During our peak reproductive years, the amount of estrogen in circulation rises and falls fairly predictably throughout the menstrual cycle. Estrogen levels are largely controlled by two hormones — follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
FSH stimulates the follicles — the fluid-filled sacs in the ovaries that contain the eggs — to produce estrogen. When estrogen reaches a certain level, the brain signals the pituitary gland to turn off FSH and produce a surge of LH. This surge triggers ovulation. After the egg is released, the leftover follicle produces progesterone, preparing the body for pregnancy.
If pregnancy doesn’t occur, progesterone drops, menstruation begins, and the cycle starts again. For decades, this hormonal rhythm not only regulated fertility but also supported mood, cognition, bone strength, and sexual health.
Perimenopause — the 4–10 years leading up to menopause — is when this rhythm begins to falter. Ovaries become less responsive to FSH and LH, and estrogen levels fluctuate unpredictably. One week you may have sky-high estrogen (and feel great); the next, levels plummet — leaving you exhausted, irritable, and disinterested in sex.
These hormonal swings impact not just the body, but also the brain, which is rich in estrogen receptors. Estrogen plays a key role in regulating neurotransmitters like:
Serotonin – mood and well-being
Dopamine – motivation and reward (linked to sexual desire)
Oxytocin – bonding, trust, and intimacy
When estrogen fluctuates, these neurochemicals fluctuate too. This helps explain why many women describe feeling “off,” disconnected, or unable to “get in the mood,” even when they still feel love and attraction for their partner.
As neuroscientist and sex therapist Dr. Nan Wise explains, “Our brain is the most important sex organ. When it’s not getting the right signals — from hormones, emotions, or environment — desire can fade.”
Once you’ve gone 12 months without a period, you’re officially in postmenopause. At this stage, estrogen and progesterone stay low and stable, while FSH and LH remain high. These changes affect nearly every system in the body — particularly the genitals and urinary tract.
Low estrogen means:
Decreased blood flow to the vaginal tissues
Reduced elasticity and collagen
Thinning of the vulvar and vaginal lining
Increased vaginal pH (raising risk for infections)
Together, these changes create what’s known as Genitourinary Syndrome of Menopause (GSM) — symptoms like dryness, burning, itching, urinary urgency, and pain with sex. When sex becomes painful, the brain quickly learns to associate intimacy with discomfort, further dampening desire.
But here’s the truth: GSM is treatable — and restoring vaginal health can reignite pleasure and connection.
While hormones matter, they’re not the whole story. Emotional connection, mental stimulation, and curiosity are huge components of sexual desire — and these can flourish at any age.
Research shows that women who address physical symptoms and engage in mental and emotional intimacy often report greater satisfaction than ever before.
Evidence-based approaches include:
Local vaginal estrogen or DHEA – restores moisture, elasticity, and blood flow
Systemic hormone therapy (HRT) – for vasomotor and libido support (for eligible women)
Pelvic floor physiotherapy – improves tone, orgasmic potential, and confidence
Mindfulness and cognitive therapy – rebuilds the brain-body connection that fuels arousal
Lifestyle strategies – sleep, movement, nutrition, and stress regulation are all sexual wellness tools
As Dr. Wise explores in her book Why Good Sex Matters (2020), desire starts in the brain — not in the bedroom. It’s the brain that integrates sensory, emotional, and hormonal signals to trigger arousal and pleasure.
When we nourish that connection — through self-care, communication, and curiosity — desire can reawaken, even in the face of hormonal change.
At PAUZ Health, we combine menopause-certified nurse practitioner care, hormone and non-hormone treatment options, and coaching support from dietitians, therapists, and pelvic experts. Our mission is to help women not just survive midlife — but thrive in it, fully.
Menopause doesn’t signal the end of desire — it’s an invitation to redefine it.
With the right medical care, lifestyle tools, and understanding of how your brain and body interact, pleasure can not only return — it can evolve into something deeper, more intentional, and more fulfilling.
🎧 Stay tuned for our upcoming PAUZ Podcast with Dr. Nan Wise, where we explore how the brain fuels sexual pleasure — and how you can turn yours back on.
Wise, N. (2020). Why Good Sex Matters: Understanding the Neuroscience of Pleasure for a Smarter, Happier, and More Purpose-Filled Life. Houghton Mifflin Harcourt.
Brotto, L. (2018). Better Sex Through Mindfulness. Greystone Books.
North American Menopause Society (NAMS). (2023). The 2023 Nonhormone Therapy Position Statement of The North American Menopause Society.
Kingsberg, S.A., et al. (2019). “Vulvar and Vaginal Atrophy in Postmenopausal Women: Findings from the REVIVE Survey.” Journal of Sexual Medicine, 16(7): 1080–1089.
Naftolin, F. et al. (2022). “Brain and Menopause: The Neuroendocrine Transition.” Frontiers in Neuroscience.
McEwen, B.S. (2023). “Estrogen Actions on the Brain: From Physiology to Behavior.” Annual Review of Neuroscience.