Painful Sex During Menopause

Painful Sex During Menopause: Causes & Remedies

Painful sex during menopause is experienced by 17-45% of postmenopausal women. Menopause is a biological process signifying the end of a woman’s fertility and menstruation.

Menopause starts in different ways:

  • Naturally, as the woman ages into it, or
  • Surgically, if the ovaries are removed surgically (oophorectomy); or
  • Medically, as an outcome of cancer treatment such as chemotherapy, hormone suppression medication, or radiation to the pelvic area.

When in menopause, the female’s body makes less estrogen, a hormone whose function is maintaining vaginal lubrication, elasticity, and thickness.  Therefore, declining level of estrogen during the menopausal years gradually makes the vagina thinner, less elastic, less self-lubricating, and less acidic (pH levels rise above 5) and thus more prone to chafing irritation, infections, bleeding, and painful intercourse. Watch our video here.

Additionally, the urinary tract, which runs parallel to the vaginal canal and is also estrogen-dependent, becomes symptomatic by way of increase frequency & urgency, burning upon urination.

The medical term for these urogenital changes is Genitourinary Syndrome of Menopause (GSM), previously known as Atrophic Vaginitis.

Causes of Painful Sex During Menopause

Painful sex during and after menopause is a common issue that many women experience. Here are some of the most common things that make sex painful.

Hormonal Changes & Estrogen Levels

The reduced levels of estrogen will make the vagina less ‘friendly’ to the mechanics of sexual intercourse: less elastic, more prone to chafing irritation, and more sensitive to the ‘action’ of the act.

Vaginal Dryness & Atrophy

The declining estrogen levels lead to decrease in vaginal lubrication, increase in chafing irritation, increased susceptibility to micro tears, and urinary urgency and frequency.

Psychological Factors

Menopause is not just the cessation of menstruation but rather multi-system changes – hormonally, physiologically, and chemically – bringing about emotional mood swings, hot flashes, sleeplessness, depression, lower energy, feeling ‘old,’ etc.

Decreased Libido

Sexual arousal for a woman begins ‘between her ears’ because her mind is THE on/off switch to her libido.  As such, is there a surprise that it is not easy for woman to ‘get into it’ when she is not feeling good, when her vagina is dry and uncomfortable, or when sexual intercourse or sexual activity causes pain? Watch our video Menopause and Libido for more tips and information.

Medical Conditions

In addition to menopause, the woman may also struggle with associated medical conditions that impact her vagina, libido, and sexuality, including infections, pelvic inflammatory disease (PID), pelvic organ prolapse, endometriosis, incontinence, dyspareunia or Sjogren syndrome. 

Primary or Secondary Vaginismus

Vaginismus, or Genito-Pelvic Pain/Penetration disorder, is characterized by the inability or great difficulty with vaginal penetration.  Primary vaginismus is when the woman has always struggled with this condition which causes pain during sex, whereas secondary vaginismus is the result of disruptive life events.

Menopausal secondary vaginismus is quite common because of the above-mentioned changes associated with menopause.  But, just like primary vaginismus, menopausal secondary vaginismus can be resolved with proper management. 

Remedies for Painful Sex During Menopause 

In addition to the following list, watch our video for postmenopausal women that offers remedies and information for painful sex: Menopause, Vaginal Dryness, and Painful Intercourse.

Hormone Replacement Therapy

Barring medical contraindications, vaginal estrogen replacement therapy is an essential component of addressing Genitourinary Syndrome of Menopause (GSM), and the only one to restore/reverse the estrogenic decline.

Vaginal estrogen replacement preparations are by prescription only and are available as a cream, a tablet, or a vaginal ring.  Clinically speaking, we have found that the cream version works best (despite some discharge) and offers a secondary benefit of treating the menopausal vulva – the area between the vaginal lips – by applying a bit of the cream to it as well.

Speak with your healthcare provider about which option would be most suitable for you.           

Vaginal Moisturizers and Lubricants 

These non-hormonal preparations are inserted, with an applicator, into the vagina/vaginal tissue at different times for different functions.  Watch this video How to Use and Clean an Applicator.

  • Vaginal moisturizers are like a hand lotion for dry hands: their purpose is to lubricate the vaginal canal and should be inserted at bedtime so they can do their ‘job’ while the woman is sleeping;
  • Vaginal lubricants are specifically used for vaginal penetration at time of intercourse or dildo use. They are of a consistency that withstands the normal friction associated with sexual intercourse (or a dildo).  Note: it is recommended to stay aways from lubricants that are oil-based as they may cause irritation, so read ingredients carefully. Watch our video How to Use Vaginal Lubrication.

Genital Hygiene

Genital hygiene plays an important role and proper management will aide in addressing menopausal painful intercourse:

  • Proper hydration. Be mindful of factors that affect hydrations, such as winter heating, certain medications (allergy pills included), insufficient fluid intake, and watch for urine that is darker than light yellow;
  • No hot water on genitals, ever! Use lukewarm water only as hot water tend to chaff and make the genitals/vagina super dry and painful to touch and stretch;
  • Use mild soaps, no scented soaps, no scrubbing;
  • No douching unless medically advised;
  • Use a topical ointment like Aquaphor Healing Ointment or Vaseline on your genital lips if they feel sticky, dry, and when engaging in sweaty activity like cycling, running, rowing, etc.           

Have sex!

Yes, you read this right.  Staying sexually active has benefits, including

  • Increasing blood flow to the genitals;
  • Muscle strengthening: an orgasm is a pelvic floor muscle exercise!
  • Giving a ‘feel good’ hormonal lift, an endorphin boost;
  • Enhances the intimacy of the relationship for both partners.

Staying sexually active during menopause can be penetrative (intercourse) or non-penetrative (oral, manual, masturbation) – whichever you choose, regardless of family status and sexual orientation.

Vaginal Dilators

A home dilator kit may be of great help in restoring vaginal elasticity and pain-free intercourse.  Be sure to use ample lubrication and increase sizes gradually.  If in doubt, seek professional guidance from a pelvic floor physical therapist or your healthcare provider.

Medical Management 

Consult with your healthcare provider if you cannot sort out the menopausal pain on your own, as well as to discuss associated medical concerns and conditions.  

Counseling or Therapy

Mental health professionals offer a variety of services to address breakdowns associated with menopause, painful sex, and relationship conflicts.  Choice clinicians include social worker, psychologist, or sex therapist/counselor.  Explore and find the one the works best for you.

Talk to Professionals Who Can Help with Painful Sex and Menopause

Women often choose to live with pain and suffering instead of speaking up and searching for solutions.  They often believe that it is ‘their fault’ and that ‘nobody will listen to them,’ which is an unfortunate fact.  We encourage every woman to hold her head high and to advocate for her needs regardless of feeling inadequate and hopeless.

We welcome your inquiries, and have in-person and virtual treatment programs for overcoming menopausal painful sex so do not hesitate to Contact Us.

About The Author

Dr. Ditza Katz

Ditza Katz, PT, Ph.D., is the founder of Women’s Therapy Center, a practice specializing in urogynecologic rehabilitation, treatment of female sexual dysfunction, breast & female cancer rehabilitation, and management of somatic disorders. Dr. Katz holds an undergraduate degree in Physical Therapy, a Master’s degree in Pastoral Psychology & Counseling, a doctorate in Clinical Sexology, and clinical training in manual therapy and urogynecology. Dr. Katz is a Diplomate with the American Board of Sexology, Professor at the American Academy of Clinical Sexology located in Orlando, Florida, and the only physical therapist in the USA who is a clinical sexologist.

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