Pain with Sex During Menopause: Understanding and Overcoming Intimacy Challenges

Menopause is a natural phase in a woman's life that marks the end of her reproductive years. Despite it being a nearly universal experience, there is little support or information regarding the changes you can expect in your physical and sexual health. One common issue experienced by women in menopause and perimenopause is pain with sex, medically known as dyspareunia. These symptoms are often not talked about, glazed over, ignored, and stigmatized, leading many women to avoid seeking help. Despite common belief, there are several options for addressing this discomfort and its impact on intimacy. 

Understanding Pain with Sex (Dyspareunia):

Dyspareunia is characterized by persistent or recurrent pain experienced before, during, or after sexual intercourse. The pain may manifest as a burning, stinging, or sharp sensation in the vaginal area, making sex uncomfortable or even unbearable. Some women describe the sensation of “hitting a wall”, making vaginal penetration impossible. In addition to physical pain, this condition can lead to emotional distress, relationship strain, and a decline in sexual desire, impacting a woman's self-esteem and overall quality of life. Dyspareunia is a condition that can occur at any age for many reasons, but often develops in association with menopause. We will dive into why this may occur and what to do about it next. 

Causes of Dyspareunia During Perimenopause/Menopause:

• Vaginal Dryness: During perimenopause and menopause, there is a significant fluctuation and eventual decline in estrogen levels, which can lead to thinning and dryness of vaginal tissues. This change in estrogen levels is expected and normal, but the subsequent lack of lubrication can make the vaginal walls more sensitive and causes irritating friction to dryer tissues. 
  

• Vaginal Atrophy: The decrease in estrogen levels can also result in vaginal atrophy, where the vaginal walls become thinner, less elastic, and more delicate. As a result, friction during intercourse can cause pain and discomfort.
  

• Psychological Factors: Menopause often brings emotional and psychological changes that can include stress, anxiety, and unexpected changes in mood. These factors can impact a woman's ability to relax and enjoy intimacy, leading to heightened sensitivity to pain during sex.
  

• Previous Medical Conditions: Certain pre-existing medical conditions, such as endometriosis, pelvic inflammatory disease, or urinary tract infections, often contribute to pain during intercourse. If these symptoms or conditions were present prior to menopause, the pain experience associated with them may change as the hormonal environment changes. 
  

Pelvic Floor Dysfunction: When the body experiences pain, a common and unconscious defense mechanism is for muscles to contract or “guard”. The overactivity of already sensitive muscles can increase friction, sensitivity, and pain while attempting penetrative or even non penetrative sex. 

Treatment

If you notice discomfort or pain during intercourse, you should always reach out to your doctor for possible treatment options. Many women benefit from medical management of their menopause symptoms, including but not limited to hormone replacement therapy (HRT) or topical vaginal medications. Your provider can work with you to identify what would be most helpful for addressing your needs. 

While medication is one option for managing symptoms associated with menopause, there are many other things you can do to optimize your pelvic functioning: 

Lubrication:. Lubrication can decrease friction and discomfort, reduce associated muscle guarding, and increase pleasure during intercourse. Look for a lubrication without scents or flavors to reduce likelihood of irritation (we like Slippery Stuff or Good Clean Love for water based lubricants, or Uber Lube for silicone based). 

Vaginal Moisturizers: Some women find that vaginal dryness is bothersome beyond intimacy. In these cases doctors may suggest hormonal treatment, but there are also topical, non hormonal agents that can be used to provide longer term relief from dryness. (we like Revaree or Replens). 

Stretching and Strengthening: Tissue health in any part of the body can be improved with stretching and movement, pelvic floor included! Many patients get relief from gentle yoga based stretching focusing on relaxing their pelvis and opening up the hips. Depending on symptoms, patients sometimes need strengthening as well to decrease tissue thinning and combat atrophy.

Pelvic Floor Physical Therapy (PFPT): When independent exercise isn’t enough, a pelvic floor physical therapist can work with you to identify what movements will work best for you to decrease tension, improve coordination, and optimize overall muscular functioning. Pelvic floor PTs can also help reduce muscle tension manually with myofascial treatments aimed to relieve overactive muscles and reduce sensitivity. 

Remember, pain during sex is common, but not normal. There are many options for treatment and management- reach out to your GYN or physical therapist to get your personalized treatment plan today!

Additional resources: 

Find a Menopause Informed Doctor

Books: “The Menopause Manifesto” by Dr. Jen Gunter 

Instagram: @menopause_doctor , @themenopausesociety 

Youtube: “Discussing Sexual Health Concerns With Your Health Care Professional” by MenopauseSociety 

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