The Sexual Wellness Conversation Women Over 40 Deserve

One thing people are not talking about is the sexual satisfaction of middle-aged women. If I were running for president, that would be my platform. (Dr. Cat 2030 — lol, just saying 😂)

Women's pleasure has been a taboo issue since the dawn of time, but in the most recent decades, male pleasure has been front and center. You might remember that presidential candidate Bob Dole was seen championing medication for men — namely Viagra, 30 years ago — to maintain erections. At the time, it was a bit hush-hush. Of course, many jokes have flown around about the power of the Little Blue Pill — all the while the sexual wellness and fulfillment of women has remained suspiciously silent.

For women of a certain age, even OB-GYNs don't ask, "How is your libido?" Research published in the Journal of Sexual Medicine found that only about 40% of OB-GYNs routinely ask patients about sexual problems — and even fewer ask about specifics like desire, pain, or satisfaction. That silence speaks volumes.

The Complicated Truth About Women and Sex

For women, the issue of sex is a complicated one. Starting with the hard truth that many women report being sexually assaulted in their lives — and report outright rape. So our connection to sharing our bodies, and sexuality itself, can be fractured from the get-go.

Adding to this: if you're a woman of a certain age, perhaps you've procreated, you've shared your body with a fetus, you've nursed, and if you have multiple children, perhaps those children have been on top of you, touching you, needing you — so the idea of sharing one's body with a partner sexually can become hard. I have heard clients say, "I cannot have one more person touch my body!" and "I am too exhausted for sex." This is what I hear from women in their reproductive prime.

This issue is often pronounced for older women, but for different reasons. As estrogen drops, and testosterone too, and perhaps sleepless nights arrive courtesy of low progesterone — what is there left of a woman's libido?

For women in their 40s, 50s, and 60s who never really enjoyed sex, this may be a polite moment to introduce one's husband, if one has a husband, to the joys of masturbation. However, for women for whom sex was important — a great pleasure, a stress reliever, and a way to connect with a partner — letting it languish is a downright depressing thought, and possibly unthinkable.

The Experts Who Are Actually Talking About This

There are things that women who want to keep a sex life in play (no pun intended) will want to think about. I haven't heard a ton about this in mainstream media, but Dr. Lauren Streicher, MD, has a great podcast called The Inside Information: Menopause, Midlife and More and a Substack called Come Again, which is worth a try. She's the founding Medical Director of the Northwestern Medicine Center for Sexual Medicine and Menopause, an OB-GYN by training, and a Senior Research Fellow of the Kinsey Institute — so the sexuality of midlife women is basically her thing.

Kelly Casperson, MD, of the podcast You Are Not Broken, among many other books and resources, is a champion of hormone replacement therapy and often talks about ISSWSH — the International Society for the Study of Women's Sexual Health, an organization dedicated to the sexual health and wellness of women.

If you're looking for practitioners who take this seriously, both of these women are doing important work. I encourage you to explore their resources.

What Changes — and Why Nobody Tells You

One thing no one ever tells you: just as puberty brings visible changes — hips widening, breasts developing — menopause brings its own set of physiological shifts. The vagina changes. The labia change in anatomy and sensitivity. And of course, there's the issue of dryness.

The medical term for this constellation of changes is Genitourinary Syndrome of Menopause (GSM), and it affects the majority of postmenopausal women. It's not a failing of your body — it's biology. And there are real, evidence-based solutions.

Vaginal Estradiol: A Game-Changer Worth Knowing About

So let's talk specifics. First: vaginal estradiol. What is it, and could it help? I'm a big fan.

It works to plumb and thicken the skin inside the vagina, including the vaginal opening, the labia, and the clitoris. This topical application may also do double duty by helping with nerve sensitivity to the clitoris and the labia, while having a positive effect on urogenital issues such as urinary leakage and UTIs.

Women of a certain age are more susceptible to UTIs — and this is not your daughter's UTI that clears up quickly. UTIs in middle-aged and older women can be hugely problematic, with a lot of upsetting downstream effects.

A 2024 review in Clinical Interventions in Aging confirmed that intravaginal estrogen has a favorable safety profile with minimal systemic absorption — meaning it works locally, right where you need it. And in a significant move, the FDA removed its misleading black box warnings on hormone therapy in March 2025, acknowledging that these warnings had unnecessarily scared women and providers away from effective treatments for decades.

The Two Kinds of Lubrication Your Midlife Body Needs

Getting down to the nitty-gritty: when you're 18 and having sex, lubrication is generally not something you think about. My OB-GYN, Dr. Huma Farid, MD, who is also a professor at Harvard Medical School, says the vagina is a self-cleaning oven. I'd like to add that, at a certain age, it's not a self-lubricating one.

For the midlife vagina, there are actually two different kinds of lubrication needed, as the skin is thinner, more delicate, and possibly drier:

1. Lubrication used during sex — and it must be vibrator-compatible if you use one.
2. A daily moisturizer. As one person put it: if your face needs moisturizer at a certain age, your vagina probably does too — on the daily.

Rethinking What Sex Looks Like Now

Another thing worth considering is that the kind of sex you've had for years may need to be modified to accommodate bodily changes and stamina. Having that conversation with your partner — as awkward as it can be — seems to be genuinely important if keeping your sex life alive matters to you.

If you're looking for encouragement on this front, I'd also recommend our earlier post on pleasure as medicine in menopause — because advocating for your pleasure is advocating for your health.

What About the "Female Viagra"?

Over the counter, there is something often referred to as a woman's Viagra. It's called Addyi (flibanserin), and it's known as the little pink pill. Unlike Viagra, which works on blood flow, Addyi works on brain neurotransmitters — serotonin and dopamine — to address low desire. It was FDA-approved in 2015 for premenopausal women with hypoactive sexual desire disorder and has since been expanded to a broader group of women.

I haven't tried it myself, but I'd encourage you to do your own research and speak with your clinician about whether it might be right for you. One important note: it carries a warning about not mixing with alcohol.

Finding the Right Provider

Speaking of clinicians — it can be surprisingly hard to get to the bottom (no pun intended) of how to navigate sexual changes as you age. Many OB-GYNs are focused on the obstetrics side of the practice, where the financial incentives are clear. The interest in women's vitality and midlife sexual health may not always be their strong suit.

Look for a provider affiliated with The Menopause Society (formerly the North American Menopause Society) or ISSWSH — someone genuinely interested in helping you feel your best. The Menopause Society offers a certified practitioner directory that can help you find a provider in your area who has specific training in menopause care.

What Chinese Medicine Brings to the Table

Last but not least: as a doctor of acupuncture and Chinese herbal medicine, I'll add that Chinese herbs can help with both libido and vaginal dryness. These are not a replacement for topical applications — they would be used in addition to them.

In Chinese medicine, low libido is associated with yang deficiency — not enough fire in the body to generate the spark of desire. This can be compounded by poor sleep, whether from general midlife sleep changes or hot flashes. It's hard to imagine getting into bed hoping for anything other than a solid, uninterrupted eight hours.

A 2022 clinical study found that acupuncture significantly improved sexual desire, arousal, and overall sexual function scores in women with sexual dysfunction — and a 2025 review in the literature supports the role of complementary therapies, including traditional Chinese medicine, as part of a comprehensive approach to Genitourinary Syndrome of Menopause.

Your Sex Life Is Worth Advocating For

If any of this resonates, please talk to your practitioners. If you're not getting the answers you need, keep looking for someone else. Your sex life is worth advocating for — and so is your quality of life.

This is not a conversation anyone should have to navigate alone, and it's certainly not one that should be met with silence in your doctor's office. You deserve better — and the resources, the research, and the right providers are out there.