Perimenopause: Vaginal, Sexual & Urinary Health
Vaginal dryness, painful intercourse, low libido, and urinary changes are common but often overlooked symptoms of perimenopause and menopause. As estrogen levels fluctuate and decline, women may experience vaginal irritation, burning, reduced lubrication, discomfort during sex, frequent urination, urinary urgency, recurrent urinary tract infections (UTIs), and overactive bladder — symptoms often associated with Genitourinary Syndrome of Menopause (GSM). Hormonal changes, disrupted sleep, stress, and vaginal discomfort can also contribute to decreased sexual desire and female sexual dysfunction, affecting intimacy, confidence, and overall quality of life.
At Maze Women’s Health, we specialize in understanding and addressing these interconnected concerns through personalized vaginal dryness treatment, painful intercourse treatment, low libido evaluation, and perimenopause sexual health care. From vaginal estrogen therapy, non-hormonal moisturizers, and pelvic floor therapy to prescription treatments for overactive bladder and hypoactive sexual desire disorder (HSDD), including carefully selected hormonal and non-hormonal options, we take a comprehensive, evidence-based approach to restoring comfort, improving sexual wellness, and supporting bladder health. These symptoms are common, but they are not something you simply have to accept as part of aging.
Vaginal dryness, discomfort with intercourse, and bladder changes like urgency and frequent urination are often experienced as separate, unrelated annoyances — but they share a single underlying cause and are now grouped clinically under one umbrella term: genitourinary syndrome of menopause (GSM). Because the tissue involved and the treatments that help are so closely linked, it makes sense to consider the vaginal and urinary symptoms together rather than as two separate problems.
Why it happens. The vulva, vagina, urethra, and bladder all develop from the same embryonic tissue and are rich in estrogen receptors. Estrogen helps maintain the thickness, elasticity, blood flow, and natural lubrication of this tissue. As estrogen declines through perimenopause, the vaginal walls can become thinner, drier, and less elastic, while the urethra and bladder lining undergo similar changes — which is why dryness and urinary symptoms so often appear together and respond to many of the same treatments.
How common is it, and what does it look like. GSM is common and substantially underrecognized: by various estimates, it affects roughly half of menopausal women, with one frequently cited study finding prevalence around 4% during perimenopause, rising to about 25% within a year after menopause and 47% by three years after — a trajectory showing it tends to worsen progressively rather than appear all at once. Symptoms include:
- Vaginal and vulvar symptoms: dryness, burning, irritation, itching, reduced natural lubrication, pain with intercourse (dyspareunia), light bleeding after sex, and changes in discharge
- Urinary symptoms: urgency, frequency, waking at night to urinate, a higher rate of urinary tract infections, and overactive bladder (OAB) specifically — urinary urgency, usually with frequency and nighttime urination, with or without leaking, and without an infection or other clear cause
It’s worth knowing that these symptoms aren’t exclusive to menopause — breastfeeding, certain antihistamines and antidepressants, Sjögren’s syndrome, and cancer treatment can cause a similar picture, which is one reason a proper evaluation matters rather than assuming every case is hormonal.
Diagnosis. As with perimenopause generally, GSM is diagnosed clinically, based on symptoms and a physical exam, rather than through a specific lab test. A urine test is typically done when urinary symptoms are prominent, to rule out an active infection as the cause of urgency and frequency. Treatment isn’t required if symptoms aren’t bothersome — the decision to treat is driven by impact on daily life and intimacy, not by a number or scan.
Treatment options.
- Vaginal moisturizers and lubricants are the appropriate first-line, non-hormonal starting point for vulvovaginal symptoms, and are appropriate for all patients, including breast cancer survivors. Moisturizers (often hyaluronic acid- or polycarbophil-based) are used regularly, typically every two to three days, to maintain tissue moisture, while lubricants are used specifically with sexual activity to reduce friction and discomfort. Oil-based lubricants can damage latex condoms, and products with added flavors, sugars, or warming agents are generally best avoided since they can irritate already sensitive tissue.
- Vaginal (local) estrogen is considered the gold-standard prescription treatment for GSM and is specifically recommended by current AUA/SUFU/AUGS guidelines for women with genitourinary syndrome who also have overactive bladder, since restoring estrogen to the local tissue improves urinary symptoms alongside vaginal ones. Delivered as a cream, tablet, or ring with minimal absorption into the bloodstream, it’s generally considered a distinct, lower risk category from systemic hormone therapy, and may be an option even for some women who can’t use systemic estrogen — though that determination should always be individualized, particularly for women with a personal history of hormone-sensitive cancer, ideally in consultation with their oncologist.
- Vaginal DHEA (prasterone, brand name Intrarosa) is a hormone-containing insert placed in the vagina nightly, FDA-approved for vaginal dryness and pain with sexual activity, offering a non-estrogen prescription alternative.
- Oral ospemifene (Osphena), a selective estrogen receptor modulator (SERM) taken as a 60 mg tablet once daily, is FDA-approved for vaginal dryness and painful intercourse for women who prefer an oral option to local vaginal treatment.
- Systemic hormone therapy, when used for hot flashes and other symptoms, often improves vaginal dryness as a secondary benefit, though some women still need an additional local treatment layered on top for full relief of vaginal and urinary symptoms.
- Vaginal laser therapy (such as fractional CO2 laser) remains more controversial: a preliminary study found it improved dryness, burning, and dyspareunia, in some cases as effectively as vaginal estrogen, but also found more reported pain in the laser-treated groups, and the FDA issued a 2018 warning against marketing these energy-based devices for vaginal “rejuvenation,” citing insufficient evidence of safety and effectiveness along with reports of burns, scarring, and chronic pain. Some clinicians have pushed back that the warning, aimed primarily at cosmetic marketing claims, may have been overly broad for legitimate symptom treatment — but the overall evidence base remains more limited than for estrogen, DHEA, or ospemifene, and it’s not a first-line recommendation.
- For overactive bladder symptoms specifically, beyond local estrogen: behavioral strategies (bladder training, pelvic floor exercises, moderating fluid and caffeine intake, timed voiding) are usually the starting point. Beta-3 agonists — mirabegron and the newer vibegron — relax the bladder muscle to increase storage capacity and have shown similar effectiveness to each other in head-to-head trials in postmenopausal women, with vibegron showing a possible edge for urgency incontinence and generally fewer drug interactions. Anticholinergic (antimuscarinic) medications remain a mainstay but carry an important caution for midlife women specifically — research has linked cumulative anticholinergic use to effects on cognition, brain metabolism, and brain volume in older adults, which is worth discussing directly with a provider, particularly for women already navigating perimenopausal brain fog. Third-line options, including Botox injections into the bladder muscle and nerve stimulation therapies, are reserved for OAB that doesn’t respond to the approaches above.
The bottom line. Vaginal dryness, painful sex, and bladder changes in perimenopause share a common cause and a largely overlapping set of effective treatments, from simple over-the-counter moisturizers to several FDA-approved prescription options — so there’s little reason to simply tolerate any of these symptoms as an unavoidable part of this transition, and addressing one often meaningfully improves the others.
Decreased Libido
Non-Medical Treatment Options
- Address underlying contributors first
Because libido is so often affected by other symptoms, treating vulvovaginal atrophy and dryness, improving sleep, or addressing mood can meaningfully restore interest in sex on its own, before any additional treatment is needed.
- Sex therapy and counseling
A therapist focused specifically on sexual health can address the emotional, relational, and psychological layers of libido change in a way medication alone doesn’t reach.
- Communication and relationship-focused strategies
Openly discussing changes with a partner and adjusting expectations and routines around intimacy is, for many, as important as any medical treatment.
Pharmacotherapy for Low Libido
Flibanserin (Addyi)
- What it is and how it works. A non-hormonal daily pill that’s thought to work by rebalancing neurotransmitters involved in sexual desire — increasing dopamine and norepinephrine activity while reducing serotonin’s inhibitory effect. The exact mechanism isn’t fully established.
- Dose. 100 mg taken once daily at bedtime, regardless of anticipated sexual activity.
- FDA approval. Originally approved in 2015 for premenopausal women with acquired, generalized HSDD. In a significant and recent update, the FDA expanded that approval on December 15, 2025 to include postmenopausal women under 65 — making Addyi the first medication approved for HSDD in this population and directly relevant to women moving through and past the perimenopausal transition.
- Efficacy. Clinical trials showed a modest but statistically significant improvement in satisfying sexual events and desire compared with placebo; efficacy is generally described as modest rather than dramatic, and it requires several weeks of daily use to assess benefit.
- Side effects. The most common are dizziness, sleepiness (somnolence), nausea, fatigue, and insomnia.
- The alcohol interaction. Addyi carries a boxed warning for severe low blood pressure and fainting, with risk substantially increased by alcohol. Patients need to wait at least two hours after one or two standard drinks before taking a dose, or skip the dose entirely after three or more drinks — a real practical limitation for many patients.
- Who it’s not for. Not intended for low desire caused by a medical or psychiatric condition, relationship problems, or medication side effects (including antidepressant-induced low desire) — it’s specifically for HSDD without another identifiable cause.
Bremelanotide (Vyleesi)
- What it is and how it works. An as-needed injectable medication that activates melanocortin receptors in the brain, a pathway involved in sexual arousal — a different mechanism from flibanserin’s neurotransmitter-rebalancing approach.
- Dose. Self-administered by autoinjector under the skin, used as needed at least 45 minutes before anticipated sexual activity, with a maximum of one dose in 24 hours and no more than 8 doses per month.
- FDA approval. Approved in 2019 for acquired, generalized HSDD in premenopausal women — it does not currently carry an approval for postmenopausal women.
- Efficacy. The pivotal Phase 3 RECONNECT trials (1,247 premenopausal women) found bremelanotide significantly improved sexual desire and reduced the distress associated with low desire compared with placebo.
- Side effects. Nausea is common, affecting roughly 40% of users (often more pronounced with the first few doses and lessening over time), along with flushing (about 20%), injection site reactions, and headache. It can also cause a temporary, modest rise in blood pressure and drop in heart rate after each dose.
- A practical advantage over Addyi. Unlike flibanserin, bremelanotide has no known interaction with alcohol and no daily dosing requirement — it’s used only around sexual activity, which some patients find more appealing.
Off-Label Bupropion (Welbutrin)
- What it is and how it works. An antidepressant that increases dopamine and norepinephrine activity, distinct from SSRIs’ effect on serotonin. Because SSRIs commonly cause sexual side effects while bupropion has a comparatively low rate of them, it’s used off-label in two overlapping ways: as a direct treatment for HSDD in women not on other antidepressants, and as an add-on to reverse SSRI-induced sexual dysfunction in women already taking one.
- Dose. Studied at 150 to 450 mg/day in the sustained-release or extended-release formulations.
- Efficacy as a direct HSDD treatment. Evidence is mixed: a randomized, placebo-controlled trial in ovulating women found meaningful improvement, and an earlier single-blind trial found about 29% of participants responded, but a separate double-blind RCT trended positive without reaching statistical significance. A 2024 international consultation on sexual medicine summarized the evidence as showing effectiveness but with inconsistent statistical strength across trials.
- Efficacy for SSRI-induced sexual dysfunction specifically. Here the picture is more clearly favorable in some studies and more mixed in others. One randomized, placebo-controlled trial of 218 women found adjunctive bupropion (150 mg twice daily) significantly improved sexual function over 12 weeks. However, a more recent systematic review and meta-analysis of randomized trials found bupropion at 150 mg showed the strongest effect among agents studied for this specific problem, while cautioning that overall evidence for treating antidepressant-induced sexual dysfunction remains mixed across the available trials, and that improvements in sexual function didn’t track with changes in depression symptoms.
- Side effects. Insomnia, dry mouth, headache, and a lower seizure threshold at higher doses are the main concerns; it’s generally avoided in women with a seizure disorder or eating disorder history.
- Why it’s relevant to perimenopause. Given how often SSRIs and SNRIs are used for hot flashes and mood symptoms in this population (as discussed above), bupropion is a reasonable option to raise directly with a provider if a chosen antidepressant is helping mood or hot flashes but dampening desire.
Testosterone Therapy (off-label in the U.S.)
- What it is and how it works. Testosterone, though present in much smaller amounts in women than men, contributes meaningfully to sexual desire, arousal, and overall well-being; levels decline gradually with age through the perimenopausal transition. Testosterone therapy aims to restore desire by replacing this decline.
- FDA status. There is currently no FDA-approved testosterone product specifically for HSDD in women in the United States — all use in women is off-label, typically via compounded creams or gels, or by prescribing a small fraction of an FDA-approved male testosterone product (gels, solutions, or patches) at a dose adjusted down for female physiology.
- Guidance and dosing philosophy. Since 2019, a global consensus position statement — endorsed by leading international societies focused on women’s sexual health — has recommended that testosterone therapy in women aim for blood levels approximating normal premenopausal physiologic concentrations, rather than the higher doses used in men, and be delivered transdermally rather than orally.
- Efficacy. A meta-analysis pooling 36 randomized controlled trials and 8,480 participants found testosterone therapy — whether used alone or alongside estrogen therapy — produced short-term (up to 24 months) improvement in sexual function in naturally and surgically postmenopausal women, with the overall therapeutic effect generally characterized as moderate rather than dramatic.
- Side effects. The main concerns at appropriate, physiologic doses are scalp hair loss, excess hair growth (hirsutism) on the face and body, acne, possible changes to the voice and/or enlargement of the clitoris; effects on cholesterol, cardiovascular risk, and long-term breast or endometrial safety are less well studied over longer time periods than the short-term desire outcomes are, which is part of why current guidance emphasizes staying within physiologic dosing and monitoring.
- A note on formulation. Because no FDA-approved product exists for women, dosing relies on off-label use of male-formulated products at reduced doses or compounded preparations, which introduces more variability in blood levels than a purpose-built product would — one more reason regular follow-up and monitoring matter with this option.
Choosing among these options
- Addyi may suit women (now including postmenopausal women, following the December 2025 approval) who want a daily oral option and don’t mind the alcohol restriction.
- Vyleesi may suit women who prefer as-needed dosing tied to anticipated activity and want to avoid the alcohol interaction, though it’s currently limited to premenopausal women by its approval.
- Bupropion is particularly worth considering when low desire coincides with SSRI or SNRI use for mood or hot flashes, or when a patient wants a familiar, generically available medication rather than a newer targeted therapy.
- Testosterone may be considered when desire remains low despite addressing other contributing factors (vaginal dryness, relationship context, mood, other medications), understanding that it’s an off-label option requiring careful, individualized dosing and monitoring.