex. Like, what does it mean? What does it mean to have a really great sexual life? Right. So it's not weird to get here and be like, oh my God, I can't talk to the person I love the most about this. Right. So this is the relationship impact, right? When it's not really about your partner. Many women, you know, have told me over the years that loss of the sexual desire has damaged their relationships. And I want to be clear about this. This is not your fault. And it's not your partner's fault either. It's that biological shift. You're having a very big biological shift. They are too. Their testosterone may be declining. Their blood flow may be declining. They may feel like a stranger in their own body. They may feel like they're getting a little bit over the hill, right? Or things are changing and they don't like it. And they aren't the same guy they were 20 years ago. Like, all of those things are true. And we have to interpret low desire and low understanding that it's not rejection, right? Because men often say, well, she doesn't find me attractive anymore. And the truth is, she doesn't find anyone attractive right now, honestly. You know, she doesn't even think about it, right? A man at 55 has more estrogen in his body than a woman at 55 that's gone through menopause. Right? We don't even think about it. We're blasted back to pre-puberty, right? It doesn't even occur to us. And, and the other part is all these other pieces that I've talked about has changed it, right? So we don't have access to the same neurochemistry we had before. And the experience of desire is different. It's not personal, right? And this is where, like, the radical honesty really comes in. We have to be able to talk about it. And truthfully, a lot of the times, ladies, We're the ones that can have initiate those conversations because we're usually the one often being vulnerable first, right? You have to be able to say, hey, my hormones are shifting, I'm working on it, right? And then involve them, help them understand the solution. I think one of the most powerful things you can do is have your partner go with you to a medical, a medical appointment so they understand. That's, of course, only if you found one that's actually going to listen to you, not gaslight you, and is your partner. And is helping you improve things, not just judging, right? We have to just assume that we have that. But it helps to have them in the room so they understand what's going on. You know what often happens then too? They start to open up about what's going on with them. Because guess what? Men's hormones decline too. Often their testosterone is half of what it was when they were 20. And testosterone levels today are lower than what they were 50, 60 years ago, probably because environmental things, more body fat, less activity, all of those things, you know. So men feel it too. And so we have to be able to involve them in the solution. And we have to understand that it's not permanent either. It's a phase. And often it can get better. But here's the thing I can tell you. You got to use it. We got to use our body parts. So the other part is, is really if we want to have a good intimate life that has sex as part of that intimacy, because sex and intimacy are not the exact same thing. Sex is sex, intercourse, you know, cunnilingus, all those things. Intimacy, sex is a part of, right? But if I want sex as part of my life, I have to work on it. I can't just go, okay, 10 years from now or 5 years from now, I'm going to engage in it again, right? Those organs, those desires, those other things help when we get the physiology on board, replacing hormones, all the other things. But we have to engage in sexual activity. And sometimes that means bringing toys into the game. Sometimes that means bringing vibrators and lubricants in. Those are not signs that you're not a good partner. Those are not signs that sex is worse than it was. Those are just things to enhance the pleasure and the experience. And I think that's the other thing. Unless you were highly, like, adventurous when you were younger, that can also be perceived as problematic. Like, oh my God, we're bringing lube and all these other toys into the game. I've never done that before. What does that mean about me or you? It just means we have to use different tools, right? Just like we might have to use different tools on a car that's 40 years old, 50 years old than a brand new car, right? Brand new car has a lot of computers. You can still work on a 19— you know, '65 Mustang with a couple tools, right? It's because it's an older car. It needs a different set of tools. And it's okay, right? But we have to, you know, start looking at it that way. And a lot of times pivoting to a different form of intimacy can help. Touch that isn't goal or sex-oriented, right? Because a lot of times that's the connection. I know when I talk to men, they'll be like, if I kiss, then I touch, then it's sex, right? Because that's how they were trained, right? We have to understand that's kind of how it's perceived. It's how it's presented to us. But we could massage, we could hold hands, we could cuddle, we could kiss without ever going into a sexual experience. It doesn't have to be goal-oriented, right? It doesn't have to. It's about bringing the emotions and the physical touch together because we are animals that require physical touch. If we were— if we didn't have language and all the cool little toys we would have, we would pile up on each other just like puppies, right? We are a physical being that requires physical closeness, whether you think so or not. And it helps when both people feel less pressured and more connected in general. So those other intimate acts can really help. All right. So let's talk about some 5 strategies. What are your 5 strategies to bring back that lovin' feelin', right? Okay. So, fix your sleep. This is non-negotiable. We got to get dialed in. If you're not having restorative sleep, you're not going to feel sexy and you're not going to have the same sexual experience, right? You're gonna— it's one of the most impactful suppressors of libido, right? So, we need 7 to 9 hours. If you can't sleep because of perimenopause, it's time to look at hormones and get it fixed. If you've got breathing difficulties, airway, other things, get it fixed. This is time to really help that. Probably one of the most powerful things you could do for your longevity and your health through your longevity is get your sleep fixed. Right? And we got to address it, the hot flashes, night sweats, whatever may be upsetting your sleep. Because when you sleep deeply, testosterone production normalizes, your cortisol resets, your nervous system comes down into parasympathetic drive. We can also do some targeted supplementation, things like magnesium glycinate that can help you sort of downregulate, or adaptogens like ashwagandha, and, and also things like L-theanine and progesterone. Progesterone is probably one of the most powerful things here for women, is because it helps get GABA on board. And so GABA helps drop your core body temperature so you can get into deep sleep and starts to support long sleep. And then estrogen also helps you support staying asleep. And so hormone replacement therapy is really important. So number one, start working on your sleep because you won't feel like it regardless of what else you're doing. Number 2, optimize your hormones, right? I— this is, this is really, really valuable. We've already talked a lot, so if this is your first time listening to my podcast, I talk a lot about hormone replacement to reduce your risk of diseases of aging like Alzheimer's, heart disease, stroke, vascular disease, osteoporosis. But the reality is hormone replacement therapy also has a gigantic impact of quality of life. I don't know about you, but quality of life is as important as length of life to me. I don't want to live a long life and have a really crappy, shitty life. I want to feel great and have a long life, and I want those two to correlate and ride together. And hormone replacement therapy with bioidentical progesterone, estrogen, and testosterone helps. And bioidentical just means it looks exactly like the chemistry your body made it. It's synthesized in a lab, yes, but it's chemically exactly like what your body does. Estrogen restores vaginal health, and often that may mean using a topical estrogen on your body, like a cream, oil, patch, or injectable. And vaginal estrogen may also be necessary just to protect the tissues locally, but vaginal estrogen doesn't work systemically. But what does happen when I have both dialed in is I get blood flow, I optimize dopamine signaling, and I regulate the stress response. And then progesterone helps with sleep and anxiety. Testosterone drives sexual motivation and desire and orgasm support. All of those things make sex more pleasurable. And it's important that it's personalized, right? It's not a one-size-fits-all. It'd be awesome if it was. It'd be super easy. But your dose depends on you and your biochemistry. And so, you want to make sure that you're working with a clinician who understands that. Willy-nilly taking hormones and not really knowing if it's right for you, you may not get the results you deserve. Now, strategy number 3, address stress and activate your parasympathetic nervous system. So parasympathetic is rest, restore. Stress is stress, that's sympathetic. You can't be aroused in that sympathetic drive. And so, you have to work towards activating your relaxation. So, this is doing things that help lower your cortisol. This might be owning your no. One of the most powerful things you can do is own your boundary and actually enforce it. Especially your boundary with yourself. So that means like saying yes to something you didn't want to do. Today's the day, right? You start saying no. The other thing is doing things like meditation, breathwork, yoga, deep breathing, time in nature, right? Nature bathing, woodland bathing, forest bathing. This stuff is real, right? Our bodies respond. We're supposed to be in nature. So even doing that, significantly reducing your workload, right? Or stress if possible. Like I said, when my mom had her heart attack and stroke and my husband was hurt, you know, and couldn't, like, literally couldn't walk without crutches, and I still had to run my clinic, I still had patients at the time, I had, I was defending my dissertation at the same time, I couldn't turn any of those things off. So sometimes we have to go, okay, I can't reduce the workload, but I can definitely reduce the things that I say yes to outside of that. You know, so no, I wasn't going to take on extra responsibility for something else, right? So that's important, right? And it also means creating conditions for intimacy, right? I kind of joked about this, but it's real. Like, some couples feel that removing expectation of any sexual activity helps a lot, right? Finding time, put it on your damn schedule. You don't have to say exactly what it is. You don't have to say booty call. Find a time where you're both going to be there, where there's not going to be other things in your way. No cell phones, no text messages, no Zooms, all those things, because that takes away the stressors. And if you go into it saying, hey, we're just going to have some time with intimacy without sex at all, no penetration, right, that removes the performative side of it, right, the expectation of performance. And you can focus on sensual touch, massage, emotional connection, without any goals. And this automatically usually builds desire over time. Alright, number 4, restore vaginal health. You can't have a good sex life when it feels like sandpaper, right? Systemic hormones address the underlying hormonal deficiency. Low-dose vaginal estrogen restores the tissue, which increases blood flow, restores lubrication, and the kind of fleshiness of it, and supports the elasticity of the vaginal tissue. And we get better sensation and sexual response returns, orgasm returns. Pelvic floor therapy can also help here. This helps if women have had pelvic floor tension or in anticipation of pain, right? If you know it's going to be painful, your pelvic floor will tighten up. We call it kind of the pucker factor, right? And that make— can make it more painful, right? You could also need pelvic floor therapy if you've got damage from childbirth, right? Those things are real. Because if you've already got stuff there and we've added tension to it, it makes it very hard to have a good sexual experience. All right. Number 5, create conditions for pleasure, intentional intimacy practices. Right. So this is about rebuilding the sexual self-concept around reconnecting with pleasure. And many women have disconnected from this. Right. We just kind of like, okay, forget that because I've had discomfort for a long time. Or maybe I had, you know, sex was just fine, but I didn't like what my body was up to. Like, it didn't feel like me anymore. There could be a multitude of reasons. So you have to spend time with your own body, right? So lots of women, myself included, you know, I remember taking some pictures one day for my husband. I'm going to be really honest. I put on like a little like lingerie-like thing, probably hadn't done that in 20 years. And I took about 100 pictures. Only about 2 of them did I like. I'm just being really honest. I put on I put my camera on a tripod. I took a bunch of pictures and then I showed them to my husband the next day. It wasn't for him, it was for me, right? And yeah, 98 of those pictures I thought were terrible, but you'll find 1 or 2 that you like. It's not for him, it's for you. It's for you to reconnect with your body, right? It's for you to see your beauty in you. We pride youth in our culture, but I can tell you the brilliance and beauty of a woman who has been through some stuff is by far more beautiful, right? Youth is always fleeting, but wisdom and, and, and compassion and all the other things that women have is by far more beautiful. We just have to remove ourselves from that and appreciate ourselves first. And the other thing is masturbation, right? It's getting to know where your body is and touching yourself, because how are you there to help somebody else understand how to touch you if you yourself don't do it, right? So it sounds very scary for a lot of women. They're like, I don't do that, right? This would be the time to sort of explore your body to see what feels good, because you can't expect somebody else, your partner, to kind of guess their way through that. That's like, hey, we're going to send you out in a starship and you go figure out if you can find Mars. We have no nav, right? Don't make somebody do that. That's not fair, right? So help, help by helping yourself. Because the other thing is, is you use it or you lose it, right? So that means you need to participate also. And then we have to learn how to openly communicate with our partner. And it's hard, right? I'm obviously super talkative. I don't have much of a filter, but I can tell you, I have a filter with my husband because I love him, you know, and it's, and it's much more intimate. It's oddly enough, not intimate to get on here and just talk about stuff, but it's much more intimate to have a conversation directly with my husband.. And so you have to be real about that and create safe, non-pressured environments for you to have a sexual discussion. And if, if the certain activities are uncomfortable, you need to help bring that up so they understand. And then as your hormone replacement, everything else improves, then it might improve. So if you're having painful sex right now, as you fix things, it starts to go away. Right. And then be present with yourself, right? So sexual desire often returns as other symptoms improve, right? We sleep better, our stress gets better, our hormones are optimized. And it's not like a light switch, right? We come to a slow boil, right? We don't just wake up boiling hot, right? So we have to understand that and we have to gradually rebuild that. And that's okay. You know, and here's the other thing, too. You know, I've had people go, well, do I have to have sexual experiences? Do I need those things? No, not really. But what I can tell you is universally the majority of women and men would love to have that. Because here's the thing, we— so in our culture, we don't like appetite, right? The word appetite, like, is almost synonymous with weight gain. So I'm talking about food right now. So you say, oh, I've got an extraordinary appetite. Like people all the time, I was like, I need an appetite suppressant, I don't want to have an appetite. Look at the GLP-1 and GIPs, right? What does it do? Makes you disinterested in food, right? Appetite is lots of things. Appetite for food, appetite for excitement, appetite for adventure, fun, joy, appetite for intimacy, appetite for sexual pleasure, appetite for connection and love. We have an appetite for all those things. And I would argue that sexual activity, even minus a partner, right? I can tell you with my girlfriends, we joke all the time because the reality is a good, a good power tool and some lube pretty much can knock out a feel good within a few minutes for most women because we often know how our body feels, right? And so we often have that desire and we often have that appetite. So feed the appetite first for yourself, then help your partner do it with you. So again, I've seen so many women that have had a sex life that, you know, was great before, and now they're like, ah, but here's the thing. It's also understanding that we don't need to fake it. This is not a fake it till you make it kind of game. It's not about performance. It's about understanding how your body is, and it's changing in very predictable ways. And that you have ways in which you can address it. And that if you're ready to like think about that, it's okay to think about that. And it's time. And if that's the only thing that you're upset about, maybe the rest of your menopause and perimenopausal symptoms are fine. Cool. Cool. That's easier to fix, right? The more issues we have, the laundry list that's longer, maybe harder to fix, right? So here's the thing. Think about that part of your body and that part of your experience. As being a really important part of zest for life, right? Zest for life. That's how I look at it. And that's how I want everybody to understand that your body's doing the normal thing. And the normal thing is not the optimal thing because in 1900, we would only lived a couple years after this. It wouldn't have mattered. But I don't know about you. I don't want to do 30 years without intimacy and sexual appetite. Alright, so if this gave you a good piece of understanding about the complex biochemistry of sexual health during perimenopause and menopause, not just the hormones, but like what's really happening, thanks. I'm glad that you listened. And if you have a friend that has been talking about this kind of quietly, or a partner that maybe doesn't understand what's going on, share this episode with them, right? Rent a stranger. That's what I always do. Rent a stranger. They get to have the intimate and awkward conversations that are hard to have, right? I'll be your stranger today. All right. So thank you for listening to Menopause Mastery. I hope that this helped you have a much better sex life, and I'll be back with you next week.