She came in for hot flushes.

The case

What she is not saying

She has framed pain as low desire, and low desire as ageing. She has framed the problem as her husband's annoyance, not her own loss. She raised it at the door, the moment with the least risk of a conversation.

Each of these is common. Each is a reason the problem goes untreated. Pain with sex is often the first cause of lost desire, not the result of it. Treat the pain and desire frequently returns.

Hope's commentary. The doorway disclosure is a test. She is checking whether it is safe to talk about. If the answer is a pamphlet and a rushed goodbye, she will not raise it again for years. If the answer is "Thank you for telling me. Can you sit back down for two minutes?" you have changed her care.

How to ask

Normalise first, then ask directly. Three questions cover most of it.

"Lots of women notice changes in their sex life around menopause. Has anything changed for you?"

"Is sex ever painful or uncomfortable? Where do you feel it, and when?"

"How do you feel about it? Is it a problem for you, not just for your partner?"

Use her words back to her. Avoid euphemism. Say vagina, vulva and sex. Clinical plain speech signals that the topic is allowed.

Check safety

Her partner's annoyance deserves one more question. Ask privately and without assumption: "Do you ever feel pressured into sex, or unsafe at home?"

The October 2026 issue of Menopause includes a study of sexual function and intimate partner violence in middle aged women. Coercion and violence in midlife relationships are under recognised. A routine safety question costs seconds.

Assessment

Take a focused history: site of pain, at entry or deep, onset in relation to menopause, bleeding after sex, urinary symptoms, lubrication, arousal, orgasm, mood, medicines, relationship and her goals.

Examine with consent. Look for pale, thin, dry tissue, loss of folds, narrowing at the entrance, fissures and signs of lichen sclerosus. Check pelvic floor tone. Pain with light touch at the entrance and high muscle tone point towards a pelvic floor component.

Evidence based options

Vaginal oestrogen. Systemic hormone therapy does not relieve vaginal symptoms fully in every woman. Adding low dose vaginal oestrogen is safe and appropriate. Review after eight to twelve weeks.

Moisturisers and lubricants. A vaginal moisturiser two to three times a week, and a water or silicone based lubricant during sex.

Pelvic floor physiotherapy. For high tone, pain at entry and fear of pain. Dilators under guidance where needed.

Sex therapy or couples counselling. For avoidance, anxiety, mismatched desire and conflict. Suggest the couple pause penetrative sex while pain is treated, and keep touch that does not hurt.

Testosterone. Consider only if distressing low desire persists after pain, mood and relationship factors are addressed. The 2019 global consensus supports a trial of transdermal testosterone in postmenopausal women with hypoactive sexual desire disorder, with levels checked at baseline and three to six weeks, kept in the female range, and stopped at six months without benefit.

What to document

Pain with penetration since about a year after menopause. Distress present. Relationship strained. Safety question asked. Examination findings. Plan: vaginal oestrogen added, lubricant advice, referral to pelvic floor physiotherapy, review in ten weeks.

Clear documentation means the next clinician continues the conversation instead of restarting it.

Key points

• Ask about sex at every menopause review. Do not wait for her to raise it.
• Low desire in midlife is often secondary to pain. Treat pain first.
• Systemic hormone therapy may not be enough for vaginal symptoms. Add vaginal oestrogen.
• Ask about safety when a partner's reaction drives the disclosure.
• Refer: pelvic floor physiotherapy and sex therapy change outcomes.