28: Let’s Talk About IT, Baby – What’s Actually Happening in Your Body Part 1

INTRO

Good morning and welcome back to Mornings with Megan. I’m Megan Pfiffner, Certified Nutrition Specialist and perimenopause expert, and this is the show where we spend a little time together every week unpacking what is actually happening in your body during this transition and, more importantly, what you can do about it.

Today we are starting something a little different. This is part one of a three-part series on sexual health in perimenopause. And before you think about skipping ahead, I need you to stay with me. Because this is one of the most important conversations we are going to have on this show, and one of the most neglected ones in women’s healthcare.

Today is all about what is actually happening in your body. Part two is what you can do about it. And part three is a deep dive into one specific tool I consider the most underused and underappreciated in the entire perimenopause toolkit.

Alright. Let’s go.

PERSONAL STORY

I remember when Salt-N-Pepa’s Let’s Talk About Sex came out. I was so excited by that song. Not because I had any real context for what they were singing about, but because it was the first time I had ever heard anyone talk about sex out loud like it was not something shameful.

I grew up in the American South. Land of sweet tea, abstinence education, and very enthusiastic slut shaming. My family was not particularly religious. Purity and virginity were not things my parents talked about explicitly. But culture is culture, and high school is high school. The gossip network around sexually active girls was vicious. And those messages do not stay in high school. They follow you.

So I grew up carrying a lot of guilt and shame around sex. There was a rebellious part of me that was angry about it. I knew it was wrong to use fear and misinformation to keep people in line. But knowing something is wrong and untangling it from your nervous system are two very different things. The narratives were still there, living in my body, shaping how I felt about myself.

Then at 14 I was put on birth control for terrible periods. And for the next twenty years, I had essentially no libido. I saw doctors. Therapists. Counselors. A physical therapist. A sex therapist. Not one of them connected it to the pill. I spent two decades genuinely believing something was wrong with me. That everyone around me was lying about orgasms and desire because none of it applied to me.

It was a nutrition counselor who finally, gently, said: did you know birth control can cause low libido?

I cannot overstate how that one sentence changed my life. I stopped taking birth control and for the first time had a sex drive. Which sounds like a happy ending. But then all of the baggage showed up. All the guilt, the shame, the false narratives I had been carrying since I was a teenager. Getting desire back was just the beginning. I had a lot of unpacking to do.

And then, just as I felt like I was finally getting my footing, I entered perimenopause. And things started shifting again.

I am telling you this because I know I am not alone. I hear versions of this story from clients all the time. And what I want you to understand is that for many of us, the psychological weight around sex and the physiological changes of perimenopause arrive at exactly the same time. That is a lot to navigate without a roadmap.

So today we are going to build that roadmap.

THE PERIMENOPAUSE MATRIX: WHERE SEXUAL HEALTH LIVES

Before we get into the physiology, I want to place this conversation inside the Perimenopause Matrix. Sexual health lives in the Connect pillar. And I want to be very clear about something: everything we are going to talk about in this series applies whether you have a partner or not. Solo sex is health. Connection with your own body and your own pleasure is health. That matters whether you are partnered, single, or anywhere in between.

The Connect pillar also touches the mental health dimension of the Matrix more than almost any other. When we experience pleasure, solo or partnered, our bodies release oxytocin. Cortisol comes down. Blood pressure drops. Mood improves. And the cardiovascular research we are going to cover later in this episode ties sexual health directly into the metabolic conversation as well. This is not a frivolous topic. This is a longevity conversation. And I want you to hold that frame for this entire series.

THE NUMBERS

Let’s start with something that might surprise you.

Female Sexual Dysfunction, which covers low desire, pain, difficulty with arousal or orgasm, affects approximately 22% of women under 20. That number climbs to somewhere between 40 and 75% in women between 40 and 50.

That is not a coincidence. That is perimenopause.

And yet most women never bring it up with their doctor. And when they do, they are frequently dismissed. Told it is stress. Told it is in their head. Told it is just part of getting older. So most women suffer in silence, thinking they are the only one, carrying shame about something that is actually incredibly common and, this is the important part, very often addressable.

I want to say that again. Very often addressable. You do not have to accept this as your new normal.

HORMONES AND DESIRE: THE FULL PICTURE

Let’s talk about what is actually going on hormonally.

When we are in our cycling years, sex hormones drive desire in a fairly predictable pattern. Estrogen rises through the follicular phase. Testosterone, and yes, women have testosterone, and it matters enormously, peaks right around ovulation. That is typically when libido is highest. Then progesterone rises in the luteal phase, estrogen and testosterone ease off, and desire quiets down before your period.

That monthly rhythm, that predictable arc of desire, many women do not even notice it until perimenopause, when it starts to disappear.

Here is what happens. Progesterone typically starts declining first, often well before estrogen does. This is a pattern I see over and over with clients. And I want to spend some real time here because the downstream effects of low progesterone go way beyond sex drive, and they all feed into each other.

Progesterone is our warm and cozy hormone. She supports sleep. She helps you self-regulate emotionally. She brings down anxiety. She keeps your mood stable and puts the brakes on estrogen so you are not dealing with heavy periods and cramps. When progesterone is strong, you do not have to work as hard to hold yourself together. She does that heavy lifting for you.

But when progesterone starts declining, either because of chronic stress, or because perimenopause is beginning, or both, things start to unravel in a way that is hard to trace back to a single source. Stress tolerance drops. The threshold to anger or overwhelm gets lower. Sleep becomes disrupted, often with those classic 2am to 4am wake-ups where you lie there running your mental to-do list. Anxiety ticks up. The capacity that used to feel automatic starts to feel like something you have to fight for every single day.

And here is the critical piece for this conversation: low progesterone and elevated cortisol travel together. They are deeply connected. When progesterone drops, cortisol tends to rise. And chronically elevated cortisol is one of the most powerful suppressors of sexual desire, especially in women.

So you have a situation where the hormone that was quietly keeping you calm, rested, and regulated has stepped back, and the stress hormone has stepped in to fill the space. That combination is not a recipe for feeling present, embodied, or remotely interested in sex.

THE LIFE CONTEXT: BANDWIDTH, BURNOUT, AND BEING UNSEEN

Now I want to add the real-world layer on top of the hormonal one. Because this does not happen in a vacuum.

Think about what most women’s lives look like in their 40s. Career demands. Kids, if they have them, often at their most logistically complex stage. Aging parents who need more support. Financial pressure. A household that does not run itself. The invisible load of managing everything and everyone.

And what used to be manageable, the juggling act that she had down, that she could do with her eyes closed standing on one foot, now feels like it takes everything she has. The bandwidth that used to exist does not exist anymore. The hormonal changes we just talked about are not happening alongside a calm, spacious life. They are happening in the middle of the busiest, most demanding season most women will ever navigate.

So when her partner turns to her at the end of that day and she has nothing left, that is not a character flaw. That is a woman who has been running on empty for months, whose stress cup is overflowing, whose nervous system is depleted, and whose hormones are making all of it harder to regulate.

And then there is a layer that we do not talk about enough. The layer of not feeling heard or seen.

This is something I hear from women constantly. As we move out of what society defines as our fertile years, there is a shift in how partners see us, in how we are treated at work, in how we are portrayed in culture. The cultural narrative around women in midlife is not exactly flattering. Think about how mothers are portrayed in film and television. The midlife woman. She is managing. She is capable. She is often invisible as a full person with her own desires, her own needs, her own interiority.

She is not having a fulfilling sex life. That is not part of her story. She is sacrificing. She is holding everything together for everyone else. Her pleasure, sexual or otherwise, is not part of the picture.

And when that is the story being told about you, when you feel unseen by your partner, undervalued at work, erased in the broader culture, what does that do to desire? What does that do to your sense of yourself as someone who deserves pleasure?

This is the ultimate she matters moment.

Because here is what I want to say directly: you matter. Your pleasure matters. Your desire matters. Not because it makes you a better partner or a more functional person, though it does do both of those things. But because you are a full human being whose quality of life and wellbeing count. Full stop.

Perimenopause has a funny way of forcing this reckoning. It is a time when many women start caring less about what other people think. When the tolerance for putting yourself last starts to crack. And the question underneath all of the physical symptoms is often: what do I actually want? Not what I should want. Not what I am supposed to want. What do I actually want?

That is not a small question. And the answer starts with deciding that you are worth asking it.

WHAT IS HAPPENING IN THE TISSUE

Let’s come back to the body, because there is a physical dimension to this that is just as important as the hormonal and emotional picture.

Estrogen is responsible for maintaining the health, thickness, and lubrication of vaginal tissue. As estrogen declines through perimenopause, that tissue begins to change. It becomes thinner, less elastic, and less well-lubricated. The medical term is Genitourinary Syndrome of Menopause, or GSM. It affects the vulva, the vagina, and the urinary tract. And it is far more common than most women know, because most women are not told to expect it and do not feel comfortable bringing it up.

GSM can mean reduced natural lubrication, burning or discomfort during sex, more awareness of friction, a higher risk of micro-tears and irritation, and more frequent UTIs and urinary urgency. That last connection is one we are going to come back to in a lot of detail in part three.

Here is what I want you to hear: you do not have to wait until sex is painful to address this. The time to pay attention is when you first start noticing things shifting. A little less lubrication. A little more awareness of friction. A little discomfort you did not have before. That is the moment to act, not years down the road when the tissue has changed significantly and every experience is uncomfortable.

We have good tools for this. We are going to talk about all of them. But I want you to walk away from today knowing that this is not something to push through and ignore.

THE CORTISOL CONNECTION

So let’s tie all of this together.

You have declining estrogen and testosterone affecting desire and tissue health from one direction. You have declining progesterone driving up anxiety, disrupting sleep, and lowering stress tolerance from another direction. You have elevated cortisol, driven by both the hormonal shifts and the relentless demands of midlife, suppressing desire from a third direction. And you have a cultural context that has been quietly telling you for decades that your pleasure is not important, that is now getting louder as you age.

It is a lot. Of course desire is complicated right now. Of course sex feels like one more thing on a list that is already too long. That is not a personal failure. That is a system under enormous pressure.

And the reason I am laying all of this out for you is because understanding it changes everything. When you know what is driving something, you can work with it instead of fighting it or feeling ashamed of it.

THE HEALTH CASE FOR SEXUAL HEALTH

I want to close with the research, because I want you to have this in your back pocket.

There is decades of research on the importance of sexual health to overall wellbeing, going back to Masters and Johnson in the 1960s. More recently, a study of over 3,000 participants between 57 and 85 years old found a clear positive relationship between sexual health and decreased risk of cardiovascular disease. For women specifically, having pleasurable sex and feeling emotionally satisfied was associated with lower rates of cardiovascular events. Not just frequency of sex: pleasure and emotional satisfaction. That distinction is important, and it is very specific to women.

We also know that orgasm, solo or partnered, releases oxytocin, which lowers cortisol and blood pressure. The stress relief is real and measurable. And given everything we just talked about regarding cortisol and perimenopause, that is not a small thing.

Sexual health in perimenopause is not separate from metabolic health, cardiovascular health, or mental health. It connects to all of them. It belongs in the longevity conversation just as much as blood sugar management or resistance training does.

And you deserve to have it.

CLOSE AND SERIES TEASE

So that is part one. We covered the personal and cultural history that shapes how we arrive at this conversation. We talked about what perimenopause does to desire hormonally: declining progesterone driving up anxiety and cortisol, fluctuating estrogen and testosterone changing how the body responds. We talked about what is happening in vaginal tissue. And we placed all of it inside the real-world context of midlife: the load, the bandwidth, the invisible work, the cultural erasure, and the very important question of what you actually want and whether you believe you deserve it.

You do. She matters. You matter.

Next week in part two we are getting into what you can actually do. Communication frameworks, chore play, and I cannot wait to get into that one with you, the truth about lubrication and why the lube you have been using might actually be making things worse, solo sex as body literacy, and how to start having honest conversations with yourself and your partner about what your body needs right now.

I will see you next week.