Painful Sex

Falling estrogen levels during perimenopause and menopause can decrease production of moisture and lubrication, resulting in vaginal dryness as well as thinning and loss of elasticity of vaginal tissues. These changes can result in discomfort during vaginal penetration and sexual intercourse (dyspareunia). The discomfort can range from a feeling of dryness to a feeling of vaginal “tightness” to severe pain during or after sex.

Over time, and without treatment, the fragile vulvovaginal tissues become susceptible to injury, tearing and bleeding during intercourse. This is perhaps the most common cause for painful sex after menopause. In addition, when a woman is not sexually active on a regular basis following menopause, her vagina may also become shorter or narrower. Some other causes of painful sex include bacterial infection, skin conditions, vaginitis, urinary tract conditions, endometriosis, fibroids, ovarian cysts and pelvic organ prolapse. These conditions are not addressed here.

Beyond the immediate effects of the pain itself, pain during sex (or simply fear or anticipation of pain during sex) can trigger sudden and involuntary contractions of the pelvic floor muscles, performance anxiety or future arousal problems in some women. The result can be a vicious cycle, highlighting how self-reinforcing sexual problems can become.
  • Use a vaginal lubricant for temporary relief of dryness before and during sex. For longer-term relief from dryness, use a vaginal moisturizer on a regular basis, regardless of sexual activity.
  • Practice open communication with your partner. Speak up when you’re in pain, and be honest about what hurts and what helps.

  • Limit your alcohol intake. Alcohol tends to diminish sexual response by dulling the central nervous system. In women experiencing menopause, alcohol may also trigger hot flashes and night sweats.

  • Exercise regularly. Exercise improves circulation, which is important for sexual arousal. It also releases endorphins, which are the body’s natural pain relievers.
  • Certain types of strength training can help improve muscle tone in the core, pelvis and upper thighs, contributing to more pleasurable sex.
  • Kegel exercises, in which the muscles of the pelvic floor are repeatedly squeezed then released, can help promote healthy blood flow and muscle tone throughout the pelvis, vulva and vagina.

  • If you’re a smoker, please quit. This is one of the most positive steps you can take for your overall health. Smoking is a major contributor to peripheral arterial disease, which curbs blood flow to your clitoris and vagina.
  • Engage in regular sexual activity or self-stimulation to promote vaginal health and blood flow. The vagina, like other parts of the body, can become stiff and sore when not exercised enough. The more often you have sex, the lower your risk of severe vaginal thinning, dryness and tightness.
  • Women with depression or anxiety are more likely to have sexual health concerns. If there’s a chance these conditions might be contributing to your pain during sex, talk to a health care provider or counselor about diagnosis and treatment.

Stress Management:
  • Chronic stress can upset the balance of female hormones, making the “rollercoaster” effect of perimenopause and menopause more pronounced and your physical response to sexual stimuli less predictable. To help bring more balance to your hormones and sex life, decrease stress through daily meditation, deep breathing, progressive muscle relaxation or other therapeutic relaxation techniques, like biofeedback.
Medication: Vaginal estrogen can help counteract vaginal skin thinning, dryness and loss of lubrication. Vaginal estrogen comes in many forms: creams, pills (for the vagina), caplets, suppositories and a three-month slow-release vaginal ring. Used as directed, these therapies do not increase systemic levels of estrogen above the normal postmenopausal range.

Pelvic Floor Physical Therapy: If pain during sex is caused by tight, unexercised pelvic muscles, working with a pelvic floor physical therapist can help train the muscles to loosen and relax.

Psychotherapy/Sex Counseling: Talking to a qualified sex therapist can help identify behavioral or emotional triggers for pain during sex, and offer strategies for addressing them.

Sexual Devices: If your pain is caused by vaginal constriction or tightening, periodic use of a vaginal dilator and/or vibrator can help to stretch and relax the vaginal muscles. The dilator provides a gentle stretch and comes either as a static device or one that expands while inserted. Vibrators can increase blood flow and help relax the muscles and aid expansion.
What causes painful sex during menopause?
The most common cause is a condition called genitourinary syndrome of menopause (GSM). In GSM, which includes vulvovaginal atrophy, the tissues of the vulva (exterior genitals) and lining of the vagina become thinner, drier, and less elastic or flexible, due to a decrease in estrogen. Low estrogen can also cause vaginal secretions to be reduced, which results in less lubrication during sex, and a higher vaginal pH, which makes bacterial infections more likely.

When should I talk to my health care provider about pain during sex?
If you’re experiencing ANY amount of pain during sex, it’s important to talk to your health care provider. Deep pain can be a sign of pelvic inflammatory disease, endometriosis, a pelvic tumor, ovarian cysts, bowel or bladder disease, or scar tissue. Superficial pain can be caused by bacterial infections, skin conditions, muscle dysfunction, hypersensitive nerves or hormonal deficiencies, among other causes. In almost every case, pain during sex can be resolved with proper treatment.

Now than I’m in menopause, shouldn’t I expect a certain amount of pain during sex?
While lower estrogen levels can contribute to pain during sex, not all women develop vaginal atrophy during menopause. Approximately 20% to 50% of U.S. women experience vulvovaginal symptoms sometime during menopause. The most common symptoms of vaginal atrophy (vaginal dryness, irritation, burning, pain, soreness) may be due to other causes. It’s always a good idea to get pain checked out by your health care provider.

What kinds of tests will I need to determine the cause?
The first “test” will likely involve a conversation with your health care provider so they can better understand your pain and start zeroing in on possible causes. The next step will likely be a physical exam to help your provider determine potential causes. Based on what they find during the physical exam, other tests may be necessary (like a bacterial culture) to determine the best course of treatment.

I went through menopause years ago, but I’m just having pain now. Is this normal?
Menopause-related vaginal symptoms, including pain during sex, may occur early in the menopause transition or not until after several years of reduced estrogen levels. Either way, symptoms are usually quite treatable using a variety of methods.

I’m so embarrassed about this I can’t even talk to my partner. How can I bring this up at my appointment?
There’s no shame in wanting a healthy and satisfying sex life. Sexual health is an important part of overall health. Your provider wants to be aware of all your health concerns so they can connect you with the care you need. At your next appointment, try saying something like, “Lately I’ve been having sex less often than I’d like, because when I do have sex, it’s uncomfortable for me. What do you recommend?”

If you don’t know who to talk to, call our Care Navigator and they will set you up with the right provider to help you evaluate treatment options and next steps.