Two words, two very different realities
Menopause is an event: the definitive end of periods, established after twelve months without bleeding, around fifty-one on average, between forty-five and fifty-five for most women. It is preceded by several years of transition — perimenopause — when cycles become irregular and symptoms begin, and followed by a lasting fall in oestrogen that affects the whole body. “Andropause” does not exist in the same sense: nothing stops in men, fertility persists, and testosterone falls slowly, by about one per cent a year from the forties. Only a small minority of men — a few per cent after fifty — develop a true deficiency with symptoms, which medicine calls late-onset hypogonadism. The word “andropause” is convenient; above all it is misleading, because it suggests a symmetry that does not exist.
In women: what changes
Three groups of symptoms, very unequal from one woman to another. Hot flushes and night sweats affect three quarters of women, for a few years most often, sometimes much longer; they break sleep, and it is the lack of sleep that does the rest — irritability, tiredness, mood. Mood and sleep disturbances, precisely, which are not “in the head” but linked to hormonal fluctuations and to waking. And the genitourinary syndrome: vaginal dryness, burning, pain on penetration, recurrent urinary infections, urgency. This one concerns about one woman in two after menopause, it worsens with time instead of passing, and it is the great absentee of consultations, because women do not mention it and doctors do not ask. Yet it is the easiest to treat.
Desire changes too, on average downwards, but for reasons that can be untangled: pain, first — one does not desire what hurts —, sleep, body image, and the context of the couple, far more than the hormones themselves. Women who have no pain and who sleep keep, in the studies, a desire close to what it was before. And orgasm does not disappear: it may require more time and more direct stimulation, which is useful information for both partners.
In women: what can be treated
- Dryness and pain can almost always be treated. Lubricants for sex and vaginal moisturisers used regularly are often enough; otherwise, local oestrogen — cream, pessary, ring — restores the tissues with minimal absorption into the blood, which makes it usable by most women, including many of those who cannot take systemic hormones, after medical advice. Other local options exist depending on the country. A pelvic-floor physiotherapist helps when pain has made the muscles tighten.
- Hot flushes respond to menopausal hormone therapy, the most effective treatment, whose benefit-risk balance is favourable for most women who suffer from them, when it is started before sixty or within ten years of menopause, and in the absence of contraindications — a history of breast cancer, thrombosis or stroke, in particular. The fears born of a large American study in the early 2000s have been largely reassessed since: the risk exists, it is small, and it is discussed case by case. For those who cannot or do not want hormones, there are non-hormonal treatments, including a new class of medicines approved since 2023 in several countries, some low-dose antidepressants, and cognitive behavioural therapy, which reduces the bother more than the number of flushes.
- Desire: first treat pain and sleep; then what applies at any age, on the page low desire. Low-dose testosterone is used in some postmenopausal women, under medical supervision, in the countries where it is available.
- What has not proved itself: custom-compounded “bioidentical hormones”, herbal supplements sold for menopause, and, to date, vaginal laser treatments, for which the studies are insufficient.
In men: what changes, and what can be treated
The slow fall in testosterone is not a disease, and most men do not notice it. What changes with age is the erection — slower to come, less firm, more dependent on direct stimulation, longer to return after an orgasm —, and that is first of all a matter of blood vessels: smoking, excess weight, diabetes, high blood pressure and inactivity weigh more than hormones. The page on erectile dysfunction and the one on erection medicines detail what can be done. A real testosterone deficiency is recognised by a cluster: low desire, disappearance of morning erections, tiredness, loss of muscle mass, sometimes hot flushes — and is proved by two morning fasting blood tests, both low. Only then is treatment discussed, with regular monitoring, and not in a man who still wishes to father a child, who has prostate cancer or untreated sleep apnoea. Taking testosterone “for fitness”, without a proven deficiency, improves nothing and carries risks.
Sex life goes on
About half of people aged sixty-five to seventy-four, and one in four after seventy-five, are sexually active, mostly as a couple — and the first factor that ends it is not age, it is the absence of a partner or the illness of one of the two. What changes is the tempo: more time, more caresses, sometimes less penetration, and more words. The couples who come through this period best are those who accepted to redefine what “making love” means, instead of measuring sex at sixty by the yardstick of sex at thirty. The page on sex and ageing continues on that ground.
Two practical reminders. Contraception remains necessary until one year after the last period over fifty, two years before that age: perimenopause is a time of unexpected pregnancies. And sexually transmitted infections are rising among the over-fifties, because new partners after widowhood or divorce did not grow up with condoms: the rules of prevention and testing are the same at any age.
When to seek help
For a woman, as soon as dryness or pain set in — they will not pass on their own —, when hot flushes break sleep, or in case of bleeding after menopause, which is always shown to a doctor. For a man, when erections or desire change markedly, because it is sometimes the first sign of a cardiovascular problem. The family doctor is the first door, then the gynaecologist, urologist or endocrinologist; the page who to see, and when gives the details.
Frequently asked questions
Does menopausal hormone therapy cause breast cancer?
It slightly increases the risk with combined treatments taken for several years — of the order of a few additional cases per thousand women treated —, and this excess decreases after stopping. It is not considered for a woman who has had breast cancer. For the others, the decision is made by weighing symptoms, age and history, and is reviewed every year.
Is oestrogen cream “hormones”?
Yes, but at a very low dose and with local action: absorption into the blood is minimal, and that is why it is offered to women who would not take systemic treatment. Most guidelines consider it safe in the long term.
My husband is fifty-five and has less desire: is it andropause?
Perhaps, rarely. Before blaming testosterone, one looks at sleep, alcohol, weight, mood, medicines and erections — and testosterone is measured in the morning. A confirmed deficiency is treated; a drop in desire without deficiency belongs to the page on low desire.
Can you have sex with bleeding after menopause?
Any bleeding after menopause must be examined first, however slight, even once: it is most often atrophy or a polyp, but it is also the warning sign of endometrial cancer, which is all the more curable the earlier it is seen.