Midlife sexual changes are common and treatable, so start the conversation yourself

Key takeaways

• Estimates of how many women have genital and urinary symptoms after menopause run from about 27% to 84%, yet only about half have talked with a clinician about them¹.
• A 2025 guideline from three U.S. specialty groups gives low-dose vaginal estrogen a strong recommendation for dryness and painful sex, and says no evidence links it to breast cancer¹.
• In a 2021 Australian trial, 85 women got three rounds of a vaginal laser or a sham treatment, and after 12 months the laser group did no better⁷.
• In an industry-sponsored trial of women past menopause, flibanserin raised satisfying sexual events by 1.0 per four weeks, compared with 0.6 on a placebo, a gain of 0.4 by our math¹¹.
• In an Italian trial of 110 obese men with erection problems, 31% of men in a weight-loss and walking program regained normal function, compared with about 5% of men given general advice¹⁴.

In 2025, the American Urological Association (AUA) and two partner groups published a guideline on a condition many women have never heard named: genitourinary syndrome of menopause, or GSM¹. It covers the dryness, burning, bladder trouble and painful sex that can follow the drop in hormones at menopause¹.

The panel behind it found a gap that has little to do with medicine. Roughly half of people with these symptoms say they’ve talked about them with a clinician¹. Most of those who did said the clinician didn’t bring it up first¹.

Men have their own version of the silence. In the Massachusetts Male Aging Study, reported in 1994, 52% of men aged 40 to 70 had some degree of erectile dysfunction, or ED, a 2006 pharmacy review notes¹². The same review lists embarrassment and the belief that ED is just part of aging among the reasons men don’t ask for help¹².

These changes are common, and many respond to care. Some of the best-tested options are simple and low-dose, while one heavily marketed laser failed a fair test.

Dryness and pain after menopause have a medical name

GSM is the medical term for symptoms and physical changes caused by falling estrogen and androgen levels in the genital and urinary tissues¹. The guideline lists dryness, burning and irritation; urgency, frequency and pain when urinating; repeat urinary tract infections; and painful sex¹.

How common is it? The guideline’s estimates run from 13% to 87% in one section and 27% to 84% in another¹. Studies count symptoms differently, which explains much of the spread.

One feature sets GSM apart from hot flashes. Some genital symptoms, such as dryness, tend to grow more common and more intense with age instead of fading¹. The guideline calls GSM a chronic condition and says long-term treatment and follow-up may be needed¹.

The federal Office on Women’s Health (OWH) says GSM can be treated, and that treatment can also help when interest in sex shifts⁴.

Moisturizers, lubricants and vaginal hormones do different jobs

• Moisturizers are for everyday dryness. They add fluid to the vaginal lining and lower its pH, a measure of acidity¹. Compared with a placebo, they may ease dryness, though the evidence is of low certainty¹.
• Lubricants are for comfort during sex. They come in water-, silicone- or oil-based forms¹. Our companion article on sexual wellness products explains how they differ.
• Vaginal hormone treatments act on the tissue itself, as the table shows.

Option	What it is	2025 guideline rating1
Low-dose vaginal estrogen	Estrogen applied in the vagina	Strong recommendation
Vaginal DHEA (prasterone)	A hormone building block that vaginal cells turn into estradiol and testosterone	Moderate recommendation
Ospemifene	A pill that acts like estrogen in vaginal tissue	Conditional recommendation
Moisturizers or lubricants	Nonhormonal products, alone or with other treatment	Moderate recommendation
Pelvic floor physical therapy	Referral when pelvic floor muscle problems are also present	Expert opinion

The guideline also backs low-dose vaginal estrogen to cut future urinary infections in women who keep getting them, and it advises avoiding irritating cleansers¹.

Safety is where many women hesitate. Low-dose vaginal estrogen skips the liver’s first pass, and typical use leaves blood estrogen near or within the normal range for women past menopause, a December 2025 advisory from the American Urogynecologic Society (AUGS) says². The studies it cites found no significant rise in heart disease, cancer, blood clots or dementia².

The AUA panel adds that no evidence links low-dose vaginal estrogen to breast cancer, and that vaginal estrogen doesn’t raise the risk of endometrial cancer or precancer¹. It advises against routine checks of the uterine lining just because a woman uses these treatments¹. For women who have had breast cancer, it says vaginal estrogen may be an option, decided together with the cancer care team¹.

The warning label is catching up. Our article on menopause sleep covers the FDA’s November 2025 request to rewrite the boxed warnings on hormone products. For vaginal products, the agency also asked makers to shorten the safety section and focus it on vaginal use, the AUGS advisory notes².

In February 2026, The Medical Letter, an independent drug-review newsletter, reported that vaginal products’ labels will no longer carry boxed warnings about heart disease, breast cancer or possible dementia³. We couldn’t confirm which vaginal products had new labels by October 2026.

What about herbs? The guideline says the evidence doesn’t support herbal supplements, plant estrogens, vitamins or probiotics for GSM, and most of those studies were small¹.

A fair test undercut vaginal lasers

On July 30, 2018, FDA Commissioner Scott Gottlieb warned about laser and other energy-based devices sold for “vaginal rejuvenation”⁵. The FDA had cleared such devices for serious uses, such as destroying abnormal or precancerous tissue and treating genital warts. Their safety and effectiveness for rejuvenation hadn’t been established⁵.

They were being marketed for menopause symptoms, bladder leaks and sexual function, some to women who had finished breast cancer treatment⁵. The FDA wrote to seven companies⁵. It cited reports of vaginal burns, scarring, pain during sex and long-lasting pain, and urged women to report problems to MedWatch, its safety reporting program⁶.

A 2021 trial used a sham control: one group got the real treatment and the other an imitation that looks and feels similar, so hope alone can’t explain the results.

Researchers in Sydney, Australia, randomly assigned 85 women, average age 57, to three sessions of fractional carbon dioxide (CO2) laser or sham, 4 to 8 weeks apart⁷. At 12 months, symptom scores had improved in both groups, and the laser showed no advantage: overall scores fell 17.2 points with the laser and 26.6 with the sham, a gap too small to be meaningful statistically⁷. Quality of life and tissue samples showed no difference either⁷.

The study, published in JAMA, was partly funded by an Australasian gynecologic surgery society and a Sydney hospital, not a device maker⁷. The 2025 guideline now tells clinicians to counsel patients that evidence doesn’t support CO2 laser, Er:YAG laser or radiofrequency treatment for GSM, and it calls CO2 laser experimental outside of trials¹.

The sham group’s gains hold a lesson. Symptoms rise and fall, and attention itself can help, so only a comparison group shows what a treatment adds.

Low desire is a diagnosis only when it causes distress

Desire shifts with health, medicines, stress and relationships, so a drop isn’t automatically a disorder. The diagnosis used in drug trials is hypoactive sexual desire disorder, or HSDD. It means low desire that causes distress and isn’t explained by another illness, a medicine or serious relationship problems⁸. Not everyone accepts the label: some psychologists argue that low sex drive shouldn’t be treated as a medical problem, the Associated Press reported¹⁰.

Two FDA-approved drugs treat HSDD, both tested mainly in company trials. Flibanserin (Addyi) is a daily pill. The FDA turned it down twice over modest benefit and worrying side effects before approving it for premenopausal women in 2015, after a lobbying push by its maker, Sprout Pharmaceuticals, and a supporters’ campaign called Even the Score¹⁰. In December 2025, the FDA extended approval to women past menopause, up to age 65¹⁰.

That expansion rested on SNOWDROP, an industry-sponsored 2014 trial of 949 postmenopausal women¹¹. Over 24 weeks, satisfying sexual events rose by 1.0 per four weeks on the drug and 0.6 on placebo¹¹. By our math, that’s about one extra satisfying event every 10 weeks.

Drug-related side effects affected 29.8% of women on flibanserin and 12.7% on placebo, about 17 more women in every 100 by our math¹¹. Its boxed warning, the FDA’s most serious label alert, covers severe low blood pressure and fainting, risks raised by alcohol and some other drugs, such as fluconazole and diltiazem¹¹. Public Citizen, a consumer watchdog group, rates it “Do Not Use”¹¹.

Bremelanotide (Vyleesi), approved in June 2019, is a shot that women give themselves in the belly or thigh at least 45 minutes before sex⁸. It’s approved for premenopausal women with HSDD, not for women past menopause or for men⁸.

In two 24-week trials with 1,247 women, about 25% on the drug and 17% on placebo had a meaningful rise in desire scores, and distress eased in 35% versus 31%⁹. By our math, that’s 8 more women per 100 with more desire and 4 more with less distress. The drug didn’t increase sexual satisfaction⁹.

Blood pressure rises after a dose and usually returns to normal within 12 hours, so it isn’t meant for women with uncontrolled high blood pressure or high heart risk⁸⁹. Testosterone is a third option some clinicians discuss for women past menopause; our testosterone article covers what the evidence supports.

Erection changes can be an early heart warning

Age is the strongest predictor of ED. In the Massachusetts study, the chance of complete ED was 5.1% at age 40 and 15% at age 70¹². Men with diabetes have two to three times the risk of men without it¹².

Because an erection relies on blood flow, ED often shows up before anyone has diagnosed the heart disease behind it, the pharmacy review notes¹². The AUA’s guideline calls ED a risk marker for cardiovascular disease¹³. Our circulation article explains the artery connection.

The same guideline says men with ED should hear about FDA-approved PDE5 inhibitor pills, the class that includes sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra)¹²¹³. It also calls for a morning blood test of total testosterone¹³.

Two safety facts apply. These pills should never be used by men taking nitrate heart medicines, because blood pressure can fall dangerously¹². And an erection that lasts longer than four hours needs immediate medical care¹².

Weight loss and walking restored function for a third of men in one trial

At the Second University of Naples in Italy, researchers enrolled 110 obese men aged 35 to 55 with erection problems¹⁴. None had diabetes, high blood pressure or high cholesterol¹⁴.

For two years, 55 of the men worked toward a weight-loss goal of 10% or more. They cut calories, kept food diaries, met in groups and got personal advice on walking more¹⁴. The other 55 received general spoken and written advice on healthy eating and exercise¹⁴. The study was published in JAMA in 2004, with academic funding from Naples¹⁴.

The program group lost about 15 kilograms, roughly 33 pounds by our math, versus about 2 kilograms in the comparison group, and raised weekly activity from about 48 to 195 minutes¹⁴. On a standard erection questionnaire, 17 of 55 men in the program reached a score in the normal range, or 31%, versus 3 of 55 in the comparison group, about 5%¹⁴.

By our math, for every four men in the program, about one regained normal function who otherwise wouldn’t have. It was one trial in one city, and most men in the program didn’t reach the normal range. The AUA guideline draws a careful conclusion: for men with other health conditions, better food and more activity can improve overall health and may improve erectile function¹³.

This is where natural health and medicine overlap most. The habits that protect arteries, moving more, eating well and reaching a healthier weight, are the same ones that helped these men. They work alongside proven treatment, not against it.

Be wary of “natural” improvement pills, though. Our article on adulterated herbal products describes FDA findings of hidden prescription drugs in pills sold for sex, and our companion article on sexual wellness products rates maca and other libido supplements.

Sex also happens between people. The AUA suggests clinicians consider referring men to a mental health professional, who can help them stick with treatment, ease performance anxiety and fit treatment into their sexual relationship¹³.

The midlife sexual health guide

Change	Common causes	Options with evidence	When to see a clinician
Vaginal dryness, burning or irritation	Falling estrogen after menopause (GSM)1	Moisturizers; low-dose vaginal estrogen; vaginal DHEA1	Burning, redness or swelling, or discharge that smells foul or comes with itching15
Pain during sex	GSM; pelvic floor muscle problems1	Lubricants; vaginal estrogen; pelvic floor physical therapy1	Pain or discomfort during sex15
Repeat urinary infections after menopause	GSM1	Low-dose vaginal estrogen1	Pain when urinating15; infections that keep coming back1
Low desire that bothers you	Health, medicines, mood or relationship strain810	Look at causes first; two drugs for specific groups810	When it causes distress8
Erection problems	Age, diabetes, blood vessel disease, inactivity, smoking12	Weight loss and more activity1314; PDE5 inhibitor pills13	New problems, especially with heart risk factors1213
Erection lasting more than four hours	Can occur with ED treatment12	Not a home-care problem	Get immediate medical care12

How strong is the evidence?

Approach	What was tested	Rating
Low-dose vaginal estrogen for dryness and painful sex	Systematic review behind the 2025 guideline; strong recommendation1	Strong evidence
Vaginal DHEA and ospemifene	Same review; moderate and conditional recommendations, based on low-certainty evidence1	Promising but early
Vaginal moisturizers	Low-certainty benefit over placebo1	Promising but early
Herbs, vitamins and probiotics for GSM	Mostly small studies; guideline says evidence doesn’t support them1	Not enough evidence
CO2 laser and other energy devices	Sham-controlled trial; guideline review; FDA warning157	Evidence says no, or unsafe
Desire drugs give small gains for women with HSDD	Several company trials; side effects common911	Strong evidence
PDE5 inhibitor pills for ED	AUA standard-level guidance13	Strong evidence
Weight loss and exercise for ED	One 110-man trial; guideline recommendation1314	Promising but early

When to get checked

• Any vaginal bleeding after 12 months without a period. OWH says to see a provider right away⁴. Our article on reproductive symptoms that need assessment explains why.
• Pain or discomfort during sex, burning, redness, swelling, pain when urinating, or discharge that smells foul or comes with itching. OWH advises a call to a doctor or nurse, and says not to douche before the visit¹⁵.
• An erection that lasts more than four hours. Get immediate medical care¹².
• New erection problems. They’re worth a visit, especially with diabetes or other heart risks, because ED can signal heart disease¹²¹³.
• Any ED treatment while you take nitrates. Tell every prescriber, because the combination can drop blood pressure dangerously¹².
• Problems after a vaginal laser or other energy treatment. You can report them to the FDA’s MedWatch program⁶.
• Hopelessness or thoughts of self-harm. Call or text 988 to reach the 988 Suicide & Crisis Lifeline at any hour⁴.

Questions readers ask

The bottom line

Midlife sexual changes are common, and most have names and treatments. For dryness and painful sex after menopause, low-dose vaginal estrogen has strong support and a reassuring safety record, while moisturizers and lubricants offer hormone-free relief. Vaginal lasers didn’t beat a sham, and the desire drugs offer small gains with real side effects.

For men, erection changes deserve a heart check as much as a prescription. In one trial, weight loss and walking restored function for about a third of men. Clinicians often wait for you to speak first, so start the conversation yourself.

Keep exploring: personal lubricant osmolality.

Related reading

• Many lubricants miss a WHO safety limit, so learn to read the sexual wellness shelf
• Hot flashes aren’t the only thing stealing sleep in menopause
• Testosterone’s heart scare has eased, but its fertility catch has not
• Clogged leg arteries often hide, and when they hurt, Medicare pays for walking
• Some herbal pills hide prescription drugs, and others swap out the herb

Sources

1. Kaufman MR, et al. “Genitourinary Syndrome of Menopause: AUA/SUFU/AUGS Guideline (2025).” American Urological Association; Journal of Urology, 2025. auanet.org
2. American Urogynecologic Society. “Removal of Black Box Warning Label from Topical Low-Dose Vaginal Estrogen Products.” AUGS Practice Advisory, December 2025. augs.org
3. The Medical Letter. “In Brief: Label Changes for Menopausal Hormone Therapy Products.” Medical Letter on Drugs and Therapeutics, February 16, 2026;68(1748):30-1. secure.medicalletter.org
4. Office on Women’s Health, U.S. Department of Health and Human Services. “Menopause Symptoms and Relief.” Last updated October 19, 2026. womenshealth.gov
5. MedTech Dive. “FDA Warns About Vaginal Rejuvenation Device Claims.” July 31, 2018. medtechdive.com
6. CNN. “FDA Warns Against Vaginal Rejuvenation Procedures.” July 30, 2018. amp.cnn.com
7. Li FG, Maheux-Lacroix S, Deans R, et al. “Effect of Fractional Carbon Dioxide Laser vs Sham Treatment on Symptom Severity in Women With Postmenopausal Vaginal Symptoms: A Randomized Clinical Trial.” JAMA, 2021;326(14):1381-1389 (Monash University research record). research.monash.edu
8. American Psychiatric Association. “FDA Approves Medication to Treat Female Sexual Desire Disorder.” Psychiatric News Alert, June 2019. alert.psychnews.org
9. Healio Endocrine Today. “FDA Approves Vyleesi for Women With Low Sexual Desire.” June 21, 2019. healio.com
10. Perrone M. “FDA OKs Libido-Boosting Pill for Women Who Have Gone Through Menopause.” Associated Press, via News4JAX, December 15, 2025. news4jax.com
11. Public Citizen’s Health Research Group. “Update on Flibanserin (ADDYI): Avoid This Low-Libido Drug for Women.” Worst Pills, Best Pills News, June 2026. worstpills.org
12. Brown DA. “The Management of Erectile Dysfunction and Identification of Barriers to Treatment.” U.S. Pharmacist, August 25, 2006. uspharmacist.com
13. American Urological Association. “Erectile Dysfunction” guideline (2018; updated), summary. Guideline Central. guidelinecentral.com
14. Esposito K, Giugliano F, Di Palo C, et al. “Effect of Lifestyle Changes on Erectile Dysfunction in Obese Men: A Randomized Controlled Trial.” JAMA, 2004;291(24):2978-2984 (university repository copy). iris.unina.it
15. Office on Women’s Health, U.S. Department of Health and Human Services. “Douching.” Last updated February 27, 2025. womenshealth.gov