Up to half of women experience symptoms like vaginal dryness, painful sex or low desire during perimenopause and menopause — the life stage when hormone levels begin to fluctuate and eventually decline as menstrual cycles come to an end.

Yet many women don’t discuss these changes with their doctor.

Obstetrician and gynecologist Dr. Maggie Evans of Novant Health Menopause Care and Sexual Wellness Center – Daniel Island wants to change that — especially since these symptoms are treatable.

Here are five things she wants you to know.

1. Sexual health is part of your health.

Why are women hesitant to discuss sexual health with their doctor?

It goes back to the beginning of our sexual education. We’re so limited from what we learn in school — many women don't even know their own anatomy very well, and sex education only focuses on prevention of pregnancy and sexually transmitted diseases. There’s never any mention of wellness or pleasure, and these aren’t things women have been taught to be comfortable bringing up.

But sexual health is one of our basic health rights and a huge part of our well-being, whether we're in a partnered relationship or not. It deserves attention just like other areas of your health.

How does sexual health connect to overall well-being?

We look at health from a bio-psycho-social standpoint. If something is going poorly in your physical (biological) health — for example, if you’re dealing with chronic pain — then that can affect your psychological health and social relationships.

If your physical intimacy is causing distress, that negatively affects the relationship you’re in and can affect your overall well-being. But if you feel good about your physical intimacy, that improves your relationships and life quality.

Intimacy and sexual health are just as important to your wellness as eating healthy foods and moving your body. They just don’t get as much focus.

2. Changes in desire, sensation and arousal are common during perimenopause, menopause and postmenopause.

How can fluctuating hormones during perimenopause and menopause impact sexual desire?

Perimenopause, menopause and postmenopause cause a drop in hormones, and it’s not a linear drop — they go up and down. I think of our hormones during this life stage like cell phones — on any given day, they could be 98% charged or they could be in 5% low battery mode.

The areas involved in sexual wellness, arousal and orgasm can also become affected. Most women can't put a finger on it at first, except for that they just know they “don't quite feel like themselves.”

What happens in the body during perimenopause, menopause and postmenopause that can affect arousal and orgasm?

The main components involved in sexual health are the brain, the pelvic floor and its musculature, and the genital organs.

The brain starts the sexual pathway, from thinking about sex (desire), to shutting off at the end to be able to crest into orgasm. Everything starts and ends in the brain. As our hormones start to shift in perimenopause and menopause, it affects the other neurotransmitters in our brain, and that can affect interest and sexual response.

The pelvic floor, a hammock made of muscles, nerves and connective tissue that stretches across the bottom of your pelvis, is responsible for the contractions of orgasm. The pelvic floor can become tight or loose due to aging, pregnancy, caring for children, medical issues like chronic constipation, or pain. A too-loose pelvic floor may result in decreased sensation and difficulty with arousal and orgasm; an overly tight pelvic floor can lead to painful sex and low desire. Midlife is a common time for the pelvic floor to fall out of balance.

Your genital organs are directly affected by fluctuating estrogen and testosterone. This can cause tissue thinning, loss of blood flow, and — when it progresses far enough — a narrowing and shortening of the vagina and vulva. The size of the clitoris can also decrease, changing how an orgasm feels.

Most people are familiar with a man’s erection — a sudden buildup of blood in the penis. The clitoris and the male penis are essentially the same organ with the same parts — although we can’t see it, the clitoris goes all the way down the sides of the vulva, and women must have blood flow to the vulva, vagina and clitoral areas for adequate arousal.

Thinning vaginal tissue also causes problems. Your vaginal walls are supposed to be stretchy, but when they become too thin, sex can become incredibly uncomfortable. Thinning tissues also produce less lubrication. These changes can cause uncomfortable sex and decreased ability to orgasm.

3. Every woman’s experience during perimenopause, menopause and postmenopause is different.

All women go through menopause. But how we go through it is different for every woman.

If we tell our peers it’s happening and they reply, “I don't have any issues with that,” we start to feel alone, and that's when we really don't bring it up with our doctor. But it may just be that they’re experiencing different symptoms than you. Your experience is valid.

4. Sexual changes during perimenopause, menopause and postmenopause are common — but you don’t have to accept them as your ‘new normal.’

It’s common for our sexual encounters to change as we age. In a partnered relationship, if both partners are comfortable with that change, then that's OK.

Some couples say, “We have sex a few times a year and we are totally fine with that.” Others say, “We used to have sex every day, and so the fact that we're doing it twice a week is very distressing to me.” Both responses are valid.

If changes are bothering you, keep two things in mind:

These changes aren’t personal: Stigma has led us to believe that if arousal isn't easy, then we just aren't as attracted to our partner or there's something wrong with our relationship. You can be as attractive and as attracted to your partner as ever, and the arousal is still not working like you want it to. That’s biology — not a reflection of your relationship.

There’s a fix for every one of these changes: When sexual dysfunction first was being studied, it was thought to be only a psychological problem. We now know there's significant biology behind it — and that means there are medical solutions. These changes are common, but "common" doesn't mean you have to live with them.

5. Treatment for sexual health changes during perimenopause, menopause and postmenopause is available — and it starts with one conversation.

How do I bring up my sexual wellness concerns with my doctor?

Message your healthcare team ahead of time through MyChart and tell them what you want to discuss. This gives your provider time to prepare, and means the hardest part is already behind you: You've started the conversation.

Sexual health visits are billed and typically covered by insurance the same way as any routine gynecologic concern.

What treatments are available for sexual wellness during perimenopause, menopause and postmenopause?

Here’s an overview by symptom.

Lack of desire

Lifestyle treatments

Society acts like sexual intimacy and desire should just pop up spontaneously, but many factors can affect having time for intimacy: Responsibilities, jobs, travel, young kids, teens or college kids back in the house.

If intimacy has slipped down the priority list, consider intentionally making time for it, the same way you'd schedule workouts or other self-care. Books can also help you reclaim desire if it’s been lost, or find it in the first place. (Keep reading for recommendations.)

Medical treatments

We now have two FDA-approved medications for low desire for women called Addyi and Vyleesi. Many women have a great response to them. Some doctors are comfortable prescribing testosterone off-label, which could increase libido as well.

Pain during intimacy

Lifestyle treatments

Pain is never normal and should never be a normal part of our intimacy. If you’re having pain and have never tried adding lubricant to the picture, that’s certainly reasonable to try — but if that doesn’t immediately improve things, see your doctor.

Medical treatments

Painful sex sends signals to our brain saying, “I do not want this to happen.” Desire drops, and the pelvic floor shifts and gets tighter. If you continue having painful sex, it can start a landslide of problems — not just for your sexual health and your relationship, but for other functions of your pelvic floor like urination and moving your bowels.

So pain is one of the top things that you should really go in and have an exam for. Oftentimes, you will be referred to pelvic floor physical therapy, which is covered by insurance the same way that orthopedic physical therapy is and can really help. Sexual health therapists can also play a very powerful role.

When sex is newly uncomfortable, not as pleasurable, or when menopause symptoms are getting in the way

Lifestyle treatments

There’s a stigma that needing lubricant means you aren’t as aroused by your partner as you should be. However, lubrication has actually been shown to improve sexual satisfaction of both partners.

I recommend Uberlube and Good Clean Love brands. Some women apply it before things get going; others wait and see if it’s needed.

Medical treatments

When you have an orchestra and all the instruments are in tune, it sounds magical. But when one instrument is off, it's hard to enjoy the rest.

It can be the same with our other menopausal symptoms. It’s difficult to desire sex, enjoy it or seek it out if you’re not getting proper sleep, you’re having night sweats or hot flashes, or have brain fog and joint pain and feel exhausted.

Treating your menopause symptoms with hormonal or non-hormonal treatments can make a big difference in all aspects of daily life — including your sexual health.

The takeaway

Sexual health changes during perimenopause, menopause and postmenopause are common, but don’t have to be “normal.” If symptoms are bothering you, send that MyChart message to your ob-gyn and start the conversation.

You deserve to feel comfortable in your body and connected in your relationships — at every stage of life.