Clitoral Atrophy During Menopause

Research estimates that 15% of women aged 45 to 64 experience female sexual dysfunction (FSD), which includes delayed, infrequent, or absent orgasms during most sexual encounters.⁽¹⁾ While FSD has multiple causes, one significant yet often overlooked factor is clitoral atrophy. As hormone levels decline, the clitoral tissue undergoes structural changes that may lead to decreased sensitivity, reduced arousal, and difficulty reaching orgasm.⁽¹⁾

Despite its central role in sexual function, the clitoris remains under-researched, particularly in the context of menopause. Recognizing the impact of clitoral atrophy is key to understanding its role in sexual dysfunction and ensuring that women have access to the right support and treatment options to maintain their sexual well-being.

What is clitoral atrophy?

Clitoral atrophy refers to the thinning, shrinking, and loss of function of the clitoris, typically seen during menopause due to hormonal changes. It’s one of the anatomical changes associated with Genitourinary Syndrome of Menopause (GSM), an umbrella term describing the symptoms and structural changes in the genital and urinary systems caused by declining estrogen levels during menopause.⁽¹⁾⁽²⁾

Anatomy of the Clitoris

The clitoris is a multidimensional organ with a critical role in female sexual health and function. It has a broad attachment to the pubic arch and is supported by connective tissue that links it to the mons pubis and labia, providing both stability and mobility. Structurally, it’s closely associated with the urethra and vagina, highlighting its vital connection to the broader genital system.⁽³⁾

External Structure

• Glans Clitoris: It’s the only externally visible part of the clitoris, located at the midline above the urethral opening. While non-erectile, it’s densely packed with nerve endings and serves as a primary sensory region.

Internal Structures

• Erectile Bodies: These include the paired corpora cavernosa and vestibular bulbs, both of which are composed of erectile tissue. While the corpora cavernosa extend along the pubic arch as part of the crura, the vestibular bulbs lie on either side of the vaginal opening and swell with blood during arousal. The composition of erectile tissue in the bulbs differs from that of the corpora cavernosa, contributing to variations in function and responsiveness.

• Crura: These elongated structures extend from the clitoral body and anchor the clitoris to the pubic arch, forming the longest part of the organ. They curve around the vaginal canal and urethra, providing structural support.

Neurovascular Supply

• Clitoral and Perineal Neurovascular Bundles: These large, paired branches of the pudendal nerve provide sensory input and help regulate blood flow.

• Neural Trunks: These pathways remain largely intact as they extend into the glans, ensuring heightened sensory function.

• Cavernous Nerves: Part of the autonomic nervous system, these microscopic structures control vascular engorgement and contribute to erectile function.

Anatomical Changes 

Clitoral atrophy can develop gradually as the tissues lose their structure and function. Common changes include shrinking of erectile tissues, loss of smooth muscle, and reduced elasticity, which diminishes the clitoris’s ability to engorge and respond to stimulation. The clitoral prepuce (hood) may retract and expose the glans to more friction. The labia minora and majora may thin or fuse, altering the external structure and reducing protection.⁽¹⁾

Studies also indicate a reduction in blood flow to the clitoris, which can limit the supply of nutrients and oxygen needed to maintain healthy tissue. In some cases, nerve function declines, leading to a loss of sensitivity and a weaker response to touch.⁽¹⁾ 

The changes also extend to the surrounding vaginal and urethral tissues, which become thinner and drier, increasing discomfort during intercourse. Microscopically, the clitoral tissue stiffens as collagen replaces smooth muscle, making it less flexible and responsive. The result is delayed arousal, reduced sensation, and a decreased ability to experience pleasure, all of which contribute to the overall effects of clitoral atrophy.⁽¹⁾

Symptoms of Clitoral Atrophy

Clitoral atrophy can present with various symptoms that affect sexual function, sensitivity, and overall genital comfort. These symptoms may develop gradually and often accompany other changes in the genital and urinary systems during menopause:⁽¹⁾

• Decreased sensitivity to touch and pressure

• Delayed or weakened arousal, with reduced engorgement during stimulation

• Pain or discomfort during intercourse due to increased friction and vaginal dryness

• Changes in appearance, including retraction or shrinking of the clitoral hood and thinning or fusion of the labia

• Reduced ability to achieve orgasm or experience sexual pleasure

Causes of Clitoral Atrophy During Menopause

Clitoral atrophy during menopause is primarily caused by the hormonal and physiological changes that accompany this transitional period. The depletion of key hormones like estrogen and testosterone, along with reduced blood flow and vaginal lubrication, contribute to the structural and functional changes in the clitoris. These changes can significantly affect sensitivity, arousal, and overall sexual function.

Hormonal Shifts

Estrogen is crucial for maintaining the health of the pelvic and genital tissues, including the clitoris. During menopause, the drop in estrogen levels leads to tissue atrophy, reducing the size and thickness of the clitoris and surrounding structures.

This decline also affects the epithelium of vulvovaginal tissues, leading to thinning, reduced elasticity, and a loss of resilience. As a result, sensitivity to pressure and touch diminishes, making sexual stimulation less effective or pleasurable.⁽⁴⁾

Decreased Blood Flow to the Genital Area

Estrogen depletion leads to vascular changes in the genital area, reducing blood flow to the clitoris and surrounding tissues. This limits their ability to engorge during arousal, a process critical for sexual pleasure.

The clitoral prepuce and glans may appear smaller or retracted due to reduced vascular supply. Over time, the lack of blood flow can exacerbate the atrophy of erectile tissues, further reducing sensitivity and delaying clitoral response during stimulation.⁽¹⁾

Decreased Vaginal Lubrication

Estrogen is essential for maintaining vaginal lubrication. As levels drop during menopause, lubrication decreases, contributing to vaginal dryness and discomfort during sexual activity.

While lubrication does not directly impact the clitoris, it plays a critical role in enhancing the overall sexual experience and reducing friction, which indirectly affects clitoral stimulation and pleasure.⁽²⁾

Treatment Options for Clitoral Atrophy

Hormone replacement therapy is one of the most effective options for alleviating symptoms of clitoral atrophy. By replenishing hormones and improving circulation, HRT enhances the clitoris’s ability to respond during arousal, making sexual activity more enjoyable. It helps counteract the effects of menopause, supporting overall sexual health and function.⁽⁴⁾

Research shows that HRT can also improve blood flow to the clitoris, helping to reduce symptoms of sexual dysfunction. HRT works by replenishing declining hormones like estrogen, which are essential for maintaining healthy blood vessels and tissue function. In a study, women using HRT had faster blood flow in their clitoral arteries (15.0 ± 5.4 cm/second) compared to women who weren’t using it (11.8 ± 5.2 cm/second). This difference was significant, showing that HRT can make a real impact.⁽⁵⁾

There are two main types of HRT: systemic and local therapy, each tailored to meet different needs.

Systemic HRT 

This type of HRT is designed to address widespread menopausal symptoms that affect the entire body. It helps improve hormonal balance, which in turn improves blood flow to the clitoris, enhances sensitivity, and supports arousal. Systemic HRT is most beneficial for women experiencing a broad range of menopausal symptoms, not just those affecting the genital area. It’s available in different forms, including oral pills, transdermal patches, and injections.

Localized HRT

Localized HRT focuses specifically on genital and urinary symptoms by delivering estrogen directly to the affected tissues. This approach helps restore moisture, improve elasticity, and enhance clitoral sensitivity without significantly affecting hormone levels throughout the body. 

It’s available as vaginal creams, tablets, or rings. Vaginal estrogen creams are particularly effective when systemic symptoms are not present. These creams directly nourish the vaginal and clitoral tissues, making them an ideal option for women experiencing vaginal dryness, discomfort, or decreased sensation, without the need for full-body hormone regulation.⁽⁴⁾

The Impact of Menopause on Sexual Health and Quality of Life

The clitoris plays a key role in female sexual health, yet its significance during menopause is often overlooked. As hormone levels shift, changes in blood flow, nerve function, and tissue structure can affect sensitivity and arousal. While these changes are natural, they can also influence intimacy, self-confidence, and overall well-being.

Recognizing these shifts is the first step toward maintaining sexual health. Many effective treatment options are available to help preserve sensation, support blood flow, and improve comfort. Seeking guidance from a healthcare provider can provide clarity and direction, ensuring that sexual function remains a fulfilling part of life.