V.C., now 53, had heavy periods beginning in her mid-forties, followed by distressing declines in sexual function in her late forties. After delaying intervention while researching ablation and hysterectomy, she started MHT for other symptoms, which normalized her bleeding.

Haver reflects that she was ill-equipped to address midlife changes in desire and pleasure early in her practice, noting that medical training offered little on female sexual function during perimenopause. She regrets earlier, dismissive advice that overlooked underlying hormonal shifts and left patients without meaningful help. To close these gaps, she sought out experts—among them Dr. Kelly Casperson, Dr. Emily Nagoski, Dr. Lauren F. Streicher, and urologist Dr. Rachel S. Rubin—whose work sharpened her understanding of testosterone, clitoral anatomy, and sexual dysfunction.

The chapter explains how estrogen supports vaginal tissue, blood flow, and lubrication; when levels fall, tissues thin and sex can become painful, a pattern encompassed by genitourinary syndrome of menopause (GSM). Testosterone, which declines from the mid-twenties, influences libido and satisfaction. Although data support its use for hypoactive sexual desire disorder, no Food and Drug Administration (FDA)-approved testosterone product exists for women in the United States. The Endocrine Society and the International Society for the Study of Women’s Sexual Health endorse testosterone for postmenopausal women with low desire, and clinicians may consider it for perimenopausal patients when appropriate.