Women’s Health for the Long Run: Sex, When “Fine” Isn’t Fine
What I learned about desire, comfort, pelvic health, and the cost of being dismissed
I want to start by being honest about something.
Sex was never something I was comfortable with until my 40s. I was raised in a conservative Catholic environment where sex was something you didn’t talk about, didn’t explore, and definitely didn’t ask questions about. A lot of shame and guilt came baked into the experience long before I had language for my own body. No one taught us about our vaginas, our arousal, or our bodies. Our mothers weren’t taught either. That gap didn’t start with us. It’s generational.
So when things started changing in my late 30s and early 40s, I did what most high-functioning women do: I rationalized a lot because none of it arrived like a clear breaking point.
I told myself I was tired. Overworked. Burnt out. Stressed. Traveling too much. Running too hard. I didn’t wake up one day with symptoms; they crept in slowly enough to feel like “just life.”
Until they didn’t.
When “you’re fine” becomes the most damaging sentence
Here’s what actually happened.
I started experiencing vaginal dryness; not mild discomfort, but dryness to the point where I thought something was wrong with me. Sex started to feel uncomfortable, then painful. I began questioning myself in ways that quietly broke me:
Am I not attracted enough to my partner?
Am I not turned on enough?
Is this a relationship issue? A me issue?
At the same time, my urinary patterns changed. I used to be able to hold my pee forever. Suddenly I couldn’t. I had urgency. Frequency. I peed on myself more than once because I couldn’t get to the bathroom fast enough. Right before my period, I started getting symptoms that mimicked UTIs, burning, urgency, even when tests came back “normal.”
My desire didn’t just dip. It disappeared.
And that was the most destabilizing part. I’m not someone who has ever been indifferent to desire — for sex, for life, for pursuit. Losing it felt like losing part of my identity. I felt ashamed. Embarrassed. Quietly depressed. I kept thinking: Is this it? Is this just how it goes now?
Medically, I was told I was fine.
More than once.
At one point, I was told to “focus more on foreplay.”
No one examined my vaginal tissue. No one talked to me about estrogen decline. No one mentioned perimenopause. And most physicians aren’t trained to diagnose or treat it, especially when symptoms show up before cycles fully change.
What I learned from clinicians I trust
Across sessions with Dr. Kelly Casperson, Dr. Mary Claire Haver, and pelvic health expert (aka The Vagina Coach) Kim Vopni, a few truths kept resurfacing, regardless of specialty:
Sex health suffering that doesn’t show up in bloodwork is still medical.
Vaginal pain, dryness, recurrent UTIs, low desire, urinary urgency, discomfort with penetration: these are not “normal aging.” They are treatable physiological changes that deserve real care.
Pleasure isn’t indulgent. It’s preventative.
Arousal and orgasm increase blood flow to the genitals and brain. Blood flow maintains tissue health, nerve signaling, and responsiveness. Ignoring pleasure doesn’t make symptoms go away, it often accelerates decline.
Vaginal estrogen is not cosmetic. It’s foundational.
This was one of the clearest messages I heard. Vaginal estrogen is a local blood-flow medicine. It replaces what the body naturally loses as estrogen declines and helps restore tissue thickness, elasticity, lubrication, and resilience. It’s often the missing first step, not the last resort.
Dr. Casperson put it bluntly: we spend a fortune caring for the skin on our face, yet we’re told to ignore the tissues of our vagina. Those tissues are just as hormone-responsive and just as deserving of care.
This isn’t vanity. It’s physiology.
Vaginal care is basic maintenance for tissue that depends on estrogen to stay healthy.
Pelvic floor health underpins everything.
The pelvic floor supports continence, posture, core stability, sexual response, and confidence in movement. Dysfunction isn’t always weakness; tightness and poor coordination are often part of the problem. Internal evaluation by a pelvic floor physical therapist is one of the most underused tools in women’s health.
Desire is not just about sex.
Declining hormones affect dopamine pathways: the brain circuits responsible for motivation, curiosity, and pursuit. Loss of desire often reflects a neurochemical shift, not a personal failure or relationship issue.
Desire isn’t broken: the pursuit circuitry is quieter
This was one of the most important reframes for me.
Dr. Casperson explained that declining hormones, especially in midlife, affect dopamine pathways. Dopamine isn’t just about sex. It’s about pursuit. Interest. Motivation. Curiosity. Drive.
She said something that has stayed with me ever since:
Women sometimes start businesses after testosterone therapy, not because it suddenly makes them “horny,” but because it restores their desire for pursuit.
That landed hard.
She reframed testosterone not as a taboo “sex hormone,” but as a motivation and drive hormone that acts on the brain. Not everyone needs it. Not everyone should take it. But the mechanism matters.
Sometimes “I have no libido” is actually: “The part of my brain responsible for interest and pursuit has been turned down.”
That insight alone removed so much shame. Desire isn’t just about sex. It’s about wanting. Wanting anything.
Not everyone needs testosterone. Not everyone should take it. But understanding the mechanism matters more than forcing willpower.
Your “why” matters more than any protocol
This might be the part I’m most grateful for.
Dr. Casperson said: find your “why” with sex. It works best when it’s your why, not your partner’s, not your doctor’s.
Because for some women, the why is pleasure.
For some, it’s intimacy.
For some, it’s confidence.
For some, it’s healing.
For some, it’s wanting sex to stop being associated with discomfort and dread.
Your “why” determines the right next step. Without that clarity, it’s easy to chase solutions that don’t actually fit.
Comfort comes first. Period.
One of the clearest lines I heard was this:
To restore comfort in sex, you need comfortable, healthy tissues.
Put back what Mother Nature already had, not as a vanity move, but as basic physiology. Declining estrogen affects tissue quality and blood flow. When tissues become thin, dry, or fragile, discomfort follows. Expecting desire or arousal on top of discomfort makes no sense.
Kim Vopni reinforced this from another angle: she made the case for pelvic health as a hidden threat to longevity: urinary leakage, urgency, prolapse, pelvic pain, recurrent UTIs; all of it quietly erodes quality of life, sleep, and willingness to exercise.
She dropped a statistic that landed hard:
46% of women stop exercising because of pelvic floor dysfunction.
That’s not “just annoying.” That’s a downstream health risk.
And one personal light-bulb moment for me: constipation.
I’ve dealt with it my entire life and I learned how much chronic constipation strains and dysregulates the pelvic floor. No one ever connected those dots for me before.
Arousal is blood flow — not a personality trait
This deserves to be said plainly.
Arousal is blood flow.
Not willpower.
Not “try harder.”
Not “relax.”
When arousal becomes difficult, it’s often because the system that supports it (i.e. hormones, tissues, nerves, blood flow, pelvic floor) has changed.
Pleasure isn’t indulgent. It’s part of how the body stays healthy.
The missing piece: the nervous system
When sex becomes associated with pain, urgency, leaking, or embarrassment, the nervous system shifts into protection mode.
Arousal shuts down not because you don’t want sex but because your body no longer feels safe there.
Sexual health is cyclical.
When pain, fear, or leaks enter the loop, the body adapts by shutting down arousal.
When comfort, safety, and blood flow return, desire often follows.
This isn’t about forcing desire back. It’s about rebuilding the conditions that allow it to emerge.
If you take one thing from this post:
Low desire, discomfort, or changes in sex are not moral failures, relationship failures, or personal flaws. They are physiological shifts and they are addressable.
I’m sharing this because so many women quietly assume something is wrong with them when sex becomes complicated.
Often, nothing is “wrong.”
Something has simply shifted.
Understanding the why is the beginning of agency, not the end of desire.
In the next post, I’ll go deeper into what this looks like in practice: pelvic floor health, urinary symptoms, local hormone support, and what I’m personally navigating right now including the tension between perimenopause care and fertility decisions that almost no one talks about.
You’re not broken.
You’re not alone.
And this isn’t the end of the story.
A question I’m holding:
How do we break the generational silence around women’s sexual health so my nieces and your daughters don’t have to unlearn shame before they can learn their bodies?
If you’re holding questions, I’m listening.
xoxo💋
Paola
This post is part of Women’s Health for the Long Run—a series grounded in lived experience, careful listening to experts, and shared learning. It is not medical advice.
This reminds me of a book I read last year called “this ends with us.” It showed the hard work we put to break the generational trauma or in this case, silence. If we want daughters to stop measuring their worth based on the outside body, I think having blunt conversations and giving them opportunities for honest questions and discussion of feelings. No shame, no judgment. Setting an example is also impactful, seeing us take care of our bodies from a physiological perspective is encouraging for them to follow suit with confidence. Sometimes, this is easier said than done, breaking patterns is a continuous journey!