Pain with Intercourse After Menopause

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What causes sex to hurt?

Pain during sex can be experienced at any age, but it may be more common around and after the age of 50 years. Any time there is a significant drop in estrogen in your body, you are at risk of experiencing pain with intercourse. Menopause is the most common reason for pain during sex, but there may be other factors at work in your life. It’s important to talk to a health care professional about any pain felt during intercourse, as there are many things you could do to make intercourse more pleasurable and enjoyable.

What are the different kinds of pain during sex?

Pain with sex can happen just before, during or after intercourse. The pain or discomfort can be superficial, deep, or both. Superficial pain means pain is present upon entry or penetration, and deep pain means pain is felt on deep thrusting. As such, pain can be felt in a number of places: in the vagina, the vulva (external genitalia including the labia and vaginal opening), and deep in the pelvis. Your pelvis and belly may feel sore after having sex.

What does menopause have to do with it?

Between 48 to 55 years of age, the ovaries stop making eggs and women’s menstrual periods stop. During the transition to menopause, the ovaries make less amounts of estrogen. Estrogen works by keeping the vagina healthy, moist and flexible. After menopause, when the estrogen levels fall, the vagina loses flexibility and lubrication. As a result, your vagina can become thin and dry, and you may experience pain with sex. A common term used to describe these symptoms is vulvovaginal atrophy.  These symptoms are experienced by 45% of all women who enter menopause.

What is “genitourinary syndrome of menopause”?

This is a fancy term used to describe the vaginal symptoms some people experience during menopause. The vulva and the vagina become thin and dry, causing burning, irritation, vaginal discharge, and pain or soreness with sex. Because your bladder and urethra also respond to low estrogen, you may also experience symptoms like pain with urination, frequency of urination, or more frequent urinary infections. Because all of these symptoms may go hand-in-hand, “genitourinary syndrome of menopause” or “GSM” seems to be a more inclusive term.

What other conditions could lower the estrogen in my body and make my vagina dry?

A number of other things can make your vagina dry, making sex uncomfortable and painful. Other than the natural drop in estrogen that happens at menopause, the following situations could also cause pain with sex:

• If you just had a baby, particularly if you are breastfeeding
• If you are taking medications known to block the estrogen that our bodies make (medical menopause)
• If you had your ovaries removed (surgical menopause)
• If you had chemotherapy or radiation therapy of the pelvis for cancer

 Treatments

There are a number of therapies that can help treat your vaginal dryness and reduce pain with sex. Lubricants and moisturizers do a good job at treating minor symptoms. These products do not contain medication or hormones. They do not require a prescription and are easily obtained. If your symptoms are mild, we encourage you to try these options first. If your symptoms are more serious, or if lubricants and moisturizers have not provided relief, you should talk to your health care provider. Your provider could prescribe vaginal estrogen or a non-hormone treatment option. Options range from therapies made to be placed directly in your vagina, to a pill that can be taken by mouth.

Lubricants & Moisturizers

Lubricants

A number of different lubricants may help you. These come in both liquid and gel forms and are either water-based or silicone-based. Water-based lubricants may cause less irritation and may be better tolerated. Silicone-based options may be more slippery and may last longer. You can apply the lubricant of your choice inside and around the opening of your vagina right before sex. They work by reducing friction, making sex more comfortable. You may need to try a few products in order to find the one that works best for you. Here are some examples:

Water-based	Silicone-based	Oil-based**
Astroglide® liquid	Astroglide®	Olive oil
Astroglide® Gel liquid	K-Y Intrigue®	Coconut oil
K-Y® Jelly	ID Millennium®	Vitamin E
Pre-Seedä	Pjur® Eros	Ele’gance Women’s Lubricants
Slippery Stuff®	Wet® Platinum®

**Oil-based lubricants should never be used in conjunction with latex or polyisoprene condoms.

Moisturizers

A number of different moisturizers may also help you. Unlike lubricants, moisturizers are intended to be applied to the vagina several times per week as needed, not just before sex. Some may be used everyday, depending on the severity of your dryness. Always follow instructions provided by the manufacturer and, when in doubt, consult your healthcare provider. Moisturizers work by trapping moisture and by hydrating your vagina. As such, you may find relief of other symptoms such as dryness, burning and itchiness in your vagina. Compared to lubricants, the effect of a moisturizer is intended to last longer. You may also need to try a few products in order to find the one that works best for you. Some examples are: Replensä, RepHreshä, Vagisil®, K-Y® Silk-E®, Me Againä, Feminease®

Vaginal Hormone Therapy

Vaginal estrogen

If you do not get sufficient relief from lubricants and moisturizers, your healthcare provider could prescribe you low-dose vaginal estrogen. These products do a very good job at treating the vaginal dryness and irritation that causes sex to hurt. Vaginal estrogen will make the tissue in your vagina moister and thicker. The tissue will be less pale, as more blood will flow to your vagina.

It’s very important to consult your healthcare provider before using estrogen. For some people, estrogen use can increase your risk for stroke, blood clots high blood pressure, and heart attack.

You can choose from a number of different vaginal estrogen products. You may notice relief after a few weeks of use, but depending on how bad your symptoms are, it may take several months.

• Vaginal cream– You can put a pea-size amount of estrogen cream into the vagina using your finger or an applicator. If the vaginal opening is also affected, you may apply a very small amount to this area as well. You will put estrogen cream in your vagina one time, each day for two weeks, and then one time, two days per week.
• Vaginal tablet– If you find the cream to be messy, you can put a small tablet into the vagina using your finger or an applicator. You will put this tablet in your vagina one time, each day for two weeks, and then one time, two days per week.
• Vaginal ring– You can put a small flexible plastic ring in your vagina for 3 months and then remove and replace with a new one every 3 months. You do not need to remove the ring to have sex or bathe. If you choose to remove it to have sex, make sure to put it back inside the vagina afterwards.

Vaginal Cream	Vaginal Tablet	Vaginal Ring
Estrace® 1mg per 1gm cream	Vagifem® 10mcg	Estring® 7.5mcg
Premarin® cream 0.625 mg per 1g cream	Imvexxyä 4mcg or 10 mcg

Which vaginal estrogen form is better?  The cream, the tablet or the ring?

All three forms do a very good job at treating vaginal dryness and pain with sex. Choose the estrogen form you are more comfortable with or the one that is more convenient to you. Talk to your insurance company and explore the costs of all your options. Cost and affordability may also be a factor to take into consideration. Note that estrogen is only available with a prescription and you should only take it after carefully discussing and learning the risks and benefits of estrogen for you.

Non-Estrogen Treatments

DHEA- This is a hormone which works like estrogen on the vagina. It is a suppository that is placed in the vagina at bedtime.

Ospemifene- Ospemifene is the only oral non-hormone treatment available to treat vaginal dryness and pain with sex during menopause. You can take the pill by mouth one time, each day. This medication is not estrogen, but it works like estrogen to help improve the tissue in your vagina. It also helps with your bones. If you don’t want to use any vaginal product, or have a hard time putting products inside your vagina, ospemifene may be a good option for you. Relief may be noticed after using the medication for 12 weeks.

Vaginal prasterone- You can put a suppository inside your vagina using an applicator one time, each day, at bedtime. The vaginal suppository contains prasterone, an ingredient that is changed in your body to estrogen. If you do not want to use estrogen, this may be a good option for you. However, keep in mind that vaginal prasterone was recently approved by the FDA and we know less about this therapy option as compared to vaginal estrogen.

Other Treatments

Vaginal Laser

Laser therapy appears to be a safe and potentially good option to treat vaginal dryness and pain with sex during and after menopause. During this procedure, a numbing cream is applied to the vulva and vagina, and a probe is carefully inserted into the vagina by your healthcare provider. This probe delivers laser energy to all your vaginal walls, and to your vulvar area or vaginal opening, if necessary. Multiple sessions may be needed. The laser works by creating many small punctures in your vagina which help stimulate the growth of new, healthy vaginal tissue. Currently, there are not enough data to recommend this treatment over other therapies, such as vaginal estrogen. More research needs to be done. However, vaginal laser treatment holds promise for women who cannot use estrogen, cannot tolerate hormone treatment, cannot afford long-term hormone treatment, or are not willing to use products with hormone. 

Physical therapy

Many women who experience pain with sex have tight muscles in the pelvis. With the help of a physical therapist, you can be taught how to identify and relax the muscles of your pelvic floor (pelvis). This treatment occurs over a number of sessions. Learning how to relax the muscles of your pelvis may help you have easier, less painful sex.

Vaginal dilators

If your vagina narrows and shortens, or you have been contracting your pelvic muscles in such a way that you are unable to have sex (such as in anticipation of the pain that is usually felt), a set of vaginal dilators could help you. You will gently stretch your vagina with well-lubricated dilators starting with the smallest one, and gradually increasing the size of the dilator until you are able to have sex. Your health care provider or therapist can guide you during this process.

Behavior Changes

There are some things you can do to potentially reduce pain during sex. The most common recommendations are:

• Empty your bladder before having sex
• Increase the amount of time spent in foreplay as this may improve natural lubrication
• Change positions during sex- don’t be afraid to speak about what feels right or wrong
• Choose positions that allow you to have control of the depth of penetration
• Place ice packs around a towel and apply to your vulva if you feel discomfort after sex
• As long as there is no major pain, try staying sexually active- sex itself keeps the vaginal tissue healthy and maintains the vagina soft and stretchable.
• Practice yoga- Yoga has many benefits! Some yoga poses work by strengthening and relaxing the muscles of your belly and pelvis. This exercise may help increase sensation during sex, and may even help ease pain during penetration. Practicing yoga can help you improve your sexual function.

Common Questions about Treatment Options

I have a history of breast cancer, Am I able to use any treatments?

If you have had breast cancer, you should talk to your healthcare provider. It is safe to use lubricant and moisturizers. If these don’t work, there is a possibility you could use other treatments, but this should only be done in consultation with your oncologist.

How about herbal remedies and soy products to treat my vaginal symptoms and pain with sex?

We do not have enough data or information to support the use of herbal remedies or soy products to treat vaginal symptoms or pain with sex during menopause. Therefore, we cannot recommend these options.