Menopause & Painful Sex: Understanding Discomfort & Finding Relief

As women transition through menopause, the decline in estrogen levels often leads to changes that might make sex uncomfortable or even painful. Vaginal tissues become more fragile, less elastic, and prone to tearing, bleeding, or pain during intercourse or pelvic examination. This condition, known as dyspareunia, affects approximately 8% to 45% of postmenopausal women.¹

Beyond the immediate physical pain, this discomfort can cause performance anxiety and arousal issues. This creates a cycle where diminished lubrication and painful vaginal muscle tightening, known as vaginismus, exacerbate the problem. These issues can significantly impact sexual health.¹

Painful sex does not mean the end of a fulfilling sex life. Speaking with a physician can help manage these symptoms effectively. With the right medical support and treatment, women can continue to enjoy sex for as long as they wish and maintain their sexual health and pleasure throughout menopause.

When does painful sex occur?

Painful sex can occur at any age, but it’s especially prevalent among women who have reached menopause. Research indicates that between 25% and 50% of postmenopausal women experience discomfort during intercourse.²

What causes painful sex during menopause?

The primary cause of painful sex in postmenopausal women is the decline in hormones, particularly estrogen. This hormonal drop can trigger changes in the tissues of the body, including those in the vagina, making them more fragile and less elastic. Other causes include the following:^1,3

Vaginal Dryness

Estrogen loss causes vaginal tissues to become thin and dry, increasing friction during sex. The vagina also becomes less elastic, making it tighter and more prone to irritation and tearing during intercourse. 

Reduced Blood Flow

With reduced estrogen levels, blood flow to the genital area decreases, impacting arousal and lubrication. Without sufficient blood flow, the tissues in and around the vagina may not become fully or quickly engorged with blood, leading to less sensation and wetness during sexual activity. As a result, sex can become painful due to inadequate lubrication and decreased arousal.

Pelvic Floor Weakness

Pelvic floor weakness often occurs after menopause, leading to decreased stability in the pelvic region. This weakening can cause the bladder or uterus to press against the vagina, resulting in painful sex.

Vulvodynia

Vulvodynia is a chronic condition characterized by pain in the vulvar area, which can worsen with sexual activity. This condition may cause the outer region of the vagina to sting or burn when touched or during sex. While vulvodynia is not exclusive to menopause, it often becomes more common at this stage of life.

Symptoms of Painful Sex During Menopause

Painful sex can present a variety of symptoms:

• Pain during vaginal penetration

• A burning or stinging sensation during intercourse

• Vaginal discomfort following sex

• Difficulty achieving or maintaining arousal

Without treatment, infrequent sex combined with insufficient vaginal lubrication can lead to inflammation, resulting in tearing and bleeding of the vaginal tissues.

Treatment Options for Painful Sex During Menopause

Experts recommend these treatment options to manage painful sex during menopause:³

Lubricants

To enhance lubrication and reduce discomfort during sex, women can opt for water-based or silicone lubricants. These products help minimize friction and prevent pain. They should be applied to the vagina or the partner’s penis right before intercourse.

Women whose menstruation hasn’t ceased or who use condoms should choose water-based lubricants, as oil-based ones can damage condoms and decrease their effectiveness.

Moisturizers

Regular use of vaginal moisturizers helps maintain the moisture balance in vaginal tissues. These products add water to the tissues and can be applied two or three times per week. Moisturizers also reduce friction during sex, and because they penetrate the skin, their effects are long-lasting. So, there’s no need to apply them before every intimate moment. 

Low-Dose Estrogen Therapy

A doctor may prescribe low-dose topical estrogen for more severe dryness and pain that do not respond to moisturizers or lubricants. Estrogen improves vaginal health by enhancing the thickness and flexibility of vaginal tissues and increasing blood flow. Estrogen therapy can come in various forms, such as creams, tablets, or rings inserted into the vagina. Up to 93% of women using low-dose vaginal estrogen report significant relief from pain during sex.

Other Medications

Ospemifene, the only FDA-approved non-hormonal treatment for painful sex related to menopause, functions similarly to estrogen by thickening the vaginal lining. Its primary side effects include hot flashes and an increased risk of blood clots.⁵

Hormone Replacement Therapy (HRT)

Systemic HRT might be recommended if estrogen creams or inserts are not effective in alleviating pain during sex. Estrogen pills can help relieve not only vaginal discomfort but also hot flashes and other menopausal symptoms. For women with a uterus, doctors will prescribe progesterone alongside estrogen to prevent the risk of endometrial thickening, as progesterone counteracts this effect commonly seen when estrogen is taken alone.

Pelvic Floor Exercises

Weak or tight muscles supporting the bladder and vagina can make sex uncomfortable. Kegel exercises can help retrain the pelvic floor. To find the right muscles for Kegel exercises, women can practice stopping the flow of urine midstream, which can help isolate the pelvic floor muscles responsible for controlling urination. 

For a narrow vagina, a therapist may suggest dilator therapy to gently stretch the surrounding muscles. These tube-shaped devices come in various sizes to gradually increase vaginal elasticity and improve comfort during sex. 

When to See a Doctor

Sex should never be painful, regardless of age or menopausal status. Women should not hesitate to seek medical help if lubricants or moisturizers don’t alleviate the discomfort. A doctor can recommend the most effective treatment tailored to each individual case.

Maintaining a Healthy Sex Life During Menopause

Even during menopause, when sex drive may decline, individuals can still enjoy intimacy. The following practices can help enhance physical intimacy during menopause: ⁶

• Experimenting with erotic videos or books, masturbation, and different sexual routines

• Using distraction techniques to boost relaxation and ease anxiety during sex, such as indulging in erotic or non-erotic fantasies, listening to music, or watching videos

• Enjoying foreplay activities like sensual massage or oral sex to improve comfort 

• Choosing sexual positions that allow control over the depth of penetration to minimize pain 

• Taking warm baths before sex to relax

• Using vaginal lubricants to minimize friction

• Communicating openly with a partner about what feels comfortable and what doesn't

Experiencing painful sex during menopause? Discover if HRT is right for you.

If you’ve entered the menopause transition and are struggling with painful sex, you don’t have to suffer in silence. Take our brief menopause quiz to see if you’re an eligible candidate for HRT. Get started with Winona to take the first step toward feeling better.