Most of the time, it doesn't happen in a pelvic health appointment at all.
She's come in about a shoulder that won't settle. Or a hip, or an Achilles, or aches that have turned up in several places at once without any obvious reason for them. Nothing changed. She didn't do anything to it. It just started. Somewhere in the session we end up talking about perimenopause, because it's often part of the picture.
And once perimenopause is on the table as something we're allowed to say out loud, something else tends to follow.
She didn't book for this. To be honest, she didn't even know that booking for this was an option. But it's in the back of her mind.
Sorry, this is a bit embarrassing. I don't even know if this is your area.
Then out it comes.
Sex has changed. Or it hurts. Or it doesn't hurt exactly, there's just nothing much there any more. Women tell me it feels like sandpaper. They tell me it's like hitting a wall, that there's no space, that their body simply won't open. They tell me they've gone numb, that they can want it and want it and their body doesn't answer.
Or they tell me they just don't want it. And that one almost never arrives on its own. It comes with guilt attached, sometimes shame, and usually a quiet worry about what it says about her, or about her relationship, or about whether this is simply who she is now.
Here is what I say back. I have had this exact conversation with several women this week. Not this year. This week.
And yes, it matters.
It matters because it is affecting your life, which is reason enough on its own. And before anything else: not wanting sex is not a character flaw, and it is not something you owe anybody an apology for. We can put that down before we start.
It also matters because nearly every woman who raises it has already quietly decided what it is. It's menopause. It's just what happens now. It's my age.
That's the part I want to pull apart, because "it's menopause" is doing an enormous amount of hiding.
Symptoms that wear menopause as a costume
The musculoskeletal part is worth a moment first, because it's the door this conversation usually comes through and almost nobody connects it either.
Women arrive with a stiff, painful shoulder, or joints that ache in the morning, or a new problem in a body that hasn't changed what it's doing. They put it down to getting older, or to something they must have done and can't remember doing. A 2024 review in Climacteric gave the pattern a name, the musculoskeletal syndrome of menopause, and estimated that more than 70 per cent of women have musculoskeletal symptoms through the transition, with around a quarter disabled by them. That's a narrative review rather than a prevalence study, so hold the numbers loosely. But it matches what walks through my door.
I mention it because it's the same failure, repeated. A symptom appears, it gets attributed to something plausible and wrong, and the actual explanation never gets raised.
Which brings us back to the other conversation.
Some of what changes sexually genuinely is menopause. Falling oestrogen changes the vulval and vaginal tissue, and that's real, well understood and worth treating.
But a lot of what gets filed under menopause isn't the tissue at all.
It's a pelvic floor that has been quietly bracing for months, because sex became uncomfortable and the body took note. It's a medication nobody thought to revisit. It's a change in sensation that has its own explanation and its own answers. And sometimes it's the reverse problem entirely, where perimenopause is the thing that never gets named, and every symptom gets treated as its own separate event.
Either way, the label goes on and the thing underneath goes untouched. Which is how a woman ends up with a drawer full of lubricant and no change at all.
The part nobody says out loud
The other reason I wanted to write this is that it is such a lonely thing to be carrying.
Women don't talk about this. Not to their friends, often not to their partner, and frequently not to me until the appointment is nearly over and it can be said sideways. They google it at eleven at night with the phone tilted away. They assume everybody else's body is behaving normally and theirs has quietly broken.
None of that is true, and I'd say it to every one of them if I could. But I also don't want to flatten it into a reassurance, because it isn't only a medical problem. It sits right up against how you feel about yourself, your relationship, getting older, and what you thought this stage of life was going to look like. There is no version of this that isn't deeply personal, and no two women take the same route through it.
Which is why I want to introduce you to someone.
The woman who decided she'd had enough
Martina Baroncelli was 40 when she started lying awake at night, googling things she couldn't say out loud.
Her story is worth a minute of yours, and not because it's unusual. Because it isn't.
She had a scatter of symptoms that didn't obviously belong together. Sleep that had stopped working. A mood that didn't feel like hers. A body that had started behaving like somebody else's. Nothing on the list was dramatic enough on its own to walk into a doctor's office and lead with, and nothing on the list connected to anything else, so she did what almost everyone does, which is carry it privately and assume it was just her.
When she did go looking, what she found didn't help much either. The information was either clinical to the point of being unreadable, or it was sexualised, or it was clearly written for a woman twenty years further along than she was. None of it sounded like where she actually was.
What she was offered, eventually, was antidepressants. She got close to taking them before anybody said the word perimenopause.
I want to be careful with that sentence, because it can be misread. Antidepressants are the right treatment for an enormous number of people and this is not an argument against them. It's an argument for perimenopause being on the list of possibilities in the first place.
I hear a version of that story so often that I've stopped thinking of it as a story about one doctor having a bad day. It's a story about how the information is organised. Perimenopause arrives as a handful of things that each look like something else. Poor sleep looks like stress. Low mood looks like depression. A shorter fuse looks like a personality problem. Losing interest in sex looks like a relationship problem, and that one gets filed under psychology rather than physiology almost by default.
If any of that sounded like your last few years, you are in extremely ordinary company. That is the first thing I would want you to know.
The second is what Martina did next, which is why I wanted to tell you about her. She could have accepted it. That's what most of us do, and I don't say that as a criticism. It takes a certain amount of nerve to decide that the explanation you've been handed isn't good enough, particularly about something you can't comfortably discuss with anyone.
She decided it wasn't good enough. So she went and found out for herself. She read. She joined the private online conversations where women actually say what's happening to them. She went to a women's health conference. She talked to the women in her own family. And when she'd worked out what was missing, which was information for women in the middle of it that was neither clinical nor written for someone twenty years younger, she went and built it. Arousi came out of that.
I'm not telling you this as a nice origin story. I'm telling you because the move she made is the move I want for whoever is reading this. Not starting a company. Just the part before that, where you stop treating this as something happening to you and start treating it as something you're allowed to do something about.
She and I come at it from opposite ends. She's lived it. I have my hands on the muscle layer several days a week. Where we land in the same place is that the sexual side of perimenopause is explained badly, and the vocabulary women are handed is doing them no favours.
So here's mine.
"Low libido" is usually three problems wearing the same coat
Almost every woman who raises this with me uses the phrase low libido. Then we take a proper history and it turns out to be one of three quite different things.
Desire. You don't want it. The thought doesn't arrive on its own the way it used to. This is the one that genuinely is libido, and it's tangled up with sleep, stress, mood, medication, relationship context and hormones all at once.
Sensation. You want it, and your body isn't answering. Things feel muted, orgasm takes longer or takes more or arrives flatter. Plenty of desire, no response. That gap is its own particular kind of frustrating and it is not the same thing as not wanting sex.
Pain, or the memory of it. You want it, and it hurts, or it hurt last time and your body now remembers. This one is very often mechanical, and it's the one most likely to be mislabelled.
That third one also spreads, which almost nobody warns you about. Once penetration has become associated with pain, the pulling back doesn't stay confined to penetration. Cuddling goes. Kissing goes. Sitting close on the sofa goes, in case any of it reads as a starting point that then has to be turned down. Women describe losing the affection long before they lost the sex, and grieving that far more.
If you take one thing from this, take that separation. A woman who has been told her libido is low, when what she actually has is a pelvic floor bracing in anticipation of pain, has been sent down entirely the wrong road.
When it's sensation
This is the one that gets discussed least. When I went looking, I couldn't find anything from the Australasian Menopause Society, Jean Hailes, Healthdirect or any Australian pelvic health clinic that treats sensation change as its own problem rather than a footnote to dryness. So here is the physiology.
Measured sensitivity does decline. A study using biothesiometry, which tests vibration thresholds at several sites on the vulva and vagina, found thresholds rose with both increasing age and menopause. A higher threshold means more stimulus is needed to register the same sensation. It was small, 58 women, and age and menopause are hard to separate in that kind of design. But it's the clearest measured evidence we have and it matches what women describe.
Blood flow matters more than most people realise. Oestrogen contributes to genital blood flow and to how tissue responds to stimulation. Arousal is largely a vascular event. Blood engorges the clitoris and the tissue around the vaginal opening, and that's what creates both the sensitivity and the natural lubrication. Less circulating oestrogen means less of that response, and a slower one.
The tissue itself changes. Collagen stiffens, elastin fragments, the tissue becomes less pliable. Same process behind dryness and painful sex, described together as genitourinary syndrome of menopause. Sensation is part of that picture even when dryness isn't the main complaint.
Three things it isn't. It isn't in your head, and I'm being direct because a lot of women have been told some version of that. It isn't the same as low libido. And it isn't necessarily permanent, because threshold is only one input. Arousal time, blood flow, muscle tension, medication, sleep and stress all feed in, and most of those are changeable.
Two things worth ruling out before you blame your hormones
Medication. A number of commonly prescribed medications affect genital sensation, arousal and orgasm. SSRI and SNRI antidepressants are the ones that come up most, and hormonal contraception is the other common one. It's worth going through the whole list rather than assuming, because this gets missed constantly. If your symptoms started within a few months of a new prescription or a dose change, that's a conversation for your prescriber rather than something to attribute to perimenopause. Don't stop anything on your own.
There's an uncomfortable loop hiding in that paragraph. If perimenopausal low mood gets read as depression, and the treatment for that affects sexual function, you can end up with a sexual symptom caused by the treatment for a misread symptom of the thing nobody named.
Pelvic floor tension. This is my area and it's routinely missed. Muscle that's holding tension restricts blood flow through it. If your pelvic floor has been guarding, which is common once sex has been uncomfortable for a while, that works directly against the vascular response arousal depends on. Tension and reduced sensation turn up together constantly and get treated as two separate problems when they're related. There's more on what that guarding feels like and how it's released in our guide to trigger points in an overactive pelvic floor.
What actually helps
Sorted by how much confidence I have in each, which is not the same as how often you'll see them recommended.
Pelvic floor work, and the evidence is better than you'd expect
This is the finding I most want women to know about, because it cuts against the assumption that pelvic floor work is only for leaking.
A 2025 systematic review and meta-analysis looked at pelvic floor muscle training in postmenopausal women across five randomised trials, 527 women in total. It found significant improvements in orgasm, in arousal, and in satisfaction, with large effect sizes.
Two caveats, honestly given. Heterogeneity between the studies was very high, with an I² of 96 to 98 per cent across only five trials, which pulls hard against those large effect sizes. And the same analysis found no significant effect on the pain domain, so this is not the evidence to lean on if your problem is painful sex. But if your problem is sensation and orgasm, this is the most directly relevant evidence that exists.
There's a plausible mechanism too. A small single arm study of postmenopausal women with genitourinary symptoms measured arterial blood flow before and after a pelvic floor training programme and found increases in internal pudendal and dorsal clitoral artery flow. Twenty nine women completed it, with no control group, so a signal rather than proof. But it's the right kind of signal.
One important qualifier. Pelvic floor work here does not automatically mean Kegels. If your floor is tight rather than weak, more squeezing is the wrong direction and you need down training instead. Which applies to you is exactly what an assessment is for. Our overview of what menopause does to the pelvic floor covers the weak versus tight question in more detail.
Time, and considerably more of it
The single most useful adjustment most women make is unglamorous. Allow much longer for arousal to build before expecting much to happen.
If the vascular response is slower, the timeline that worked at 35 will not work at 48. That isn't a failure of desire or attraction. It's circulation. The women who report the biggest improvement are usually the ones who stopped treating the old timeline as the standard.
Treating the tissue
If there's dryness alongside the sensation change, the tissue needs addressing, and this is where the evidence is strongest overall.
A vaginal moisturiser used two to three times a week works on the tissue over time. A lubricant works in the moment, on friction. Different products doing different jobs, and most people only own one of them. Our moisturiser versus lubricant guide covers the distinction, and we've written separately on lubricants for menopause dryness.
Vaginal oestrogen is the other option and it's worth raising with your GP. In Australia it's prescription only, Schedule 4, and badly underused. A 2025 article in RANZCOG's O&G Magazine put usage among Australian peri and postmenopausal women at between 4.5 and 7.8 per cent, against an estimated half of postmenopausal women having symptoms. Cochrane reviewed thirty trials covering more than six thousand women and rated the quality of the evidence as low, and only a handful of those trials were placebo controlled. I'd rather tell you that than hide it. It's still standard practice, and for good reason, but the evidence base is thinner than the confidence with which it gets recommended.
Changing what you're doing, not just how long
If the threshold has moved, the stimulation that used to work may now be not enough or, confusingly, too much. Sensitivity changes aren't always in one direction and a lot of women find they need to experiment again rather than assume the old approach still applies.
The practical advice here leans heavily towards external rather than internal, and that isn't a menopause adjustment. It's how most women reach orgasm to begin with. The largest nationally representative American study of its kind asked just over a thousand women aged 18 to 94 what they actually preferred. Just under three in four said clitoral stimulation was either necessary for them to orgasm during intercourse or made it better when it was there. Eighteen per cent said penetration on its own was enough. And there was no universal technique, with preferences for location, pressure, shape and motion spread widely, and 41 per cent endorsing only one style of touch out of the twelve they were offered.
US sample, self reported, so read it as a good description of what women say rather than a physiological rule. But it reframes the problem usefully. If clitoral stimulation was already doing most of the work, and that's where the threshold has risen, then what has changed isn't your capacity for orgasm. It's how much input the same route now needs. That's a different problem and a more tractable one.
A word about devices
I'd rather cover this properly than leave it as an awkward gap, because it comes up in clinic constantly and women are often slightly embarrassed to ask.
Start with what a device is not. It isn't a treatment. It won't change your tissue, it won't alter your hormone levels, and it won't release a pelvic floor that's holding tension. Those need the things further up this article. And the evidence for devices specifically is much thinner than the evidence for the physiology. Survey work has found that women who use vibrators report better scores on standard measures of sexual function, but that research is cross sectional, so it can't tell you whether the device is doing the work or whether women who already enjoy sex are simply more likely to own one. Nobody has run the trial that would settle it.
What a device can do is supply a stronger, steadier stimulus than a hand can sustain, which is a reasonable thing to want if the amount of input you need has changed.
If you're going to try one, the general principle I'd give you is that gentler tends to be more useful than stronger. When sensitivity shifts it doesn't always shift in the direction you'd expect, and plenty of women find that what used to feel good now feels like too much. Something that starts low, and that you can change quickly without stopping to think about it, matters more than any particular feature or format.
There's more than one type. Air pulse devices work with suction and pressure waves rather than pressing directly against the tissue, and some women prefer that, though I'm not aware of any evidence that one type outperforms another for anything.
What Martina built
Which brings me back to where this started.
The thing Martina made is called the Inara. It's an air pulse device paired with light vibration, designed and owned here in Australia.
What I find worth pointing out isn't the specification, it's the choices. Most air pulse devices seal firmly and open strong, because that's what demonstrates well and what an experienced user tends to want. Hers doesn't. The seal is deliberately softer, and the rim is shaped to sit around the clitoris rather than clamp onto it. It starts at its lowest setting and stays there until you decide otherwise. There's one button, so nothing has to be worked out in the moment. It's quiet, it's waterproof, and it charges by USB.
None of that is accidental, and none of it is what you design if you're chasing the strongest possible product. It's what you design if the person you're picturing is uncertain rather than confident, and possibly a bit nervous, and would like to be able to stop quickly. Which is to say, it was built by someone who had been on the receiving end of the alternative.
That's the part I want to champion. Martina was handed an explanation that didn't fit, went and found out for herself, and then made the thing she'd wanted to exist. You don't have to buy anything to take something from that.
One last thing, because it comes up often. If you're worried that using a vibrator will make you less responsive to other kinds of stimulation, the evidence for that is thin. If you do notice it, varying what you use and how often generally resolves it.
Does it come back?
This is the question I'm asked more than any other, and the honest answer has three parts, because the three problems don't behave the same way.
Muscle guarding unlearns. This is the most reliable of the three. A pelvic floor that has been bracing can be taught to let go, and that change tends to hold. It takes weeks to months rather than days, and it usually needs someone assessing it rather than you guessing.
Tissue change does not resolve on its own. Genitourinary syndrome of menopause is progressive without treatment, which is exactly the opposite of hot flushes and is why waiting it out doesn't work. Treated, it responds well. That's the argument for raising it now rather than at four years.
Sensation is the least predictable. Threshold changes with age are real and I won't promise you they reverse. But threshold is one input among several, and arousal time, blood flow, muscle tension, medication and sleep are all changeable. Most women I see have more room to move than they'd assumed, and none of them knew which parts were fixed and which weren't.
Nobody can give you a date. Anyone who does is guessing.
One more thing, for the group who most often gives up. If you've already done the obvious things, started HRT, used vaginal oestrogen properly, bought the moisturiser and the lubricant, and it still hasn't shifted, that isn't the end of the list. In my experience that's very often the point at which the muscle layer turns out to be the part nobody has looked at.
What I'd leave alone
You'll see "use it or lose it" repeated everywhere, usually as an instruction to keep having sex to protect your tissue. It comes from studies showing sexually active postmenopausal women have fewer atrophic changes. Those studies are cross sectional, and the researchers behind them say plainly that the direction of causation is unestablished. It's at least as likely that women whose tissue is comfortable keep having sex as it is that having sex keeps tissue comfortable.
So I'm not going to tell you that you have an obligation to keep having sex in order to look after your body. Have sex because you want to.
When to get it looked at
Book an appointment if any of these apply.
- Sensation changed suddenly, rather than gradually over months or years. Sudden change deserves a proper look.
- It started near a new medication or a dose change. Speak to your prescriber.
- There's numbness, tingling or altered sensation elsewhere, in the legs, buttocks or perineum. That needs medical assessment rather than a pelvic health approach.
- There's pain as well. Pain and reduced sensation together usually means more than one thing is going on.
- You're bleeding after sex, at any point and however lightly. That always warrants a GP appointment rather than a wait and see.
- It's bothering you, which is reason enough. You don't need to reach a threshold of severity before it's worth raising.
A pelvic health physiotherapist can assess whether your pelvic floor is contributing and whether it needs strengthening or releasing. A menopause literate GP can look at the hormonal side and at your medications. In practice the two work well together, because tissue and muscle are different problems that happen to share an address.
None of this is something you have to accept as a fixed part of getting older. It's under researched, which is not the same as untreatable, and there is usually more room to move than women are led to expect.
And if you take nothing else from this: the thing you haven't said out loud is almost certainly not the thing you think it is. It's worth saying out loud anyway.
Nothing here is a substitute for individual assessment. If sex is painful, if you're bleeding, or if something feels wrong to you, please see your GP or a pelvic health physiotherapist.
