A few weeks ago, I published an article about maintenance sex, and the comments section erupted: how dare I not mention hormones?!
And I get it! Depending on your life stage, or time of the month, they can play a role in how open you are to sex. But given that I was answering a husband’s anonymous question with limited information about his wife, I did not want to pathologize her.
So, instead of suggesting she needed to get her hormones checked, I wanted her husband to understand the foundational elements that impact desire: communication, emotional load, variety, and feeling genuinely desired rather than needed.
In fact, relationship satisfaction, stress, exhaustion, trauma history, and other emotional factors weigh more on desire than hormones do.
But you deserve the full picture.
So let's talk about what happens to your body during perimenopause (the transitional period before menopause that can begin in your mid to late thirties and last 10 years) and menopause (when menstrual periods stop permanently and hormone levels drop even further).
We'll explore why you've been misled about hormone replacement therapy, and how this conversation isn't just about sexual desire—it's about reclaiming your life.
"Years ago, I begged my doctor to prescribe me testosterone," a close friend shared on a recent call. "I told her that if she didn't, I was going to lose my relationship."
She got the prescription. She took testosterone. And then something interesting happened.
"I wanted to pounce on everyone—even the guy cleaning my office windows!—except for my ex," she laughed. "That's when I knew it wasn't my hormones. It was him."
This story perfectly captures the nuanced reality of hormones and desire. Yes, hormones matter. But they're not magic bullets, and they don't exist in a vacuum. Context—your relationship, your stress level, your sense of safety and connection—shapes everything.
In the 1990s, the Women's Health Initiative (WHI) decided to study whether estrogen could protect women from heart disease. They took women in their seventies–who hadn't taken estrogen for 20+ years since menopause–and suddenly put them on it. The study ended early when they found small, increased risks of stroke, blood clots, cardiovascular disease, and breast cancer.
The media lost it. Headlines screamed that estrogen was dangerous. Seventy percent of estrogen prescriptions were dropped overnight. Doctors stopped learning how to prescribe FDA-approved medications, pushing women into cash-based hormone clinics with riskier compounded treatments.
But what the study actually taught us was that you shouldn't throw estrogen back into the body of a 70-year-old woman who hasn't had it for decades! That’s because estrogen is heart protective. It helps prevent plaque buildup in our arteries, which is one theory for why women get heart disease much later than men.
So, once estrogen disappears and plaque starts accumulating, throwing estrogen back into the body destabilizes those existing plaques, causing the strokes seen in the WHI study.
The breast cancer findings were equally misleading.
The study wasn't properly randomized for cancer risk, and the placebo group actually had unusually lower rates. Some participants had previously been on estrogen, which would have decreased their breast cancer risk.
In fact, they found that the women who developed breast cancer while on hormone therapy lived longer than breast cancer patients not on any hormones. The reality is that breast cancer is unfortunately common—women develop it regardless of hormone use.
Here's what we now know: Estrogen taken early in menopause (usually before age 60) actually protects against heart disease, anxiety, depression, breast cancer, colon cancer, cognitive problems, insulin resistance, and osteoporosis. It increases longevity. Women on hormone therapy live on average three years longer than those who don't.
Dr. Kelly Casperson tells a story in her book You're Not Broken that perfectly captures our medical system's approach to women's health. A patient came to her regular doctor in 2021 complaining of vaginal dryness. The doctor offered her an antidepressant.
"Will that help?" the woman asked.
"Probably not," the doctor admitted, "but it might bother you less."
This is medical gaslighting at its finest.
Instead of treating the actual problem—declining estrogen affecting vaginal tissues—we're told to take psychiatric medication to care less about our suffering.
Unfortunately, your doctor probably doesn't know better. Most, including OB-GYNs, receive up to 10 hours of sexual health education in medical school, and almost none on perimenopause or menopause, if at all.
This knowledge gap combines with well-documented medical bias.
Women's symptoms are dismissed more often than men's, including reports of pain. Studies show women wait longer for pain medication and are more likely to have their symptoms attributed to psychological causes.
Add to this doctors' fear of litigation, and you have a perfect storm of inadequate care.
The statistics are staggering: More than one-third of menopausal and perimenopausal women are prescribed antidepressants. That's despite clinical guidelines favoring hormone therapy for menopausal symptoms.
We're not treating the root cause; we're medicating women's distress about being dismissed.
Here’s what's actually happening in your body:
Estrogen maintains female sex characteristics, keeps vaginal tissues moist and healthy, and protects your heart. When it declines, you might experience hot flashes, sleep disruption, vaginal dryness, and mood changes.
Progesterone is estrogen's calming sidekick. It has a muscle-relaxing effect, which is why anxiety often increases in perimenopause as progesterone drops—even before your periods stop.
Testosterone creates lean muscle mass, prevents weight gain, and is primarily responsible for sexual desire. This is why peak desire in premenopausal women happens during ovulation, when both testosterone and estrogen levels are highest.
In fact, clinical trials of testosterone therapy demonstrate 40-60% improvements in sexual desire scores compared to placebo, significantly outperforming estrogen alone.
Studies also reveal improvements in cognitive performance, psychological well-being, and musculoskeletal health in postmenopausal women. One study of women in their late thirties showed that testosterone therapy resulted in statistically significant improvements in both sexual self-rating and mental clarity.
Unfortunately, the bias against testosterone as a "male hormone" means there's insufficient research in the USA to create a female-branded version for hormone replacement. So, nearly 21% of prescriptions for branded male testosterone products are actually written for women.
This isn't just about sex. When my client Marla started testosterone therapy after years of complete libido loss, her husband said it was like getting his wife back.
But it wasn't just about desire returning—she could finally feel passionate about anything again.
That's what hormones do. They affect your capacity for pleasure and engagement with the world.
Another woman on Reddit’s r/Menopause community described her clitoris feeling "disconnected.” Vibrators had no effect, causing tremendous strain in her otherwise solid marriage.
Three months after starting HRT with testosterone, sensation returned dramatically. But more than that, she felt like herself again.
Without estrogen, 50-80% of menopausal women develop genitourinary syndrome of menopause. That's vaginal dryness, itchiness, irritation, bleeding during sex, decreased pelvic blood flow arousal, difficulty reaching orgasm, clitoral shrinkage, burning with urination, increased urgency and frequency, and recurrent UTIs.
The labia minora actually begins to resorb—to disappear. This matters because they protect the urethra from trauma. Once they're gone, UTIs and vaginal infections become recurrent and painful.
All of these symptoms can be alleviated with vaginal estrogen that is applied locally to restore tissue health and is completely safe, even if you don’t qualify for systemic estrogen.
What consistently surprises me is women who resist taking vaginal estrogen despite complaining about painful sex or recurring UTIs. The stigma around admitting they need help with their vulva and vagina runs so deep that they would rather endure pain than use a treatment that could restore their quality of life within weeks.
If you're ready to have this conversation with a healthcare provider, you need to find someone who specializes in perimenopause and menopause. Look for a Menopause Society-certified provider at menopause.org who understands what you’re going through and the nuances of hormone replacement.
You need to advocate for yourself. Research shows that when women say "I just don't feel like myself," we should trust that statement without requiring tests to "prove" their suffering. Your experience is valid.
If a doctor tells you that you can't take hormone therapy, ask why and get a second opinion. If they abruptly take you off hormone therapy, ask why and get a second opinion. Too often women quietly accept what their doctor says without understanding the full picture.
Your forties, fifties, and beyond can be some of the most sexually vibrant decades of your life. But only if we stop accepting the narrative that decline is inevitable and start demanding the care we deserve.
The conversation about hormones and desire isn't just medical. It's cultural, relational, and deeply personal. It starts with knowing you have options and that feeling good in your body isn't a luxury. It's your right.
If this shifted how you think about menopause, hormones, or what's possible for your life, please share it with someone who needs to hear it.
