Sara Szal MD
Summary: An entire industry has built biomarker panels for how well women age, and none of them measure whether she still feels turned on and wants to be touched. This is the case for sexspan, the years a woman remains erotically alive, why medicine has never asked the question, the surveillance that fills the gap where the answer should be, and a two-column exercise that shows you the ratio for yourself.
She was 47, perimenopausal, sitting across from me. A month earlier she’d confessed to her doctor, carefully, with some shame, that she couldn’t care less about sex with her husband anymore. Her labs had come back normal, and he said, “This part of your life may just be winding down. That’s normal.”
I have heard some version of that statement from hundreds of women, and it is the precise moment medicine closes the file on her desire and fails her.
What he did not ask is why she checks her reflection in the hallway mirror more times a day than she lets herself think about pleasure. He did not ask about the Botox appointment last month, or the filler before that, or the GLP-1 she started three months ago, partly for the weight, mostly to quiet a hunger she could not name until someone gave her a word for it. He did not ask about her resting heart rate, which has crept up five beats a minute since she started the medication, or her heart rate variability, which has dropped by nearly half. Both are documented effects of GLP-1 receptor agonists: a class-wide rise in heart rate on the order of 2 to 10 beats per minute,¹ ² more pronounced with long-acting agents,³ and in a crossover trial, a genuine drop in heart rate variability that persisted even after adjusting for weight and metabolic changes.⁴ Real-world wearable data confirms it outside the lab: a measurable rise in resting heart rate mediated by a fall in HRV.⁵
Nobody connected the fatigue she cannot shake to any of this. Nobody asked her about desire, only about decline and how long she’s noticed.
Most women know this appointment. You bring your body’s most private moment to your doctor and you leave with a diagnosis of normal aging.
What if we are measuring the wrong thing?
Consider what she can quantify about her own body. Her weight, perhaps a daily body composition with muscle mass and fat. Her sleep score. Her steps, strain, continuous glucose if she wears a monitor. The units in her forehead and the date of the next appointment. She knows her good side in photographs. She knows which restaurant lighting forgives and which one does not. Then ask her when she last wanted something pleasurable, and watch how long the silence runs.
Most women I know are running some version of this dance, and maybe you know the choreography. You catch your reflection in a store window and audit it before you can stop yourself. You say yes at 10 p.m. out of accounting rather than appetite, or you say nothing and do the math on how long it has been. You track your sleep, your protein, your cycle if you still have one, and no app, no annual physical, no doctor has ever asked you to track your desire. Your wearable knows your heart rate at 3 a.m. It has no field for the fact that you flinch when your partner reaches for you, or that you miss being the woman who reached first.
Perhaps your version reads differently. The wanting left after the second baby and never sent word. Or it left when the marriage went quiet, and you decided the problem was your hormones because that was the only explanation on offer. Or you are newly partnered at 68 after years alone, and your body knows the vibrator’s route to orgasm but goes silent with another person in the bed, and shame fills in where information should be. Or you sailed through menopause and the desire stayed… and now you carry it like contraband, because every headline insists you should have lost it by now.
In The Hormone Cure, I wrote about the moment a reader says to herself: Yes! That’s me! Now what?
Here is the now what, and it begins with a question medicine has never asked. What if the problem is not that her sex life is ending, but that no one in medicine has a category for the thing that would tell her whether it is? What if the winding-down speech is simply what a doctor says when he has no instrument?
There is a reason she checks the mirror more than she checks in with her own body. Sandra Lee Bartky named it decades ago. Sandra Lee Bartky (1935–2016) was an American feminist philosopher, best known for applying Michel Foucault’s ideas about power and discipline to the specific experience of being a woman in a body under constant scrutiny. She taught philosophy for most of her career at the University of Illinois at Chicago.
Her description still feels fresh and relevant:
“The woman who checks her makeup half a dozen times a day to see if her foundation has caked or her mascara has run, who worries that the wind or the rain may spoil her hairdo, who looks frequently to see if her stockings have bagged at the ankle or who, feeling fat, monitors everything she eats, has become, just as surely as the inmate of the Panopticon, a self-policing subject, a self committed to a relentless self-surveillance. This self-surveillance is a form of obedience to patriarchy. It is also the reflection in woman’s consciousness of the fact that she is under surveillance in ways that he is not, that whatever else she may become, she is importantly a body designed to please or to excite.” — Sandra Lee Bartky, Femininity and Domination
I recognize her problem because it is mine. Some mornings I catch my own reflection in the hallway mirror and the audit starts before I’m aware of doing it. Two lines (“11” between my brows. Lashes that used to need less help and now I can barely see them. A place at my neck where the light lands differently than it did five years ago. I want to be the woman who looks back and thinks, badassery. Some days I get there. Most days the old program runs first anyway, even though I have spent 30 years teaching other women to notice their bodies with compassion and kindness while running the same surveillance loop on mine.
Swap mascara for filler and stockings for GLP-1, and nothing about the argument changes. The tools got more medical but the near constant surveillance did not.
In my training, I was taught that a midlife woman’s loss of desire was a quality-of-life issue, something to address after the real medicine was done. What I know now, after twenty-five years of listening to women, is that desire sits closer to the center of her physiology than most of what we measure.
Here is what is strange. We now have an entire field devoted to measuring how well women age, and it does not measure this at all. The proposed panels of healthy aging biomarkers cover lung function, bone density, blood pressure, glucose.⁶ The 14-biomarker consensus statement covers inflammation, grip strength, gait, epigenetic clocks.⁷ Cell’s landmark aging-biomarker framework catalogs GrimAge, DunedinPACE, multi-omic clocks.⁸ Not one of them asks whether a woman still wants to be touched.
That omission is not small, because the data we do have entangles erotic vitality with almost everything longevity medicine claims to care about. Poor sleep quality independently raises the odds of sexual dysfunction,⁹ and a meta-analysis of 43 studies found sleep disorders nearly double that risk.¹⁰ Insomnia predicts sexual function even after controlling for depression and anxiety, and recent sexual activity tracks with better sleep and lower anxiety,¹¹ a two-way street ACOG itself calls commonly overlooked.¹² Relationship satisfaction and self-esteem predict sexual functioning better than hormone levels do.¹³ ¹⁴ The Nurses’ Health Study II, following 68,000 women, argues sexual well-being belongs in routine clinical monitoring.¹⁵ And the mortality data is the part that should get longevity medicine’s full attention: active sexual intercourse was an independent protective factor for longevity in a 31-year cohort of midlife women.¹⁶ NHANES data links higher sexual activity frequency to lower all-cause and cancer mortality in a dose-response pattern.¹⁷ A 14-year Taiwanese cohort found the same inverse relationship.¹⁸ Correlation is not causation, and a well-partnered, well-rested woman may simply be healthier to begin with. But a field this obsessed with biomarkers rarely asks the question rigorously. I believe the omission is a value judgment about whose pleasure counts as health.
I want to be precise here, because it would be easy to overstate this in the other direction, and that helps nobody. I have seen the claim circulating that the clitoris never atrophies, or somehow keeps developing after menopause. It isn’t that simple.
Clitoral volume holds roughly steady with age, but the clitoral body shortens and the vestibular bulbs show real age-related atrophy when a woman develops genitourinary syndrome of menopause, GSM.¹⁹ Clinical guidelines list clitoral atrophy as a recognized feature of genitourinary aging.²⁰ I am on a crusade to prevent it.
What the data does support is good news. Sexual distress, not desire itself, is what falls with age, even as low desire becomes more common, which is why desire discrepancy is often worse in midlife than later in life.²¹ Orgasmic capacity and overall satisfaction tend to be preserved, even when stimulation needs change.²² And in both clinical cohorts and consumer app data, the strongest predictors of a good sex life after 40 are relationship quality, self-esteem, and simply staying sexually active, ahead of any hormone level.¹³ ²³
This is a real finding. The story of decline blames her hormones. The scientific literatures says relationship quality, self-esteem, and staying sexually active predict the outcome better than any hormone level does.
In May I wrote about female pleasure and the sex education none of us received, and the comments became their own dataset. A 62-year-old in surgical menopause since 43 described multiple orgasms that began after menopause, a clitoris more sensitive rather than less, and a thyroid problem mainstream endocrinology missed for 14 years. A 74-year-old sex educator, unable to take hormones after breast cancer, reported several clitoral arousal cycles and orgasms each week. A 78-year-old had her testosterone measured for the first time in her life, watched it come back marked high and abnormal, and finally had an explanation for a libido that never left. A husband told me his 75-year-old wife’s orgasms carry the same intensity they did in her thirties.
Medicine calls these women outliers but I call them unmeasured. Their capacity appears in no cohort, no consensus panel, no aging clock, because no instrument exists to record the erotic years they are living. Most women never hear these stories, so most women believe the winding-down speech. We must do better.
Here is the piece I believe explains her mirror-checking better than vanity ever could.
You have heard of fight, flight, and freeze. There is a fourth: fawn. Appeasing. Self-monitoring. Managing the threat by making yourself smaller and more pleasing rather than resisting it.
I will hold this idea to the same standard I held the clitoris data. Freeze is well-documented physiology, with measurable heart rate deceleration and reduced body sway under threat, mapped to the amygdala and periaqueductal gray, and linked to cortisol and anxiety in controlled human studies.²⁴ ²⁵ ²⁶ Fawn is a clinically intuitive idea with a theoretical home in the ventral vagal social engagement system,²⁷ and no study has directly tested it as a distinct physiological state.
Still, the theory fits what we can measure. Chronic, inescapable stress produces documented autonomic wear: suppressed heart rate variability and sympathetic dominance,²⁸ ²⁹ the same signature that shows up in trauma and PTSD research.³⁰ ³¹ A woman who has spent thirty years managing how she is perceived, rather than resisting the demand to be perceived, is running a low-grade version of that appeasement circuit, day after day. And her GLP-1, lowering HRV by mechanism rather than metaphor,⁴⁵ quietly reinforces a nervous system already tilted toward sympathetic overdrive by everything she does to be looked at rather than felt.
I asked my readers a question not long ago: how much female intelligence gets spent monitoring how we look, and what would you build if that attention came back to you. The replies confirmed everything the data above only implies.
One reader, a therapist who treats eating disorders, wrote that she thinks about this every day at work and that the fatigue of witnessing it never really lifts. Another said the vigilance had cost her three decades, and named exactly what she wanted instead: a life she loves rather than tolerates, recipes that nourish instead of numbers that punish, clothes chosen for whimsy rather than concealment, more hours outdoors than hidden indoors. A third, fifty-seven and a lifelong harsh critic of her own reflection, admitted she still could not fully answer the question, but noticed something new and recent: most days now, she likes what she sees.
Several described the same redirection in different bodies. One rerouted the vigilance into strength training and now feels like a warrior staring back at herself, muscle where appraisal used to live. Another said she still spends effort on how she looks, but the difference is who it is for: her own pleasure now, not an audience, and that distinction bought her freedom instead of obligation. A psychiatrist reader named the cost plainly, the curiosity, creativity, and connection that self-surveillance quietly taxes, and asked what would change first if women simply stopped paying it.
None of them used the word sexspan. All of them were describing its opposite: the tax that gets paid before desire ever gets a turn.
Susan Sontag (1933-2004) wrote the answer to this fifty years ago. She was an American writer, critic, and public intellectual, and it still reads like it was written for us right now:
“Women have another option. They can aspire to be wise, not merely nice; to be competent, not merely helpful; to be strong, not merely graceful; to be ambitious for themselves, not merely for themselves in relation to men and children. They can let themselves age naturally and without embarrassment, actively protesting and disobeying the conventions that stem from this society’s double standard about aging. Instead of being girls, girls as long as possible, who then age humiliatingly into middle-aged women, they can become women much earlier—and remain active adults, enjoying the long, erotic career of which women are capable, far longer. Women should allow their faces to show the lives they have lived. Women should tell the truth.” — Susan Sontag, The Double Standard of Aging
That long, erotic career is what I mean by sexspan. Lifespan counts your years. Healthspan counts the years you function. Sexspan counts the years you remain a person with access to pleasure, wanting, and erotic aliveness. It is a real biological question with real mortality data behind it. Medicine has never built the instrument for it. Women will build it first.
Here is what I am proposing. For most of our lives, the mirror has been the main instrument we are given, and a mirror can only tell her how we are seen.
A sexspan measure tells her something no mirror can: whether she is still living in her body or merely maintaining its surface.
The first is surveillance. The second is sovereignty.
The woman in my office did not leave with a prescription. She left with an assignment: for one week, count the mirror checks, and count the number of times she thought about her own pleasure. Then compare.
She came back with the numbers and became tearful, because no one had ever asked her to measure the second column, and the ratio told her more about her supposed winding down of sexual aliveness than any lab had.
Her desire was not gone. It was buried under surveillance. That was the first sexspan measurement I ever took, and it required no blood draw.
Now it is yours. Ask your doctor about your labs.
Then run my patient’s assignment on yourself: one week, two columns, mirror checks against pleasure thoughts.
If you are on a GLP-1, add a third column with your resting heart rate and HRV, so you know what your own nervous system is doing rather than fearing the drug.
And notice whether you are managing how you are seen instead of asking for what you want. Appeasement is a stress response with a name, and the ratio between those two columns is where it hides.
Your labs can come back perfect while your sexspan quietly collapses, and no one in medicine will notice, because no one is measuring it. Start measuring. Start with the two columns. Then decide, deliberately, which one gets more of your Tuesday.
Her face was the most measured surface in American medicine. Her wanting went unmeasured for her entire life. I intend to close that gap, and I am starting with the women reading this.
So here is where I want your voice, not mine.
Run the two columns for one week, mirror checks against pleasure thoughts, and tell me the ratio in the comments, along with your age.
Then ask me the question this essay did not answer: what rebuilds a sexspan once you can measure it? I have an answer, and it has almost nothing to do with hormones.
Ask, and I will write it next.
xo, Dr. Sara
Notes
1. Bahtiyar G, et al. Curr Diab Rep, 2018.
2. Andreasen CR, et al. Diabetes Obes Metab, 2021.
3. Zhang Y, et al. Eur J Med Res, 2026.
4. Kumarathurai P, et al. Diabetes Care, 2017.
5. Grosicki GJ, et al. Am J Physiol Heart Circ Physiol, 2025.
6. Lara J, et al. BMC Med, 2015.
7. Perri G, et al. J Gerontol A Biol Sci Med Sci, 2025.
8. Moqri M, et al. Cell, 2023.
9. Kling JM, et al. Menopause, 2021.
10. Dilixiati D, et al. J Sex Med, 2023.
11. Pigeon WR, et al. J Psychosom Res, 2023.
12. ACOG Committee on Practice Bulletins—Gynecology. Obstet Gynecol, 2019.
13. Mernone L, et al. Front Psychol, 2019.
14. Dennerstein L, et al. Am J Med, 2005.
15. Von Hippel C, et al. Womens Health Issues, 2019.
16. Blümel JE, et al. Menopause, 2022.
17. Cao C, et al. J Sex Med, 2020.
18. Chen HK, et al. Int J Epidemiol, 2007.
19. Bowen ST, et al. Am J Obstet Gynecol, 2026.
20. American Urological Association. AUA/SUFU/AUGS GSM Guideline, J Urol, 2025.
21. Davis SR. N Engl J Med, 2024.
22. Potter JE. JAMA, 2007.
23. Goddard FBG, et al. NPJ Womens Health, 2025.
24. Roelofs K. Philos Trans R Soc Lond B Biol Sci, 2017.
25. Hashemi MM, et al. Psychoneuroendocrinology, 2021.
26. Niermann HCM, et al. Psychoneuroendocrinology, 2017.
27. Manzotti A, et al. Dev Psychobiol, 2024.
28. Wekenborg MK, et al. Sci Rep, 2022.
29. Kim HS, Yosipovitch G. Exp Dermatol, 2013.
30. Terpou BA, et al. J Neurosci Res, 2019.
31. Thome J, et al. Hum Brain Mapp, 2017.
