Can hormone replacement therapy reboot your sex drive—or just complicate it?

With conversations around menopause still remaining hushed, what often gets discounted is its impact on one’s sex life. Can HRT be a solution?

Data suggests that globally, the onset of perimenopause takes place roughly around the age of 47, and menopause occurs at a median age of 51 among women. Meanwhile, for Indian women, due to lifestyle and genetic factors, the average age of perimenopause and menopause is 44.69 and 46.2 years respectively—magrinally earlier than their Western counterparts. What follows is a series of symptoms that, at first, seem undecipherable—from hot flashes to anxiety, insomnia to mood swings, and erratic menstrual cycles to extreme vaginal dryness. Though our cultural infrastructure doesn’t provide the same kind of counselling to women for menopause as it does to adolescents for periods, some common symptoms are more or less known. What often gets discounted is the impact of menopause and perimenopause on one’s sex life. 

According to an article published by the Indian Menopause Society, the hormones that influence sexual desire—estrogen, testosterone, and progesterone—reach “extremely low levels” during the menopausal period, therefore having an adverse effect on a woman’s sex life, sometimes even spawning sexual dysfunction. 

As a means to address the many health concerns that hormonal fluctuations in the body cause, including reduced libidos, hormone replacement theory (HRT) is being considered as an effective medical treatment. “The therapy involves administering the body with estrogen alone, or estrogen and progesterone together, particularly when the hormone levels in the body decline, like during menopause. It may also include testosterone or other hormones based on an individual’s requirements,” says Dr Ashwin Shetty, consultant, Obstetrics & Gynaecology, at Mumbai’s Sir H.N. Reliance Foundation Hospital. 

Also known as menopausal hormone therapy (MHT), estrogen replacement therapy (ERT), and gender-affirming hormone therapy (GAHT), depending on the objective of the treatment, hormone replacement therapy is gradually finding favour in India. According to data reports, the market size of HRT in India, valued at $606.3 million in 2022, is expected to reach $1,124.7 million by 2030, at a compound annual growth rate of 8 per cent. 

However, HRT is far from being a one-dimensional treatment—from its uses to benefits and even vehicles of administration. We speak to gynaecologists to learn more about HRT and how it can impact your sex drive. 

What exactly is hormone replacement therapy?

“Hormone replacement therapy is essentially a way to replenish estrogen and progesterone, which the body no longer produces naturally,” explains Dr Rohan Palshetkar, Professor, Department of Obstetrics & Gynaecology, DY Patil School of Medicine, Mumbai. “It mimics the natural function of these hormones in your body—the only difference is that they are supplied externally rather than being produced internally by your body.” He further states that typically, the treatment is considered when a woman is either menopausal, experiencing symptoms of menopause, has premature ovarian insufficiency, or has undergone a hysterectomy with removal of both ovaries. “In men, testosterone replacement therapy is employed to treat hypogonadism (when the body’s sex glands don’t produce enough hormones), or simply put, restore the testosterone levels,” adds Shetty.

However, HRT is becoming an increasingly viable solution for several medical challenges, from menopause to osteoporosis. It is also a crucial part of gender-affirming care, and can help with a few kinds of cancers driven by hormonal irregularities. Dr Vaishali Joshi, a senior gynaecologist at Mumbai’s Kokilaben Ambani Hospital, explains that HRT can be provided orally, transdermally,  and topically. “Oral tablets, skin patches, intra-uterine devices, and vaginal gels or creams are some ways to seek HRT,” says the expert. “They can help relieve hot flushes, night sweats, and psychosomatic symptoms along with decreased sex drive and osteoporosis.” In some cases, HRT is also administered through injectables, based on individual requirements. 

But, HRT wasn’t always the go-to choice that it has become today for both medical professionals and patients. In 2002, a study helmed by the Women’s Health Initiative (WHI), which was largely placebo-controlled, reported a higher risk of breast cancer diagnosis, blood clots, and strokes among those who opted for HRT. The news spread like wild fire, leaving patients highly sceptical about the treatment. For the longest time, HRT wasn’t even openly prescribed to women who were, perhaps, in dire need of the treatment. However, the prematurely terminated WHI study was full of loopholes and attracted a lot of critique. It was performed with only one oral pill, the results of which were applied to every type of HRT as a blanket generalisation. Furthermore, a sizeable majority of the subjects were aged between 50 and 79, already in the postmenopausal stage.

However, almost two decades later, according to a study published in 2019, out of the 24.3 per cent of women who were on HRT, only 9.7 per cent were apprehensive of it, indicating a propensity towards considering the treatment. 

HRT and sex drive: The good, bad, and ugly

While 71 to 76 per cent of middle-aged women state that sexual activity is important to them, studies suggest that roughly 50 per cent of them experience a loss of sex drive as they inch closer to the menopausal phase, underscoring the need to address the gap.

“I am much more interested in sex. Both physically and mentally. I use patches and vaginal creams as part of HRT. I’m very happy with the results, as I actually wanted my drive to come back. And the sex was getting painful, but now it’s pleasurable again,” shares a user on Reddit. 

As sex hormones such as estrogen, progesterone, and testosterone directly influence sexual desire, arousal, and functioning, HRT actually can be an enhancement to one’s sex life, cites Shetty. “In most instances, it enhances sexual well-being, correcting vaginal dryness, initiating libido, and rendering intercourse painless.” Palshetkar adds, “HRT also improves blood flow to the clitoris, which can enhance both arousal and orgasm.” Since most patients have greater sexual satisfaction after opting for HRT, it can also be included as part of an integrated sex therapy programme, especially for those with hormonal imbalances, furthers Shetty. 

However, the association between HRT and sex drive isn’t linear.

Sometimes, when the HRT plan depends heavily on oral estrogen, it can increase the sex hormone-binding globulin, thereby reducing one’s libido. “Side-effects like mood changes or breast tenderness could interrupt intimacy temporarily, at times,” says Shetty. “I’m 49 and have been on a low dose of HRT for about a year and a half. It recently occurred to me that maybe that’s killing my sex drive. I took about a week off from both the HRT prescriptions and felt a little more normal… but the hot flashes and troubled sleep are killing me,” confessed a user on Reddit.

“It is important to recognise that HRT involves substantial hormonal changes, which can lead to emotional and mental effects during the initial stages of adjustment. Some individuals may experience mood swings, anxiety, and irritability,” explains Dr Madhuri Agarwal, a Mumbai-based celebrity dermatologist. “Additionally, one of the primary effects is the growth of facial hair along with increased body hair in areas such as the chest, abdomen, and back. Scalp hair loss, or male pattern baldness, may be accelerated in individuals who are genetically predisposed,” points out the doctor. 

The challenges of HRT—and expert-approved measures to tackle them

Considering the hormonal upheaval that HRT can cause in the body, its effect on one’s physical, emotional, and mental health is inevitable. Headaches, breast tenderness, mood shifts, nausea, and disturbed gut health are a few physical consequences. “I have come across many patients undergoing HRT; they often experience body dysmorphic disorder (BDD) in various forms, even years after HRT is completed,” shares Agarwal.

Both men and women can feel confused, rejected, or insecure when their partner’s libido shifts, says psychotherapist and relationship counsellor Ruchi Ruuh, highlighting the effects of HRT on relationships. “Societal norms and gender expectations can shape reactions, though individual personalities and relationship dynamics do play a big role in altering sex drives. Men often tie their self-worth to sexual performance, so a partner’s lower libido may trigger feelings of rejection or inadequacy, leading them to question their desirability. A partner’s increased libido can feel exciting but also daunting if they can’t match it, leading to performance anxiety. Many men may withdraw rather than discuss feelings due to the fear of appearing weak or emotional. Women, on the other hand, may interpret a partner’s lower libido as a loss of emotional intimacy. They might worry, ‘Are we drifting apart?’” 

Regular follow-ups are essential for patients on HRT to ensure they are comfortable and responding well to the medication, advises Palshetkar. “Dosages may need to be adjusted based on individual needs, and treatment should be discontinued if not well-tolerated. In cases where a patient has relative contraindications, closer monitoring is required, and the therapy should be stopped as soon as symptoms subside.” Joshi adds, “HRT must be individualised depending on women’s pre-existing illnesses—like for breast cancer survivors, [those facing] risk factors like blood clotting, and compliance to be under surveillance when on HRT.” Palshetkar also explains that while HRT is a viable option, it isn’t a magical solution; turning to relationship counselling and opting for sex therapy can prove to be beneficial additions.

Since HRT can increase or decrease libido, the first step is creating a judgment-free space to discuss (libido) changes, suggests Ruuh. “Both partners should research HRT’s effects to anticipate changes. Knowing that they are more biological and not personal can reduce feelings of hurt or rejection. If the libido drops, explore non-sexual ways of connecting—through cuddling, shared hobbies or deep conversations. If libido rises, discuss pacing and boundaries to ensure mutual comfort and avoid pressure. The non-HRT partner should approach changes compassionately, recognising they’re often temporary.” 

A 2024 report by The Menopause Society states that approximately 75 per cent of women still don’t seek medical care for their menopausal symptoms. Out of those who do, around 50 per cent delay seeking treatment by over six months. Today, HRT poses as a practical and feasible solution—under medical supervision—not only to tackle hormonal imbalances in the body but also to reclaim your autonomy when it comes to your sex life. 

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