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But Where’s Our Little Blue Pill?
“That’s not going to happen to me!” my friends and I insisted as we segued into our postmenopausal years. Nope, we were convinced that things would stay fun, frequent, and fully satisfying as we aged, stereotypes be damned. We needed, wanted, and deserved great sex and assumed we would have it. Lots of it.
But it turned out, some of us were wrong.
Consider my friend Jenny*, 60, who reminisces about the weekends she used to spend luxuriating in bed, having sex. “After menopause, it was as if someone pushed a button, and my sex drive, while not totally gone, has diminished hugely,” she says. “I went from someone who really cared about sex a lot to, ‘I could have it; I could not have it.’”
It also didn’t help that sex, all of a sudden, became intensely painful. “It felt like I was going to be torn or ripped open. My husband and I would have to give up,” she says, wistfully.
Jenny, who lives in the Northeast, certainly isn’t alone struggling with this nasty later-in-life surprise. During perimenopause—the transition period when the ovaries begin to close up shop—and menopause—officially 12 months after a cis woman’s last period—estrogen production tapers off, which can wreak havoc on the body and a once-flourishing sex life. With 51 being the average age of menopause, a woman may have been dealing with these frustrations for a decade or longer by the time she turns 60.
Many find themselves facing down the twin, interrelated problems of dwindling desire and uncomfortable—sometimes even excruciating—sex. The vagina can get narrower and shorter. The tissues become thinner, drier, and less elastic. Research shows that up to an astonishing 84 percent of postmenopausal women experience dryness, burning, pain or other very unsexy sensations, while one study found that more than half report struggling with low sexual desire.
When you realize that approximately 1.3 million U.S. women enter menopause every year, you can grasp how huge a problem this is—and how confounding it is that these symptoms have been shrugged off for so long. Until recently, women like Jenny may have turned up at the doctor’s office for a cursory, possibly condescending consult and sent home without much help or even sympathy (“Who cares about your orgasm?” may have been the extent of the “treatment”).
But increasingly, there’s evidence that a sea change is underway. The medical community is realizing that aging vaginas are no longer flyover territory, and businesses are waking up to the fact that this category might be—surprise!—exceptionally lucrative. One research firm estimates that the global menopause market was worth a cool $16.9 billion—with a B—in 2023.
All kinds of companies, from pharma to personal care, are diving into this vast white space with a dizzying array of solutions, in what has been trumpeted by the media as “a menopause gold rush.” In the last seven years, start-ups addressing menopause care received an impressive $530 million or so in funding. You may have found Womaness’s Me.No.Pause hormone-free supplements in the aisles of Target or seen ads on YouTube for Imvexxy, a prescription vaginal insert that treats painful intercourse. Meanwhile, celebs like Gwyneth Paltrow, queen of all that is well, and Drew Barrymore are angel investors in a menopause telehealth start-up (and also talking openly about their own mood swings and hot flashes).
“Companies have thought, ‘Why am I going to reach out to someone in their 50s and 60s? I’d rather market to someone between the ages 18 to 35,’” says Abby Miller Levy, cofounder and managing partner of Primetime Partners, a venture capital fund that focuses on older Americans (and an investor in Womanness, for example). But these are the facts: Adults 55 and older control nearly two-thirds of household wealth in this country, although only about 5 percent to 10 percent of marketing budgets vie for the over-50 demographic.
Men of a certain age had their most common sexual dysfunction problem addressed when the revolutionary “little blue pill,” Viagra, hit the market in 1998, giving the vast majority of prescribees (up to 95 percent, according to some studies) the ability to regularly, reliably get it up again, and generating billions (again…with a B) of dollars in sales for Pfizer. Women, on the other hand, have struggled to get the medical establishment to take their sexual health seriously, much less devote the time and money needed to create a “miracle treatment” that mirrors Viagra. Need I remind anyone that women’s health has historically been vastly under-researched and underfunded? In 2020, the National Institutes of Health devoted only a meager 10.8 percent of funds to conditions that specifically or predominantly affect women.
Combine that systemic low-boil misogyny with a dose of ageism and a general fear of women’s pleasure, and you can see why the landscape has been desolate for so long.
Part of the reason that the tide may, at long last, be turning is thanks to today’s postmenopausal women, who are used to defying the limits of aging and won’t take “go away” for an answer—they are, after all, the first generation who came of age with IVF. So it’s no wonder they’re not shy about demanding attention for what might have made their moms blush. “A couple of decades ago, I’d ask menopausal women very carefully about their sexual wellness to draw them out,” says Rebecca Dunsmoor-Su, MD, chief medical officer at Gennev, a leading virtual menopause clinic, and former medical director for menopause at Providence Swedish health system in Seattle. “Now they’re walking into my office and saying, ‘My vagina is dry—you need to fix this.’”
So what does it all add up to? Could all the attention, buzz, sleek new products and spigots of funding mean a Viagra-like game changer is on the horizon—a little pink pill that will usher in a new frontier of female sexual pleasure with no expiration date? Are the sex lives of women over 60 actually getting better? Or is this menopause gold rush just the latest bright and shiny bauble that’s more slick marketing coup than genuine technological revolution?
To understand how badly some women want to fix their fading sex lives, let’s start off with why someone might be tempted to point a laser at their vagina—especially if the usual first line of defense treatments (lube, vaginal moisturizers) have failed and they’re skittish about taking estrogen (more on that later).
Consider Shari from Texas, who’s about to turn 60. Post-divorce, her sex life was slow for a while. When she did get back into bed with someone, the sex was surprisingly painful. At the same time, Shari happened to meet a doctor who recommended the MonaLisa Touch, the brand name of laser therapy, which works by destroying small amounts of tissue (like when you get a cut or scratch) triggering it to generate new blood vessels and produce more collagen and elastin to enhance flexibility and self-lubrication. These kinds of treatments emerged about a decade ago and they’re everywhere these days—advertised in doctor’s offices and medispas and so widely available that they’re as well-known as liposuction.
This technique for the purpose of improving sexual function, to be clear, is off-label, and as of yet only approved in gynecological settings for things like nuking precancerous vaginal tissue and genital warts. It is not cleared by the FDA to treat GSM (that’s “genitourinary syndrome of menopause,” used to describe the range of postmenopausal vaginal and urinary symptoms, which replaced the more catastrophic-sounding diagnosis of “vaginal atrophy”). In 2018, the FDA even warned against their use for symptoms related to menopause and sexual function, cautioning about terrifying adverse side effects, like vaginal burns, scarring, and chronic pain, although later studies found them to be relatively safe. “In general, in the hands of an experienced gynecologist, it’s a safe option to try,” said Dr. Dunsmoor-Su. But, she warns, “Do not go to a medispa. No medispa should ever laser your vagina.”
Shari noticed a difference after three treatments—enough for her to justify the $1,000 cost for each, not covered by insurance. “If I have to not eat to do this instead, I will,” she says. “I thought the sex part of my life was finished. But this has made me feel more vibrant, like I can still have fun at this age.”
While laser therapy clearly has its die-hards, the evidence that it helps treat GSM is mixed. Some doctors strongly caution against trying anything branded as “vaginal rejuvenation” and balk at claims that the treatments make the vagina “younger.”
Lately, newer techy tools have joined lasers in this wild west of cutting-edge vaginal devices—most of which are said to increase circulation and activate collagen production in the vagina, which can build lubrication and elasticity. There’s radiofrequency treatments, like the EmFemme 360 (introduced in 2022) and ThermiVa (on the market since 2015), which heat the vaginal walls, kind of like a hot stone massage. There are at-home tools on the market too (no self-lasering, don’t worry), like the Joylux vFit Gold (about $395), which is described as an “intimate health device” and is essentially a red-light wand that’s inserted into the vagina for 6- to 10-minute sessions every other day. For those who don’t like sticking devices inside their vagina, there’s the Madorra ultrasound, which was developed at Stanford and works by stimulating local heat and blood flow, ostensibly helping with lubrication and is intended to treat vaginal symptoms of GSM. Madorra received a Breakthrough Device designation from the FDA based on promising results and is currently submitting more data to the agency for priority evaluation.
But while these interventions work for some, none of them have yet undergone enough rigorous or widespread testing to be considered surefire fixes. Often, one woman’s magic bullet is another’s no-go in terms of results. And in any case, some women understandably just don’t want to heat up their vaginas.
And that’s before we even try to crack the enigmatic mystery of plummeting sexual desire. Once pain is associated with intercourse, you enter “chicken and the egg” territory: Do I have low desire because the urge is gone, or do I have low desire because sex hurts so much?
There is a long-standing belief that men are always happy to have sex (although between 12 and 52 percent of men 60 and over do, in fact, struggle with lack of desire) while women’s sexual appetite is thought to be fickle—blown sideways by all kinds of psychological and situational factors. The fact that female libido may be perceived as “here one second, gone the next” could be one of the reasons that faltering desire doesn’t always get the attention it deserves: ‘Well, of course, it’s not there. What did you expect in a woman?’ There is some evidence to suggest women’s sexuality is more complex and fluctuates more than men’s over time, though clearly it’s not as simple as all that gender essentialism.
“With something like Viagra, the problem is physical—you just need to get blood into that member. With women, we could fix the physical problem of vaginal dryness or pain, but there's so much more that goes into a desire cycle,” says Dr. Dunsmoor-Su. Add some GSM to that, and sex can be a nonstarter. “So much of the beginning of the desire cycle for a woman is in her brain, and if she’s not looking forward to sex because she knows there are 57 steps to go through, it’s very hard to get to where it’s like, ‘Oh yeah, it’s worth it to me.’”
You might have heard of Addyi and Vyleesi, two drugs engineered to enhance female desire by regulating chemical messengers in the brain. They hit the market in 2015 and 2019 respectively to great fanfare and questions about their efficacy, but neither was approved for use by postmenopausal women—arguably the people who need it the most.
Testosterone is another emerging, off-label option that certain doctors swear by, although experts say more research is needed on its long-term usage and efficacy. Urologist Christi Pramudji, MD, founder and owner of ChristiMD Medical Group in Houston, says that a dissolvable Tic Tac–size pellet inserted under the skin every few months is the number one fix to a low sex drive for her patients. “I had my pellet put in at 3 p.m., and by 8 p.m., I said to myself, ‘This is life-changing,’” says Pam*, 62, in the Southwest. “It’s made a real difference. I plan to be vital and passionate with my husband for decades.”
Doctors tend to say that if you want to keep having sex, among the most proactive things you can do is to have regular sex—the precept of “use it or lose it,” so to speak. Here’s what Melanie Marin, MD, director of the menopause program at the Mount Sinai Health System in New York, says about low sex drive: “I want to be very cautious about what I’m saying here and my younger self would probably be furious with me, but if you have a partner you love and they’re interested in having sex, it may be worth saying yes, especially if you know you’ll enjoy it once you get started, because that will often stimulate women’s desire as well.” (That’s all with the assumption that GSM doesn’t make sex utterly unbearable, as it does for some).
Side benefit: Regular intercourse can help keep vaginal tissue healthy (again, when GSM symptoms are controlled), encouraging elasticity and enhancing blood flow. Regular sex doesn’t necessarily have to be with a partner either—masturbation can be just as effective in keeping a woman’s machinery ready for action.
But let’s be real: Tackling low desire and vaginal symptoms can feel like training for a marathon for something that used to come so easily. And all this happens at the exact moment when other age-related health concerns may demand time and attention. Jenny, for instance, is also now dealing with osteoporosis. “To go to pelvic floor therapy, try dilators, buy the vaginal moisturizer your friend swears by, it’s so much work,” she says.
Combine all of these interventions with over-the-counter postmenopausal supplements (vaginal probiotics, for instance), a thicket of prescriptions meds, vibrators suggested for older women (including one so intelligent that it uses AI to analyze your orgasm patterns) and nutrition plans that may or may not work, and women are left to navigate a terrain of endless products and recommendations, figuring out what’s real and what’s just hype on their own. And while they are experimenting and their symptoms are not fully yielding, a sense of despair and futility can set in.
Jenny says after trying many of these treatments for years, she’s mourning the sex life she used to have. She can’t bear to watch sexy movies or shows anymore (no ‘Normal People’ for her). “It makes me so sad. I just feel like that’s not a part of my life anymore,” she says. “I check in with my husband…‘Are we okay like this?’”
After researching dozens of studies, talking to so many postmenopausal women about the state of their sex lives, and surveying the vast landscape of new gadgets, pills, and whatsits, I’ve got to say: I, too, am feeling deflated…borderline hopeless even. How is it possible that so much hype has yielded so little fruit for women like Jenny?
Look a bit more closely at the numbers behind the supposed gold rush, and you may see why we’re not there—at least not yet.
Between the first quarters of 2018 and 2023, investment in women’s health did increase a glorious 349 percent compared with just 15 percent across all health care, according to a Silicon Valley Bank report. But drill down on the numbers to see what’s truly being valued: In the first half of 2023, $142 million went to platforms that support women’s health (such as telehealth providers). Next in line, pregnancy and fertility bogart the spotlight, with $77 million and $33 million respectively, perhaps pointing to how much a woman’s worth is still enmeshed with her ability to have children. Bringing up the rear investment-wise is a relatively scant $11 million to menopause—which includes treatments for hot flashes, brain fog, and everything else, and lagging far behind the total $44 million figure for 2022. Investment in postmenopausal sexual health isn’t even broken out as its own category.
Why is so little cash still being thrown at sexual-health solutions needed by so many women (and those who control such a hunk of wealth)? Weren’t we promised that the Future Is Female, etc.?
Consider who continues to control the levers of power and money and you might get an idea. Women make up only about 9 percent of venture capitalists, and only 25 percent of senior roles in health care are held by women.
“Women have forever been told if you get menstrual cramps, take two Midol and suck it up. If you are pregnant and have morning sickness, eat saltines and suck it up,” observes Levy. “When it comes to menopause, no one has really encouraged women to seek solutions for a very pervasive, complex, confusing time. But public consciousness is starting to change, though it’s early days still.”
Raising that public consciousness is a more understated revolution than we had hoped for, but it’s still vitally important. Just remember what ritual humiliations used to await those who dared to seek help for menopausal symptoms. Dana*, 62, who lives on the East Coast, says that the first doctor she consulted about painful sex examined her and said, “I’ve seen worse.” She was sent home without any help.
Catherine Balsam-Schwaber, founder and CEO of Kindra, a company that focuses on menopausal wellness products (and another of Primetime Partners’ investments), says she went to a new doctor with aches and nightly fevers, only to feel dismissed after a consultation lasting maybe seven minutes. She was given a diagnosis of fibromyalgia, which she strongly suspected wasn’t the root of her issues, and an industrial-strength steroids prescription, which she didn’t take. (Silver lining: This experience spurred her to start her company.) Is it any wonder that according to a 2021 survey, a shocking 73 percent of women weren’t treating their menopause symptoms at all?
The funds that are flowing these days are headed toward improving education and accessibility, which, given how many women have had nightmarish experiences at their doctors’ offices, may be the best first step to eventually juicing up their sex lives. Capital is going toward a number of platforms (Midi, Evernow) that educate and empower women, with Gennev being a heavyweight that connects women via telehealth to board-certified ob-gyns and other medical practitioners who have experience and training in menopause. Plus, the visits are a full 30 minutes that allow for a deeper exploration than what in-person appointments with a gyno typically do. And, yes, these visits are often covered by insurance.
Surprisingly, it’s possible that all this new education around postmenopausal health could uncover that the best sexual health cure is an old one but one subjected to such a bruising PR campaign that many women continue to equate it to sucking down poison.
Estrogen is still the most effective treatment out there to treat GSM. Applied topically, prescription estrogen can amp up the vaginal walls’ lubrication and elasticity. Studies have shown local treatments—in the form of creams, inserts, and rings—are typically 80 percent to 90 percent effective for vaginal symptoms. If a woman’s life is derailed by a constellation of symptoms (night sweats, brain fog, weight gain, hot flashes) in addition to sexual issues, her doctor might recommend a systemic approach. This would be hormone replacement therapy (HRT), an oral dose of estrogen (often combined with progestin), which research has shown eliminates GSM symptoms in up to 75 percent of cases.
Once upon a time, HRT was the go-to solution for menopause’s myriad symptoms. But then, in 2002, a study called the Women’s Health Initiative found negative side effects, such as increased risk of heart disease and breast cancer. The study’s findings caused a furor and scared countless doctors and their patients off of estrogen.
Since then, many in the medical community have criticized the study’s design and findings. For instance: The age range and medical status of the participants was skewed, and only two HRT formulations were reviewed, when many more have since become available. But the damage was already done. Not only were women turned off HRT—they came to fear even local vaginal estrogen, with a 2011 international survey finding one-third of women had negative perceptions of it. (Cover star Lisa Rinna was one of those women nervous about HRT—although after consulting her doctor, she found the right hormone mix and hasn’t looked back since. You can read more about her HRT journey here.)
Dana was also among those with estrogen anxiety. She was using a vaginal cream with great results but stopped when a friend of hers was diagnosed with pancreatic cancer. Dana wanted to do everything possible to protect her own health. “I didn’t refill my estrogen cream prescription when it ran out,” she says, and sex slowed again. Her doctor eventually reassured her about its safety, but it took her three years to start using the cream again.
Yes, there can be a small correlation between some kinds of HRT and increased breast cancer risk for some women. But of local estrogen in particular, says Dr. Marin: “It is safe and effective for women who are at high risk for breast cancer, have breast cancer, or have had breast cancer.” Given how effective it is, the panic and bad press could be depriving millions of women of good sex.
Maddeningly, though, if you are using estrogen, the gender gap opens up again. Many major insurers in the country cover the generic version of Viagra, but Dr. Dunsmoor-Su says, “I spend hours trying to figure out which vaginal estrogen might be covered by an insurer to the point of affordability for a woman. Invariably, only one of them will be covered, but they’re not all equivalent; they work differently. I have patients who send prescriptions to Canada for this reason. If you’re going to give him Viagra to get it up, you need to give her the right product too.”
There are also some of the unlucky for whom even estrogen doesn’t seem to do the trick. Jenny was on a low-dose HRT both for osteoporosis and her sexual issues and uses a vaginal estrogen insert and although they’ve alleviated some of her discomfort, she still associates sex with pain and struggles with low desire—hurdles that are hard to overcome.
“I’m not ready to give up sex. I still dream about it.”
I wish I could tell Jenny that there was a simple pill for her to pop to feel like her 30-year-old self again, with no risks and side effects. In the absence of that, I wish I could tell her that there were scientists in lab coats working around-the-clock in an underground bunker to crack the code of endless female sexual pleasure, but that doesn’t seem to be happening either.
You could rage about the misogyny, the lagging funding, and the silence that shrouds the sexual problems of menopause and you’d be perfectly justified. But I choose optimism: The menopause gold rush, such as it is, is starting to make an impact. Perhaps most importantly, there’s a growing realization that women’s sexual pleasure should be taken seriously at any age, and that it can be vital to one’s quality of life. The goal, after all, isn’t just to make sex after 60 bearable. It’s about having an exciting, energizing love life, one that we dare to dream could get even better over time.
Women need to know that and accept nothing less.
As worn out as she is from chasing her former sex life, Jenny still craves what she had: “When my husband and I do have sex, it’s not penetrative, but we both say, ‘Why don’t we do that more often?’” she says. “I have a friend who’s 68 and says she’s having the best sex of her marriage. I’m so freaking jealous. So I’m not ready to give up sex. I still dream about it.”
*Name has been changed.
Magnified eye image: Stocksy. All other images: Getty Images.
