A reader, 45 and in the thick of perimenopause herself, wrote me something I can’t stop thinking about: she has stopped experiencing her waning desire as something simply disappearing and started experiencing it as an invitation, a prompt to get curious about what desire is trying to tell her.
The hormonal shifts are real, she wrote, but she is beginning to see them as a window into something deeper rather than the whole explanation, almost a mind-body-spirit inventory: what still brings her alive, where she feels connected or disconnected, what fits the woman she is becoming rather than the woman she has been. She wondered whether restoring desire, in my work, is ever really about returning a woman to who she was before, or whether it is more often about helping her discover what desire looks like in the person she is becoming now.
I answered her honestly because I see this constantly, but only in the women conscious enough to ask the question and answer it truthfully.
This work was never about restoring an old version of desire. It is about self-stewardship and authenticity. The women who move through this well are not chasing who they used to be. They are getting curious about what this emerging version of themselves is pointing toward. Her mind-body-spirit inventory is exactly the right instrument for that curiosity, and it is the frame I want you holding as you read everything below: not only how do I get back what I had but… what is this asking me to become?
The three pillars that I’ve included below are the physical half of that answer, a great start not the whole of it.
Men have more than a dozen FDA-approved testosterone products to choose from. Gels, patches, injections, pellets, an oral capsule, a nasal spray [56].
Women have zero. Not one FDA-approved testosterone product exists for a woman’s body, at any dose, for any indication [32].
Every gram of testosterone cream a woman uses for low desire or thinning vaginal or clitoral tissue is compounded, off-label, and built from a dose that was mostly designed for someone else’s body.
The precise term for this in the medical literature is **off-label fractionated dosing **of a male testosterone formulation. It is what international guidelines and expert reviews are describing when they recommend, in the absence of an approved female-specific product, roughly one-tenth of the male starting dose of 1% testosterone gel to keep serum testosterone within the premenopausal physiologic range for postmenopausal hypoactive sexual desire disorder [57].
The asymmetry in available products for women is the reason the hormone pillar below is harder to write, and harder to dose, than the other two, and it is why I have added an entire section near the end on what compounding itself risks.
One reader, 55, is on all the hormone therapy, including localized estrogen and testosterone, and she was still struggling with desire. What changed her sex life was not a prescription but low-dose THC (tetrahydrocannabinol, the primary psychoactive compound in cannabis, the one responsible for the high and for its effects on sensation and mood). She discovered this unexpected benefit almost by accident after she and her husband retired from federal jobs where cannabis use had been off-limits due to drug testing. She mentioned that it enhanced every sense in a way neither of them expected. (Note that all names of readers are de-identified.)
Another reader, 73, has been on hormone therapy since menopause, bioidentical for the last decade, under a functional medicine practitioner who knows the current literature. She told me her libido is back “like into my 30s.” Her husband, 80, cannot keep pace even with his own testosterone on board, so she takes care of herself when she needs to. She is stronger and fitter than she has ever been. She does not look like she used to. She looks good. She is satisfied with herself.
Two women doing hormones right. Two very different outcomes.
That gap is the reason I wanted to write a series of sexspan articles and protocols. Hormones are necessary but they are not always sufficient, and the tissue itself, not just the endocrine signal reaching it, has to be capable of responding.
The THC detail is one reader’s experience, and not yet a clinical recommendation I am making here. As always, let me know in the comments if you have experience with the effect of THC and your own experience of pleasure and sensuality. I imagine I’m not the only one here who is curious!
One reader, 72, a widow, wrote in with desire that is weak and fleeting, partnered orgasm nearly impossible, and in her words, “clitoral atrophy is real.” Another wrote in with the other half of the physical problem: the inability to be penetrated at all, or pain on attempted penetration that no amount of lubrication solves.
A third reader, 64, had already tried what medicine currently offers before she ever wrote to me. Fit, active, non-smoking, in a loving and tactile partnership, on a small amount of natural progesterone through menopause and otherwise no hormone therapy. Testosterone gel made no difference to her desire and made her irritable and angry instead. Vaginal pessaries did not touch the tearing and pain that made intercourse impossible even with lubrication. She did everything asked of her and the standard toolkit still failed her. I am naming her case here because it would be dishonest to write a protocol and imply it works uniformly. It does not, and a meaningful minority of women need more than a first attempt at hormones or lubrication gives them.
Between them, these readers name the two structures I think matter most to protect and, where needed, restore: the clitoris and the introitus, the entry to the vagina. Everything below is organized around those two sacred areas.
None of the three pillars below work in isolation from what I wrote about a few days ago regarding female sexspan. A body running the fawn response, appeasing instead of resisting, chronically dampened heart rate variability, sympathetic overdrive dressed up as competence, is a body whose ventral vagal system has learned that stillness and self-monitoring are safer than arousal.
You can restore tissue perfectly, and a nervous system still stuck in that pattern will not register touch as safe enough to want.
This is precisely why I do not think of the protocol below as separate from the fawn-response work.
Tissue restoration gives the body the capacity to respond.
Vagal safety gives it permission.
Both have to be present at the same time, or the tissue work alone will underperform what the biology promises.
Red light therapy, delivered as photobiomodulation, sometimes called low-level laser therapy or cold laser, has accumulating but generally low-quality evidence for three vulvovaginal indications: genitourinary syndrome of menopause, vulvar pain, and vulvar lichen sclerosus.
Specialty reviews consider the overall evidence weak, and no large, adequately powered, long-term trial exists for any of the three [1][2]. I am telling you that up front because the mechanism is genuinely interesting and while I do not want the interest to read as proof, I am both professionally and personally impressed with this sexspan tool.
A 2026 single-center prospective study using a 660 nanometer diode found statistically significant improvement in Vaginal Health Index scores through three months, with gains in elasticity, fluid, pH, epithelial integrity, and moisture. Every participant showed measurable improvement, subjective urinary and sexual symptoms improved too, and there were no adverse events and no procedural discomfort, an advantage over the thicker, friction-based probes used in fragile atrophic tissue [3]. But this was a single-arm, uncontrolled study. A randomized, double-blind, sham-controlled protocol has been published and is still awaiting results [4].
The proposed mechanism is that red light in the 620 to 700 nanometer range is absorbed by cytochrome c oxidase in the mitochondria, which dissociates inhibitory nitric oxide, restores ATP production, and activates the HIF-1α, NF-κB, and TGF-β pathways that drive fibroblast proliferation, collagen synthesis, new blood vessel formation, and a reduction in the inflammatory signals TNF-α and IL-6 [3][5]. That is a real, plausible pathway for restoring atrophied tissue energetics, not just masking symptoms.
For vulvar pain specifically, a 2025 randomized controlled trial of fifteen sessions of red or near-infrared light versus sham found greater reductions in pain across all three measures the researchers tracked, pressure pain threshold, tampon-test pain, and pain sensitivity on a validated questionnaire, with near-perfect adherence and no meaningful adverse events [1]. It did not, however, move the needle on psychological outcomes, overall sexual function, or how satisfied patients felt with their improvement, and both groups landed at similar satisfaction regardless of which light they received [1]. An earlier, smaller trial found seventy-eight percent reported some improvement in intercourse pain versus forty-four percent with sham, but nothing else moved, and reviews conclude there is currently insufficient evidence to recommend this specifically for vulvodynia [6].
For lichen sclerosus, a 2025 review of seven trials found improvement in itching, burning, pain, and quality of life in most of them, with three showing an edge over topical steroids, but nearly all of those studies used a different, heat-based ablative laser rather than true low-level red light, and the review found no evidence of an anti-inflammatory or anti-fibrotic effect strong enough to stand alone as therapy [7][8]. A small uncontrolled series using red-light photodynamic therapy found meaningful symptom resolution in the majority of participants, with transient side effects [9].
No trial has compared red light head-to-head against vaginal estrogen. The only randomized laser-versus-estrogen data we have, the VeLVET trial, used an entirely different, heat-based ablative laser, so it cannot tell us how red light specifically stacks up [10]. What we can say is that vaginal estrogen remains the guideline-endorsed, dozens-of-trials, first-line therapy, while red light remains investigational [11][12]. Red light’s honest selling point is not that it outperforms estrogen. It is that it is non-hormonal, painless, and tolerable even in a narrowed canal, which makes it a reasonable option for a woman who cannot or will not use hormones, understanding going in that the evidence is still preliminary [4][13]. A separate meta-analysis of the heat-based laser found no significant difference against estrogen across several tissue and function measures, which at least establishes the comparative bar this whole category has to clear [13].
If you decide to try red light therapy, look for a device delivering light in the red to near-infrared range, roughly 630 to 850 nanometers, used vaginally and vulvarly at the session frequencies studied, generally two to three sessions weekly for the first several weeks, tapering to maintenance.
Give it eight to twelve weeks before judging results, since the tissue-level changes in the trials showed up gradually over that window, not in days.
Let me know in the comments if you want suggestions on specific brands or if you have one that you recommend.
This pillar is the one I am comfortable putting in front of everyone reading this, subscriber or not, because the downside risk is close to zero and the upside, while unproven at scale, is biologically real. I especially recommend it for my readers who are breast cancer survivors and purposefully low on hormones.
I have seen it work extremely well, and the best results I’ve seen are when red light therapy is combined with the full protocol below.
Everything past this point is the part I have not put in front of a general audience before: the extrapolated protocol, the gap in the evidence, and what compounding itself risks. If you want to work through any of it live, I am hosting a Substack Live for paid subscribers on Wednesday, September 30th, 11 AM PT / 2 PM EST, for 90 minutes: The Vagina Makeover: Tissue, Hormones, Spirit. You can become an annual subscriber for $99 (expires tomorrow), and founding members can submit questions in advance through September 20th.
