A conversation with Dr. Laura Buchanan for Sexual Health Week

“Most of the problems or maybe all are modifiable.” — Dr. Laura Buchanan

Sex during menopause carries a strange cultural double-bind. On the one hand, it’s whispered about, the brunt of jokey asides. On the other, it’s shrouded in silence, especially when discomfort, pain, disconnection, or confusion enter the room. During Sexual Health Week, Nutrition Network sat down with Dr. Laura Buchanan, board-certified in Family and Obesity Medicine, Certified Metabolic Health Practitioner, and a Menopause Society Certified Practitioner—to ask the questions too many women (and their partners) have been afraid to voice.

What followed was a hopeful, evidence-informed, deeply humane conversation about what actually changes during the menopause transition, why it changes, and what to do about it—with a special focus on sexual health. Below, we distill the key insights, practical solutions, and a gentle but firm nudge to get the right help sooner rather than later.

“Is my sex life over?” The myth that steals joy

Let’s start with the fear many carry quietly: when menopause hits, sex is done. Dr. Buchanan’s answer was crystal clear: No. That narrative persists because of stigma, silence, and a striking lack of clinician training, “I had one lecture in residency,” she noted even though women spend roughly forty percent of their lives post-menopause.

Are there changes? Yes. Do they have to end your sexual life? Absolutely not. Dr. Buchanan regularly sees women in their 60s, some who haven’t been sexually active for years, return to joyful intimacy after targeted treatment. The headline: sexual wellness in menopause is treatable, trainable, and reclaimable, when we address what’s really going on.

“I have patients whose partners tell me, ‘You gave me my wife back.’” – Dr. Laura Buchanan

What’s happening in the body: from hormone shifts to “why this hurts”

Perimenopause brings dramatic hormonal fluctuations estrogen surges then crashes, followed by low, steady levels post-menopause. That drop in estradiol triggers:

• thinner, drier, less elastic vaginal tissue
  
• higher vaginal pH, increasing risk for UTIs and yeast infections
  
• reduced natural lubrication and arousal
  
• more frequent pain with intercourse (dyspareunia)
  
• in some, orgasm quality changes
  

Women often describe pain as “tearing” or “like little daggers.” It’s not “just part of getting older” it’s physiology. And it’s fixable.

Genitourinary Syndrome of Menopause (GSM): the name is clinical; the reality is daily life

GSM is the umbrella for symptoms like dryness, irritation, pain with sex, recurrent UTIs, and urinary urgency. It’s common and under-treated:

• Over 50 million women experience GSM symptoms.
  
• Seventy percent (70%) of those report bothersome symptoms.
  
• Only 25% raise it with a clinician, due to embarrassment, normalization (“this is aging”), or past dismissal.
  
• Of those who do speak up, only a 7% receive treatment.
  

That gap is unacceptable. As Dr. Buchanan put it: every woman should be screened, because many won’t volunteer the information.

First-line fixes that work: local estrogen & smart add-ons

For the classic GSM picture (dryness, discomfort, recurrent UTIs), local vaginal estrogen is a game-changer. Applied internally and externally (including around the urethra), it:

• Restores tissue quality (thicker, more elastic, better lubrication)
  
• Reduces UTI risk substantially
  
• Improves comfort and arousal
  

Because estrogen receptors are distributed across the vulva, urethra, and bladder, local therapy treats the actual tissues in need. For persistent arousal or orgasm issues, local testosterone can be considered; there are androgen receptors in the same tissues, and some women respond beautifully when estrogen alone isn’t enough.

“If symptoms persist with vaginal estrogen, local testosterone can help increase arousal, desire, and orgasm quality.” — Dr. Laura Buchanan

Bottom line: Many women can resolve GSM and regain comfortable, pleasurable intimacy with targeted local therapy—no systemic hormones required.

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The pelvic floor: why tension (or weakness) can sabotage sex

We tend to think of postpartum when we hear “pelvic floor.” In reality, pelvic floor function is central to sexual wellness at every life stage. Menopause can exacerbate both high-tone (overly tight) and low-tone (weak) dysfunction:

• High-tone: more urgency, pain with penetration, difficulty relaxing
  
• Low-tone: more incontinence, reduced support, diminished satisfaction
  

The win? Pelvic floor physical therapy. Studies show 50–80% improvement in pelvic pain with targeted therapy. And while YouTube can be a useful primer, in-person guidance is often the difference between guessing and mastering the subtle “contract-relax” patterns that restore comfort and control.

Pro tip: If a provider is planning surgery for prolapse or stress incontinence, many will recommend local estrogen to enhance tissue health and reduce recurrence.

Beyond GSM: desire, arousal, orgasm – naming the patterns

Midlife brings real, diagnosable shifts in sexual function for many women:

• Dyspareunia (pain with sex): extremely common
  
• Hypoactive sexual desire disorder (HSDD): low libido with distress
  
• Arousal and orgasmic disorders: difficulty getting “there,” physiologically or psychologically
  

These are not moral failings or relationship indictments. They’re patterns with multiple levers—hormonal, neural, muscular, relational—and multiple solutions: local therapy, systemic HRT (when indicated), pelvic floor rehab, and, crucially, psychosexual support (CBT, sex therapy). The mind-body relationship is not optional here; it’s the whole game.

“Even once you give the hormones back, the body can remember pain—and the brain can remember fear.” — Dr. Laura Buchanan

HRT: safer than you think, more nuanced than you’ve heard

We touched on HRT not as a cure-all, but as a contextual tool for sexual health. Much of the fear comes from legacy interpretations of the Women’s Health Initiative (WHI). Our conversation highlighted several key clarifications:

• The estrogen-only arm (using a synthetic conjugated estrogen) was associated with reduced breast cancer incidence and mortality.
  
• The increased breast cancer signal was tied to synthetic progestins (e.g., medroxyprogesterone acetate), not bioidentical micronized progesterone.
  
• Route matters: transdermal estradiol avoids the liver “first-pass” that raises clotting factors with oral estrogen. This is a safety cornerstone.
  
• Timing matters (the “timing hypothesis”): Starting HRT earlier (perimenopause or within ~10 years of menopause) appears to confer broader benefits; starting late typically becomes neutral for heart outcomes (not harmful, but less likely to help).
  

Where does this meet sexual health? Systemic transdermal estradiol can improve vasomotor symptoms, sleep, mood, tissue health and—by stabilizing the internal environment—amplify the effect of local therapy, pelvic floor rehab, and psychosexual work. Micronized progesterone is necessary for uterine protection if the uterus is intact and may also aid sleep and anxiety in some women. Testosterone (transdermal), when HSDD persists, can support desire—used thoughtfully, with symptom-guided decision-making and appropriate monitoring.

“I usually introduce estrogen first and give it a few months before adding testosterone—so we know what’s doing what.” — Dr. Laura Buchanan

The psychology of sex: why therapy belongs in the toolbox

Menopause can layer physical pain with psychological anticipation of pain. The nervous system learns quickly: “This hurts.” Muscles brace. Arousal tanks. Focus shifts to “Will this be over soon?” Hormones can restore lubrication, elasticity, and sleep—but they can’t unlearn fear. That’s where cognitive-behavioral therapy and sex therapy shine: they help couples (or individuals) re-pattern arousal cues, rebuild safety, and reconsolidate pleasure.

Resources to explore:

• The International Society for the Study of Women’s Sexual Health (ISSWSH)
  
• The Menopause Society clinician directory
  
• Psychology Today’s therapist finder (filter by sexual health specialty)
  
• Come As You Are by Emily Nagoski (book) for a compassionate primer on desire patterns
  

Relationships under pressure: why support matters now

Menopause doesn’t happen in a vacuum. Mood swings, sleep disruption, brain fog, hot flashes, and painful sex can erode patience, closeness, and confidence, on both sides. In one survey of women going through or post-divorce, a striking majority reported menopause played a role. Would the right care change every outcome? No. Would it change many? Likely, yes.

The take-home isn’t guilt; it’s agency. Partners can learn, clinicians can upskill, and women can insist on care that addresses them as whole people: body, brain, and bond.

Lifestyle: necessary, powerful… and not a substitute for everything

Nutrition and movement matter: metabolically, hormonally, psychologically. Many women notice sugar or alcohol trigger hot flashes; higher adiposity tends to correlate with more severe vasomotor symptoms. Exercise supports bone density, strength, mood, and body image. Some women thrive cognitively with low-carb or ketogenic approaches; others simply need steadier meals with protein anchors and real-food patterns. The point isn’t to turn lifestyle into another perfectionist performance. It’s to stack the deck in your favor and then add targeted therapy where needed.

“I have many patients who do everything right—keto, training, sleep focus—and still need HRT. That’s not failure; that’s physiology.” — Dr. Laura Buchanan

Your next best steps (practical, doable, today)

1. Name what’s happening. If sex hurts, if you’re dreading intimacy, if UTIs keep returning—write it down. These are medical and treatable.
   
2. Ask about local therapy first. For GSM symptoms, local vaginal estrogen (with the right placement, including periurethral) is often the fastest comfort win. Consider local testosterone if arousal/pleasure remains stubborn.
   
3. Explore pelvic floor physical therapy. Especially if pain, urgency, or incontinence are present—or if “I can’t relax” is the refrain.
   
4. Consider systemic HRT (transdermal estradiol, micronized progesterone when indicated; transdermal testosterone for HSDD) with a trained clinician, especially if sleep, mood, cognition, vasomotor symptoms, and sexual wellbeing are major issues.
   
5. Add psychosexual tools. If pain created fear and bracing, therapy rewires the loop. It’s not “in your head”—it’s in your nervous system, which is trainable.
   
6. Loop in your partner. Education reduces defensiveness and replaces guesswork with solidarity.
   

A message of hope

“It is not too late.” — Dr. Laura Buchanan

Menopause is not the end of vitality or intimacy; it’s a transition—real, bumpy, but navigable. The right plan might be simple (local estrogen plus pelvic floor work) or layered (systemic HRT, local therapy, sex therapy). What matters is that you don’t go it alone, and you don’t accept suffering as the price of midlife.

Go deeper with us: Perimenopause & Menopause Training (30% off early-bird)

If this conversation resonated, if you’re a clinician, coach, or simply someone who wants a science-grounded, compassionate playbook—join Nutrition Network’s Perimenopause & Menopause training launching at the end of September. You’ll learn from experts like Dr. Laura Buchanan across:

• Hormone therapy – what to use, when, and why
  
• Sexual health in menopause – local therapies, pelvic floor integration, psychosexual care
  
• Metabolic health, bone health, cognition, sleep, mood
  
• Practical, clinic-ready protocols and patient communication
  

Early-bird: 30% off if you enroll before launch day. You’ll find the sign-up link in the comments of the Live, or email support@nutrition-network.org for details.

Let’s retire the taboo, replace fear with facts, and give women back what menopause stole from too many for too long: comfort, confidence, connection and yes, great sex.