When Sex is the Last Thing on Your Mind

By Leslie Price

Even though more writers and experts seem to be discussing perimenopause and menopause these days, there is still one facet of the experience that's a bit taboo. It’s how women’s sexual desire can take a nosedive in their 40s and 50s.

That’s why this week, we’re featuring an interview with Jacqueline Giannelli. She’s a board-certified family nurse practitioner who specializes in women’s health with a focus on menopause, urogynecology, and women’s sexual health. Giannelli works for Elektra Health, a startup called which offers virtual menopause healthcare services, and she also practices medicine at Maze Women’s Sexual Health in New York.

Can you explain your job

When I became a nurse practitioner, I was working in urology with a urogynecologist in Westchester County in New York. So many women came to her for urologic issues, but also menopause-related issues. And conventional medicine just really wasn't helping them. [It was also] the way that they were treated in practice, like, "Okay, here. Go away." No one wanted to actually take the time to hear their stories.

That really bothered me. As a nurse, you're trained to listen to women and dig deeper with them. I felt like there was more work to do. Luckily, just down the street is the practice that I work in [now] called Maze Women's Sexual Health. It's exclusively dedicated to women's sexual health. Not just as in STDs, but [also] the categories of desire, arousal, orgasm, and pain with sex. We work with therapists, clinicians, and pelvic floor PTs to collaboratively help women to feel their best, be their best selves in their relationships, and come to terms with their sexuality.

I found a niche within a niche of taking care of women in menopause specifically. There was a large group of women, anyone basically over the age of 45, [for whom] there was no real clear path of conventional medicine. Primary care doctors don't really know what to do with women after child-bearing years. And OB-GYNs are not incentivized to take on this unique set of health needs that is different than in women of reproductive age.

I met with Jannine and Alessandra at Elektra over coffee right before the pandemic hit and we were just aligned in what we wanted to do and how we felt women should be cared for. That's how I got involved with Elektra and I continued to do both jobs.

What kind of expertise is out there right now regarding women's sexual health, especially in perimenopause and menopause?

I think right now women don’t even realize that they're in perimenopause when most are entering it. And that's a problem. There’s a clear lack of education. Women are in their childbearing years, in their 20s and 30s, and then they may just go straight into perimenopause. The changes in the beginning are subtle, so they may not be recognized. Oftentimes they'll go to their primary care doctor or their OB-GYN and say, "I don't feel like myself," or, "I feel really anxious," or, "My periods are getting a little closer together." Usually, [they turn to] their gynecologist, but as I'm sure you may know, only one in five gynecologists have any training in menopause.

And even if they do, these are doctors who are busy delivering babies and doing procedures and operating, and there's no time to talk about perimenopause. It's usually a quick, "Here, have an antidepressant," or, "Go on this birth control pill," or whatever the quickest fix is to make the problem kind of go away temporarily. 

Menopause is a natural transition. It's just something we have to learn to be okay with and anticipate. And it is a portal to the next phase of life, which is amazing. How do we want to live better in the second half of our lives, both from a hormonal-health perspective and from a sexual-health perspective? Women can have some of the best sex of their lives after menopause, right? When they're not worried about random bleeding and their mood is evened out a bit and they've kind of come into their own in terms of how much time they have and where they are in their career. It can really be a special time.

When you encounter women who are unhappy with what's going on in their sex lives and especially with their levels of desire, what are you seeing?

We definitely see a lot of concerns about desire. Women and men are both sold a bunch of lies about what sex is, looks like, and should be. And women feel like if they don't walk down the street and see the billboard of the guy with the washboard abs and get immediately turned on that there's something wrong with them. Or they are feeling not so great about their body after their childbearing years and are maybe having a little bit of stress incontinence or putting some weight on. Testosterone levels are definitely nearing the bottom of the barrel at that point. Testosterone starts to decline in your 20s and 30s. But really, by the time a woman is in her 40s and 50s, the chances are it's on the lower side.

There are some women who really need testosterone in order to feel a sense of sexual satisfaction. You can get what's called hypoactive sexual desire disorder, which is the clinical diagnosis where you miss that feeling of desire and that feeling of wanting to want it. It's distressing for women and it's a problem in relationships. In those cases, even in late perimenopause and around the time of menopause, testosterone-replacement therapy can be helpful for women. 

What is pleasurable for a woman? What turns her on? A lot of women have not spent time on their own exploring that for themselves. How can they tell their partners what they like if they don't know it for themselves? That's why a therapist, alongside a clinician, is a really great treatment plan because I can give a woman all the testosterone in the world, but if she doesn't feel good about her body or she doesn't know what turns her on, sometimes that's not helpful. 

What are some things women can do about a lack of sexual desire?

Spending some time finding out for yourself what turns you on. There are a lot of great outlets now for fantasy, for erotica. You can read a sexy story, there are audible stories, there's Audio Erotica. 

There are some supplements on the market that are easy and accessible. Ristela is one of them. It's completely hormone free and you can buy it online. Some women find it helps with arousal and even orgasms. And if you're having better sex or feeling more pleasure, you're innately going to want to have sex more often, which motivates you to explore more.

Vibrators are a great way to get in touch with your body a little bit, connect with the brain and the vagina, as we like to say. A lot of women think that they have to have this spontaneous desire and they're waiting for that. You're going to be waiting a really long time. So taking the initiative to start to figure out how to get aroused will begin this cycle of arousal, orgasm, pleasure, and then desire kind of follows secondarily rather than it being the primary means of the driver behind the sexual activity itself.

You’ve mentioned women tend to have responsive desire, and a lot of this is mental. What sort of challenges are women facing?

There are a lot of other factors that play into this, right? We are living in a time of great anxiety. Anxiety is a detractor from sexual satisfaction because in order to feel pleasure and to feel good in a sexual situation, you have to feel safe. You can't pause to get into that parasympathetic nervous system, that rest and digest mode. Treating anxiety, making sure that women feel grounded, that they can find a safe space in their body and in their mind to explore this is paramount and fundamental.

Unfortunately, a lot of SSRIs or [other] medications can have sexual side effects that are less than ideal. In our sexual medicine practice, we always look to see what medications the person is taking. Sometimes we add in other medications like Wellbutrin, for instance, that can counteract the sexual side effects of traditional SSRIs. Thyroid conditions are very common for women in their 40s and in perimenopause in general. And thyroid hormones can definitely impact other hormone levels like testosterone.

It is a very much a whole body kind of a thing. Sometimes it's an easy fix, but most of the time it takes a multimodal approach. Women need to have an open mind, be willing to shift some of their prior preconceived ideas about what sex is and what's acceptable. Having an open mind to think differently about what a satisfying sexual life looks for you is very helpful.

Women in the perimenopausal phase of life tend to have a lot going on, like young children, aging parents, stressful careers, and of course, living through a pandemic. Once people are on the other side of perimenopause, does it get easier for women in terms of sex and desire or is it just different?

Perimenopause can, for so many reasons, be one of the most challenging phases of life for women, especially if they're not prepared for it. Have some compassion for yourself. But like any good habit, if you think about sexual health as just as important as exercise or as eating well, as a wellness pillar, it becomes something you invest in and it becomes a priority. It's very easy to push sex aside and deprioritize it because we don't really see it as important to our every day, but it is. I mean, you get these hormones that are released with an orgasm and the ability to touch another human being.

Right now, we're all starved a little bit for physical touch with others, right? So that allows us to down regulate these stress hormones that we have coursing through our veins at all times, and it can be a nice escape from what's going on out in the world. What I see is that it does get a lot better after menopause for women who put that time in earlier on. So even if it's once in a while, doing something to prioritize sex will pay off postmenopausally because those neural connections you worked on are there and ready to go.

There's this confidence that postmenopausal women have where they don't care as much about what other people think. And that translates a lot in the bedroom. But I think asking somebody who hasn't had any sexual activity in 20 years to then all of a sudden turn around postmenopausally and to do all that is a reach. 

I think there is an interesting schism where some people are like, "I want to feel sexy. I want to feel desire. I want to have sex," and then others are like, "I don't feel desire right now. I don't feel like having sex right now and I'm just going to go with it because that's what my body is telling me."

And that's okay. That's not pathologic if it's not bothersome to somebody. Intimacy can come in a lot of different packages, and it doesn't have to be sexual intimacy, it can be emotional intimacy. There is no right or wrong way to look at this. We tell women to be sexy, to be sexual, and that can put a lot of pressure on somebody. And women have a lot of pressure on them in general, in life, especially in perimenopause. Even if it's just dedicating five minutes a month to something that you think would be good for you and your partner or you and yourself, sometimes that's all it needs to be. Because everyone's at a different place and that's okay. There's no gold standard for this.

If people want to go to you for help, what’s the best way for them to go about that?

If anybody's local to New York and wants a full, in-person sexual health visit with us at Maze, certainly they could come do that. But for the majority of people that's just not feasible. So I think the Elektra Health sexual wellness consultation is a great resource. There are a lot of things women can do that don't require medical treatment or a prescription. You can do that once, you can do that twice, you could meet regularly if you wanted for accountability, whatever way the person feels would be most helpful, that can be arranged and it can be all done virtually.