Perimenopause, Libido, and Your Sex Life: What’s Normal and When to Seek Help

Perimenopause, Libido, and Your Sex Life: What’s Normal and When to Seek Help

If you’ve noticed that your desire for sex has shifted, that it takes longer to feel aroused, that intimacy feels more like an obligation than something you actually want, or that your body just doesn’t respond the way it used to, you’re not imagining things. And you’re not alone.

For many women in their late 30s, 40s, and early 50s, changes in sexual desire are one of the first signs that perimenopause has begun. Yet it’s a topic that rarely comes up at annual checkups, and it’s almost never talked about openly among friends. This means millions of women are quietly wondering whether something is wrong with them.

Nothing is wrong with you. But there is a lot worth understanding.

What Is Perimenopause?

Perimenopause is the transitional phase leading up to menopause, typically beginning anywhere between ages 35 and 50, when the ovaries gradually produce less estrogen and progesterone. This phase can last anywhere from one year to a decade, and it’s marked by hormonal fluctuations that affect nearly every system in the body.

The symptoms most people associate with menopause such as hot flashes, irregular periods, sleep disturbances, and mood changes often begin during perimenopause. What gets less airtime is how profoundly these hormonal shifts can affect a woman’s relationship with her own sexuality.

How Perimenopause Affects Sexual Desire and Intimacy

Research consistently shows that sexual function changes during the menopausal transition. A study published in the Seattle Midlife Women’s Health Study found that hot flashes, fatigue, depressed mood, anxiety, and sleep problems were all associated with reduced levels of sexual desire in perimenopausal women. Declining estrogen levels are a central driver, contributing to a range of physical and psychological changes that impact sex and intimacy.

These changes can include:

•  Decreased libido. Estrogen and testosterone play a key role in maintaining sexual desire. As levels drop, many women notice their interest in sex fading, not because of their relationship or their partner, but because of what’s happening hormonally.

•  Vaginal dryness and discomfort. Lower estrogen can cause vaginal tissue to become thinner and less lubricated, making sex physically uncomfortable or even painful. This condition, known as genitourinary syndrome of menopause (GSM) affects between 27% and 84% of postmenopausal women according to the North American Menopause Society, yet many women suffer through it without knowing that effective treatment exists.

•  Longer arousal times. Hormonal changes can slow the body’s natural arousal response, meaning more time and stimulation may be needed to feel ready for sex. This is common, though it can feel disconcerting if you don’t know why it’s happening.

•  Mood shifts and emotional distance. Anxiety, irritability, and low mood, all common during perimenopause, can significantly dampen desire and make emotional intimacy harder to access.

•  Body image changes. Weight shifts, skin changes, and other physical transitions can affect how a woman feels in her body and, by extension, how comfortable she feels being intimate.

So What’s “Normal”?

Here’s the honest answer: there is a wide range of “normal” when it comes to perimenopause and sexuality. Some women notice only minor shifts. Others experience a more dramatic change in desire. Some find that sex actually improves during this time, freed from concerns about pregnancy or the pressures of younger years.

What matters most is not how your experience compares to a chart or a statistic. It’s how you feel about it. If your changing libido is causing distress, affecting your sense of self, or creating tension in your relationship, that’s worth paying attention to. You don’t have to accept diminished desire as simply “part of getting older.”

The Emotional Side That Often Gets Overlooked

The physical changes of perimenopause are real and significant. But they rarely happen in isolation. For many women, this life stage arrives alongside other major transitions such as shifting family dynamics, career changes, aging parents, and evolving relationships. The stress of it all can compound hormonal changes in ways that make desire feel even more elusive.

A 2024 meta-synthesis published in PMC highlighted that understanding women’s sexual experiences during menopause requires situating female sexuality within a broader framework of sexual health, relational health, and overall well-being rather than treating changes in desire as inherently problematic. In other words, what you’re feeling has context, and that context matters.

There’s also a grief process that doesn’t get named often enough: a quiet mourning of the body you used to have, the spontaneous desire you used to feel, or the version of yourself that felt effortlessly sexual. This emotional layer is just as real as the hormonal one and just as deserving of support.

When It Might Be Time to Seek Support

You don’t have to be in crisis to benefit from professional support. Consider reaching out to a sex therapist or mental health professional if:

•  Your low libido is causing you significant personal distress, regardless of whether you’re in a relationship.

•  There is a significant mismatch in desire between you and your partner, and it’s creating tension, distance, or resentment.

•  Sex has become painful and you’ve begun avoiding intimacy altogether.

•  You’re experiencing anxiety, depression, or shame around your sexuality that feels hard to shake.

•  You feel disconnected from your body or your sense of yourself as a sexual person.

Sex therapy during perimenopause isn’t about “fixing” you. It’s about helping you understand what’s happening in your body, navigate the emotional terrain of this transition, and reconnect with your desire on your own terms.

What Treatment and Support Can Look Like

The good news is that there are many effective, evidence-based options for supporting sexual wellness during perimenopause. A comprehensive approach might include:

•  Sex therapy and mindfulness-based interventions to manage performance anxiety and distractions. A 2024 meta-analysis in the International Journal of Sexual Health found that mindfulness-based cognitive therapies significantly improved sexual function, reduced sexual distress, and lowered depression in women. These approaches address the psychological, relational, and emotional dimensions of changing desire.

•  Couples therapy to navigate desire discrepancy and maintain connection and intimacy as a team.

•  Medical consultation with a gynecologist or menopause specialist to explore hormonal and non-hormonal treatment options. A systematic review and meta-analysis published in PMC found that estrogen therapy and related hormonal treatments may offer modest improvements in sexual function, and these options are worth discussing with your provider.

•  Somatic and body-based practices that help you reconnect with your body and cultivate presence during intimacy, often used alongside therapy for deeper and more lasting results.

These approaches work best in combination and ideally with providers who communicate with one another and see you as a whole person.

You Deserve Support Through This Transition

Perimenopause is a natural part of life, but navigating its effects on your sexuality alone doesn’t have to be. Whether you’re looking for information, guidance, or a space to process what’s shifting, you deserve care that meets you where you are.

At Embrace Sexual Wellness, our Chicago-based sex therapists specialize in helping women reconnect with their desire, navigate life transitions, and build intimacy that feels authentic and fulfilling. We offer individual therapy, couples therapy, and a warm, nonjudgmental space to explore whatever is coming up for you.

If any of this resonates, we’d love to connect. Schedule a free 10-minute phone consultation today and take the first step toward feeling at home in your body again.

Is Sexual Fantasy Healthy? How to Use Fantasies to Boost Desire and Intimacy

As a Chicago sex therapist, one of the most common questions I hear is: “Is it okay to fantasize?” This question often comes with a mix of curiosity, shame, and worry. For some people, fantasies come easily. For others, fantasizing feels foreign, awkward, or even off-limits.

The reality is that sexual fantasy is a completely normal and healthy part of sexuality. Whether you’re single, in a long-term relationship, or exploring intimacy after a change in life stage, fantasy can play an important role in reconnecting with desire and pleasure.

In this article, we’ll explore why sexual fantasies matter, how they can benefit your intimacy, and practical ways to start fantasizing if it doesn’t come naturally to you.

What Is a Sexual Fantasy?

A sexual fantasy is simply a thought, image, or scenario that creates erotic excitement. Fantasies can range from imagining a romantic, sensual moment with a partner to envisioning scenarios that you would never act out in real life.

Importantly, fantasies are not the same as real-life desires. Many people fantasize about situations they would never want to pursue outside of their imagination. This is one reason why fantasies can be so freeing: they’re a mental space to play, without consequences.

Why Do People Fantasize?

Research shows that nearly everyone has sexual fantasies, regardless of gender, age, or relationship status. Fantasies serve many purposes, including:

• Stimulating arousal: Fantasies can help the body respond when desire feels low.

• Reducing anxiety: Focusing on an erotic image or story can quiet distracting thoughts that interfere with sexual pleasure.

• Exploring identity: Fantasies allow people to try on different roles or explore aspects of themselves in a safe way.

• Enhancing partnered intimacy: When shared (with consent and comfort), fantasies can spark new conversations and closeness in relationships.

The Benefits of Fantasy for Your Sexual Health

For many of our clients, fantasy becomes a tool for healing and growth. Here are some of the benefits we often explore in sex therapy:

Reducing Performance Pressure

If you struggle with anxiety during sex, fantasies can help you shift focus away from “Am I doing this right?” toward erotic imagery that feels exciting. This mental shift can make it easier to stay present and experience pleasure.

Boosting Sexual Desire

Fantasies can reignite interest when desire feels flat. They work like a spark for your erotic imagination, offering new ideas and sensations that the body can respond to. This can be especially helpful for couples navigating loss of intimacy or low libido.

Enhancing Partner Connection

While not all fantasies need to be shared, some couples find that talking about them creates intimacy and trust. Even if you never act out the fantasy, sharing it can help you and your partner better understand each other’s inner worlds.

Healing from Shame and Dysfunction

For those dealing with sexual dysfunction, trauma, or shame, fantasy can be a safe entry point into sexual exploration. Imagining a pleasurable scenario provides a sense of control that real-life intimacy sometimes lacks.

How to Start Fantasizing

Not everyone finds fantasizing easy. Some people worry they “don’t have an imagination,” while others feel blocked by shame or religious or cultural beliefs. If that’s you, here are some steps to begin experimenting with fantasy:

1. Start with Memory

Think back to a time when you felt desired, attractive, or deeply connected. Replay that memory in your mind and allow it to expand into a new imagined scenario.

2. Use Your Senses

Fantasies don’t need to be cinematic. Start by imagining touch, sound, or smell that excites you. For example, the warmth of skin, the sound of breath, or the scent of your partner’s cologne.

3. Try Erotic Media

Erotic short stories, romance novels, or audio erotica can help spark ideas when your own imagination feels blank. Reading or listening can lower the pressure of “making up” something yourself.

4. Focus on Themes, Not Scripts

Instead of creating a detailed storyline, think about a theme that excites you, like adventure, seduction, or tenderness. Let the details fill themselves in naturally.

5. Release Judgment

Fantasies often don’t align with real-life desires, values, or behaviors. That doesn’t make them wrong. Your imagination is a safe place to explore, with no rules.

Common Questions About Fantasy

Is it normal to fantasize about things I don’t want in real life?

Yes. Most people fantasize about scenarios they wouldn’t act on. Fantasy is symbolic and exploratory, not a blueprint for your actual choices.

What if I can’t fantasize at all?

This is more common than you think. Sometimes, anxiety, depression, or trauma makes fantasizing difficult. Working with a sex therapist can help you explore these blocks in a supportive way.

Will sharing fantasies with my partner hurt our relationship?

It depends on how you share them. Approach the conversation with curiosity, not pressure. If your partner isn’t interested in hearing or acting on a fantasy, that’s okay. Talking about fantasies is about connection, not performance.

When to Seek Support

If fantasizing brings up guilt, shame, or confusion, or if you find yourself unable to access fantasies at all, therapy may be a helpful step. At Embrace Sexual Wellness, we help individuals and couples explore fantasies, reconnect with intimacy, and work through concerns like low libido, sexual dysfunction, and loss of desire. You can read more about our work with erectile dysfunction and loss of intimacy, both of which can benefit from integrating fantasy as part of treatment.

TLDR

Sexual fantasy is a natural, healthy part of human sexuality. It can reduce anxiety, boost desire, and bring new energy into your intimate life. Whether you’re imagining something tender or something bold, fantasies offer a private, safe space for pleasure and exploration.

If you’re ready to explore your erotic imagination but aren’t sure where to begin, remember: fantasy is a skill you can practice. And if you need support along the way, our team of Chicago sex therapists at Embrace Sexual Wellness is here to help and are licensed to practice in Illinois, Indiana, Kansas, Idaho and Louisiana.

Pelvic Congestion Syndrome: Causes, Symptoms, and Treatments

Chronic pelvic pain is a common occurrence among people assigned female at birth, affecting an estimated 15% of people of childbearing age in the United States. One of the causes of pelvic pain is pelvic congestion syndrome (PCS). PCS occurs when varicose veins develop around the ovaries. Varicose veins are twisted, enlarged veins that most often appear on the legs because standing and walking cause the blood to engorge the leg veins. Most of the time, varicose veins are completely benign and painless but when they appear on the ovaries, they can cause pain and discomfort. The exact cause is still unknown but pregnancy and estrogen can both play key roles in making the veins structurally unsound. Any type of chronic pain can be disruptive to your life so it is important to learn about the cause of your pain and what your treatment options are. This article will cover the symptoms of pelvic congestion syndrome, how it affects one’s sex life, and the treatment options that exist. 

What are the symptoms of pelvic congestion syndrome?

Dull and achy pelvic pain is the primary symptom of PCS, but it can manifest as a sharp pain as well. The pain can be exacerbated after standing or sitting for a long time, before and during menstruation or sexual activity. Additional symptoms include varicose veins in other places like the pelvis, buttocks, and vulva, an irritable bowel, stress incontinence, and pain with urination.   

How does pelvic congestion syndrome affect one’s sex life?

As mentioned above, pelvic congestion syndrome and the associated pain tends to be exacerbated by sexual intercourse. This not only poses physical obstacles to having sex, especially penetrative sex, but chronic pain can also cause a low libido. That does not mean that you can never achieve a fulfilling sex life though. In addition to the PCS treatment options below, there are ways to have great sex without penetration. You can engage in alternative forms of intimacy, like mutual masturbation, give and/or receive a sensual massage, or cuddle skin-to-skin. There are also ways to try to boost your libido, if you so desire. None of these options provide a permanent solution, but there are treatment options that can make it easier to live with PCS. 

   What are the treatment options for pelvic congestion syndrome?

Diagnosing pelvic congestion syndrome is not easy because the symptoms are easily conflated with other conditions and there is no test that will outright prove that PCS is the culprit. For this reason, doctors will typically run tests to rule out similar conditions, as well as use imaging like ultrasounds. Ultrasounds provide a view of the soft tissue; if more detailed imaging is required, a doctor may opt for an MRI or CT scan. The goal of diagnosis and treatment is to reduce or relieve pelvic pain, but there is unfortunately no known cure for PCS. The treatment you and your doctor pursue will depend on factors such as the severity of your symptoms and your medical history.

Treatment options for PCS may include: 

• Gonadotropin hormone drugs. Gonadotropins are hormones that regulate ovarian function; they are essential for growth, development, and reproduction functions. These drugs can block ovarian function and therefore relieve some pain.  

• Progestin hormone drugs. Similarly to gonadotropins, progestin drugs are hormonal drugs that serve to relieve pain by assisting the regulatory function of your reproductive system. 

• Sclerotherapy or embolization. A sclerotherapy is a typical treatment option for any varicose veins, including pelvic veins, such as is the case for PCS. It involves a needle that injects a solution which causes the damaged vein to scar and eventually fade as blood is rerouted to healthier veins. A similar concept but different execution is gonadal vein embolization is a minimally invasive treatment that involves a small incision for a tube that is used to dispatch a sclerosant that blocks the vein, therefore guiding the blood to healthier vessels, similar to how sclerotherapy works. 

• Oophorectomy or Hysterectomy (to remove your uterus and ovaries). An oophorectomy (removal of the ovaries) and hysterectomy (removal of the uterus) are reserved for the most severe cases of PCS after milder treatments have failed. However, these procedures have been shown to be a very effective treatment for PCS pain in treatment-resistant cases.

The Bottom Line

Pelvic congestion syndrome is a taxing condition that has the potential to significantly impact your quality of life, particularly your sex life. However, with a proper diagnosis and treatment plan, you can find relief. If you suspect you have PCS, you should consult with a healthcare professional to explore your options. Additionally, if you need extra support for your mental health and/or your libido and sex life due to the chronic pain, consider reaching out to a therapist.