Stephanie Da Silva Davis, MD
Ten clinician-written topic summaries covering the essential education every woman navigating midlife deserves.
Sexual health goes far beyond intimacy. It reflects how your body feels, how your hormones function, and how comfortable and confident you feel in your own skin. Sexual health includes libido, arousal, lubrication, comfort, and orgasm — as well as your relationship with your body. It is not dependent on whether you are sexually active. When sexual health is supported, women often notice improved confidence, more stable mood, better connection, and greater vitality.
Estrogen, progesterone, and testosterone are foundational regulators of how you feel every day — not just reproductive signals. These hormones work in a feedback loop between your brain and ovaries. As that communication becomes less predictable, women may feel more anxious, more fatigued, or less resilient — before anything on the surface seems hormonal. Understanding this early allows for proactive care.
Perimenopause can begin in your late 30s or early 40s and last several years. During this time estrogen fluctuates unpredictably, progesterone declines, and the brain is constantly adapting. Common experiences include disrupted sleep, anxiety, brain fog, cycle changes, and decreased recovery. This is not just a reproductive transition — it is a neurological one. When we recognize that, we can treat it appropriately.
The vulva is the external anatomy: labia, clitoris, urethra, and vaginal opening. The clitoris — central to sexual function — is largely internal. The pelvic floor is a group of muscles that support pelvic organs, control bladder and bowel function, and contribute to sexual function. Understanding your anatomy allows you to better identify where symptoms are coming from and communicate clearly with your provider.
Genitourinary syndrome of menopause (GSM) occurs when estrogen declines and affects vaginal, vulvar, and urinary tissue — causing dryness, burning, pain with intimacy, and urinary urgency. Many women assume this is just aging. It is not. It is a treatable medical condition. Local vaginal estradiol or DHEA restores tissue health, improves blood flow, and reduces urinary symptoms. These therapies are considered safe and effective for most women.
Libido is the result of multiple systems: hormones, brain chemistry, stress, sleep, physical comfort, and emotional connection. There are two types of desire — spontaneous (interest first) and responsive (interest develops after connection begins). Many women shift toward responsive desire in midlife and assume something is wrong. It is not. It is a normal evolution. If libido has changed, the question is not 'What's wrong?' — it is: 'What factors are influencing this?'
Women produce testosterone naturally — from the ovaries and adrenal glands. It plays a role in sexual desire, motivation, confidence, and physical strength. Levels decline gradually with age and more rapidly after menopause. In select women, testosterone therapy may be helpful, particularly when libido is persistently low and other causes have been addressed. It is most effective as part of a comprehensive plan that also addresses estrogen, progesterone, lifestyle, sleep, and stress.
Pain with sex is common. But it is never normal. The pelvic floor muscles can become tight, overactive, or uncoordinated — leading to pain with penetration, pelvic tension, and urinary symptoms. Hormonal changes can further increase tissue sensitivity. Pelvic floor physical therapy is one of the most effective treatments available — it retrains muscle patterns, reduces pain, and restores function.
Estrogen interacts with serotonin, dopamine, and sleep regulation pathways — which is why hormonal changes can feel like anxiety, mood instability, loss of focus, and emotional sensitivity. These symptoms are often dismissed. They are not imagined — they are biological. When hormonal balance is supported, women commonly see improved sleep, improved mood, and better cognitive clarity.
Hormone therapy has been clouded by outdated messaging from the early 2000s. The science has evolved. We now understand that timing matters, patient selection matters, and formulation matters. For many women, hormone therapy improves symptoms, supports bone health, and enhances quality of life. Current guidelines support individualized, evidence-based decision-making — not avoidance based on fear.
Understanding how your hormones work together — and what happens when they shift — is the foundation of informed midlife care.
Testosterone peaks in a woman’s 20s and declines roughly 50% by the mid-40s. After menopause, ovarian production stops entirely.
The goal is to restore testosterone to normal female levels — monitored by labs and symptoms. Works best as part of a comprehensive plan.
Bioidentical hormones are structurally identical to those your body produces. FDA-approved options include transdermal estradiol and micronized progesterone.
Bioidentical hormones are structurally identical to those your body produces. FDA-approved options include transdermal estradiol and micronized progesterone.
Initial evaluation: symptoms, history, goals, labs (estradiol, FSH, TSH, testosterone)
Start low, go slow: low-dose transdermal estradiol with progesterone if uterus is present
Track symptoms: sleep, hot flashes, mood, vaginal comfort
Reassess at 6–12 weeks: adjust based on symptoms, not just labs
Annual review: ongoing discussion of benefits, risks, and goals
Common conditions — clearly explained, with evidence-based treatment options. Pain, discomfort, and anatomical changes are not something to accept or push through.
Burning, stinging, or pain at the vaginal entrance — especially with touch or intercourse — is often linked to changes in estrogen and testosterone. When hormone levels drop, vestibular tissue becomes thin, dry, and sensitive.
Vaginismus is the involuntary tightening of pelvic floor muscles, making penetration painful or impossible. It is common and treatable.
What you eat, how you supplement, and how you manage your environment all influence how you feel through the perimenopause and menopause transition.
Always consult your healthcare provider before starting supplements.
During perimenopause, fluctuating estrogen increases histamine release and decreases its breakdown — causing symptoms often mistaken for stress or anxiety.
Flushing, palpitations, dizziness
Headaches, anxiety, brain fog, insomnia
Bloating, nausea, food sensitivities (wine, cheese, fermented foods)
Worsening PMS, breast tenderness, cycle-linked migraines
Managing histamine involves reducing triggers, stabilizing mast cells, and supporting histamine-clearing pathways. A low-histamine diet, mast cell-stabilizing supplements (quercetin, vitamin C, magnesium), and stress reduction are the key tools.
Physician-curated tools, products, and links — organized by topic.
Soul Source Dilators — soulsource.com
Intimate Rose Dilators — intimaterose.com
The Pelvic People — Kiwi, Ohnut — thepelvicpeople.com
Rx: Estrace, Vagifem / Yuvafem, Imvexxy, Estring, Intrarosa, Beswecken DHEA
OTC: Revaree, Replens, Medicine Mama Vulva Balm, Via Solv Wellness, Uberlube
Rx: Addyi, Vyleesi, Testosterone — Testim, Androgel, compounded
Vella Women’s Pleasure Serum — vellabio.com
Foria — foriabotanicals.com
Alice Mushroom Chocolate — Happy Endings — alicemushrooms.com
Ristela by Bonafide — hellobonafide.com
Taboo to Truth — taboototruth.com
Hormonally — hormonally.org
Pelvic Global — pelvicglobal.com
Tight Lipped — Pelvic Pain Advocacy Nonprofit — tightlipped.org
ISSWSH / Prosayla — Sexual Health Education — prosayla.com
Marcella Hill — Wake Her Up — wakeherup.co
