It’s easy to buy into the narrative that sex after 50 is more trouble than it is worth. Fluctuating or falling levels of sex hormones can play havoc with a woman’s desire and experience of sex during perimenopause and beyond. Not only are there physical changes that can render what was once pleasurable unsatisfying or even painful, but tiredness, anxiety and diminished self-confidence can also put the kibosh on sex.

Doctors don’t necessarily help. “I suspect part of the reason why a lot of people are gloomy is because they’ve had pushback from doctors who have reacted to their desire to continue having sex with a bit of amazement. Like, you’re not procreating any more, so why should it matter to you?” says Suzanne Noble, a 63-year-old entrepreneur who is determined to rewrite the rulebook on ageing.

Noble is living proof that women’s sex lives don’t wither and die when they hit menopause. Soon after entering her seventh decade, she set up a sex shop and launched a podcast called Sex Advice for Seniors. “There’s no shortage of things to talk about,” says Noble. “A lot of it is about overcoming some of the challenges that we face as older people. But the flipside is that there are lots of ways you can to get help and continue to have decent sex in later life.”

Tiredness is a real passion killer. Hot flushes, night sweats and anxiety can make it difficult to get a good night’s sleep, and even among women who sleep soundly, many report feeling tired nonetheless. Dr Shahzadi Harper, a menopause specialist and founder of The Harper Clinic in London, remembers feeling so tired, she could barely function: “I remember just doing what I needed to do. It is almost like the body prioritises more necessary functions, such as work or family. Sex is probably pushed down to the bottom of the list.”

But menopause often coincides with one of the busiest periods in a woman’s life. A recent study analysed data from 2,133 women aged 40 to 59 to understand better how health and lifestyle factors influence women’s sexual satisfaction during midlife. In-depth interviews with 23 “sexually dissatisfied” participants revealed that the biggest factor was tiredness. They described the sheer weight of the pressures they were facing – financial and relationship difficulties, work stresses, worries about family members – while juggling the simultaneous demands of children and ageing parents.

“Of the 23 women, I reckon three-quarters said that when we go to bed, we want to sleep,” says Kaye Wellings, a professor of sexual and reproductive health at the London School of Hygiene and Tropical Medicine, who led the study. “Sex needs concentration and energy. When you’re tired, and your mind is not on it, you’re not going to have good sex, and you might not have any sex.”

Not all women mind if their sex lives are quieter than in their youth. Although more than a third of the women in the study had been sexually inactive during the past month, fewer than half expressed dissatisfaction with their sex lives. “The scientific literature shows that sexual satisfaction depends as much on intimacy and closeness as on sexual frequency,” says Wellings. “Of course, sex matters, but it’s how it matters alongside other things in the relationship.”

For those who are unhappy about the impact menopause or perimenopause is having on their sexual relationships, there are tools that can help.

“When I think of sexual health, I think of four things: libido, arousal, orgasm and pain,” says Dr Rachel Rubin, a urologist and sexual medicine specialist based in Washington DC. “All of them can be significantly affected by the fluctuation and then massive decrease in sex hormones.” Though not suitable for everyone, HRT can help counter physical changes to the vulva and vagina. It may also improve sleep. “If I can get a woman sleeping, I can get her sexual health vastly improved,” says Rubin.

Locally applied vaginal oestrogen can help to combat dryness or irritation, and may reduce the risk of recurrent urinary tract infections (UTIs), says Harper. It can also be used by women with a history of breast cancer. She also suggests regularly applying a scent-free, hypoallergenic lubricant to help moisturise the skin. However, there are many factors at play: “First and foremost,” says Harper, “I would say it’s not just a question of popping a pill or applying a cream and your sex drive is going to switch on.”

Also important is setting aside time to relax and reconnect with your body. Self-pleasure is another way of reconnecting with sexual sensations, as well as boosting blood flow to the genitals, which aids lubrication. For Noble, vibrators have become an essential component of sex. “The small nerves in the clitoris start becoming less sensitive with age, and the larger nerves that take over work best with vibration,” she says. But she believes the biggest obstacle that women (and their partners) face is a shift in how they experience desire and arousal.

Women in middle age or older may not begin to get aroused or to desire sex until they have begun to get intimate with someone – it is one reason why things may need to be taken more slowly and gently. This shift from spontaneous to responsive desire appears to affect many peri- and postmenopausal women and, along with physical changes, makes communicating with your partner more important than ever. “It is worth explaining that there are changes going on, things may take a little bit longer, you still love your partner and want to have sex with them, but it is not going to be a question of wham bam, and it’s over,” Harper says.

“I often say that the journey time is longer. It is really about the two of you engaging and understanding that you are in a different stage of life, things have changed, but that you can still enjoy intimacy.”