How to Deal with Painful Sex During Menopause

Menopause is a natural transition in a woman’s life, but it can come with some unexpected and uncomfortable challenges. One of the most common yet often under-discussed issues that many women face is painful sex. Whether it's a mild discomfort or sharp pain, this condition, known as dyspareunia, can be distressing and impact intimacy, self-esteem, and overall quality of life. Around 20% to 59% of perimenopausal and postmenopausal women experience painful sex.

The good news is that there are effective ways to manage and alleviate painful sex during menopause. Let’s break down why sex can become painful during this phase and explore some science-backed solutions to help you regain comfort and confidence.

Why does sex become painful during menopause?

Understanding why sex becomes painful during menopause is the first step. The main reason is the hormonal changes that occur during this time, particularly the drop in estrogen levels. 

Estrogen is a key hormone that plays a significant role in maintaining the health and elasticity of vaginal tissues. When estrogen levels begin to decline, typically in perimenopause and continue through menopause, several physical changes can occur:

1. Vaginal dryness: One of the most common causes of painful sex during menopause is vaginal dryness. Estrogen helps keep the vaginal lining moist and elastic, and without it, the vaginal walls can become thin and dry, leading to discomfort during intercourse.
2. Decreased blood flow: Lower estrogen levels can also reduce blood flow to the vaginal area, making it less responsive and more prone to discomfort during sexual activity.
3. Pelvic floor muscle changes: Menopause can impact the pelvic floor muscles, which can lead to tension or weakness, contributing to pain during sex.
4. Hormonal shifts affecting libido: While not directly related to pain, changes in libido can lead to discomfort when intercourse is initiated without sufficient arousal and lubrication. This can make sex less enjoyable and may contribute to anxiety, further complicating the experience.

How to deal with painful sex during menopause

While the physical changes of menopause can feel daunting, there are plenty of effective strategies to help make sex more comfortable and — more importantly — pleasurable. Here are some ways to reduce discomfort and make intimacy more enjoyable:

1. Use a high-quality lubricant

Vaginal dryness is one of the main culprits of painful sex during menopause, but using a lubricant can make a big difference. Lube helps create a more comfortable experience by adding moisture to the vaginal area, reducing friction and irritation during penetrative sex. 

Look for water-based or silicone-based lubricants that are free of fragrances and harsh chemicals, such as Vella’s Intimate Elixir and Super Slip & Slide. 

2. Consider vaginal moisturizers

While lubricants are great to use during sex, vaginal moisturizers offer longer-lasting hydration by helping the vaginal tissues retain moisture over time. They’re typically applied daily to a few times a week and can help alleviate dryness, improve vaginal elasticity, and reduce pain during sex. Some popular options include those containing hyaluronic acid or vitamin E, which are known for their hydrating properties.

3. Hormone therapy

If you're dealing with noticeable discomfort during sex and lube alone just won't cut it, hormone therapy might be a great option for you. Local estrogen treatments like vaginal creams, rings, or tablets are designed to deliver estrogen directly to the vaginal area, which can help without affecting the rest of your body. This targeted approach can bring back vaginal moisture and improve elasticity, making intimate moments much more comfortable.

If you’re also feeling other menopausal symptoms, like hot flashes, anxiety, or night sweats, chat with your doctor about menopausal hormone therapy (MHT) — (sometimes referred to as hormone replacement therapy. MHT includes synthetic versions of estrogen and progesterone, which dip drastically during menopause. You can take MHT in various forms — like a pill, gel, or patch — depending on how severe your symptoms are.

Just keep in mind that because HRT releases estrogen throughout your entire body, it might not be right for everyone. So, it’s really important to have a good conversation with your doctor to discuss the benefits and any potential risks. They can help guide you in finding the best option for your needs.

4. Non-estrogen medications

If hormone therapy isn't right for you, there are non-hormonal options available. The U.S. Food and Drug Administration (FDA) has approved two non-hormonal medications to treat moderate to severe dyspareunia that occur with menopause: 

• Ospemifene: Known by the brand name Osphena, ospemifene is a medication designed to ease some of the discomforts that can come with menopause, particularly painful sex, which is medically referred to as dyspareunia. Ospemifene works as a selective estrogen receptor modulator (SERM), meaning it targets estrogen receptors in the vaginal lining. This allows it to mimic estrogen’s effects where they’re needed without impacting the whole body as traditional HRT does. One of the great things about ospemifene is that it helps improve the elasticity and moisture of vaginal tissues, which can help reduce pain during intercourse and promote better overall vaginal health. It’s a good option for women who either can’t or choose not to use standard hormone therapy since it doesn’t raise estrogen levels in the bloodstream.  
• Prasterone: Also known as dehydroepiandrosterone (DHEA), prasterone is a synthetic version of a hormone that's naturally made by our adrenal glands. It acts as a building block for estrogen and testosterone. For women experiencing menopause, prasterone can be a helpful option for treating vaginal dryness, irritation, and painful intercourse. When used as a vaginal suppository, prasterone gets converted into estrogen and testosterone right where it’s needed, helping to bring back moisture, improve elasticity, and alleviate discomfort during intimacy, all while keeping hormone levels stable in the rest of the body. This treatment is often recommended for women who may not be able to use traditional estrogen therapy. Because prasterone works locally rather than affecting the whole system, it can be a safer and more effective solution.

Be sure to discuss any medications with your healthcare provider to determine their suitability and potential side effects.

5. Pelvic floor therapy

Pelvic floor therapy can be an incredibly helpful way to tackle painful sex during menopause. This therapy focuses on strengthening, relaxing, and enhancing the function of the pelvic floor muscles, which support the bladder, uterus, and vagina. During menopause, hormonal changes can lead to tension in these muscles, decreased elasticity, and even some atrophy, which might contribute to discomfort during sex. Thankfully, pelvic floor therapy addresses these challenges and promotes overall pelvic health.

One of the benefits of pelvic floor therapy is that it can boost blood flow to the area, which helps improve tissue health, enhances lubrication, and reduces vaginal dryness. All of this can make intimate moments much more comfortable and enjoyable, helping to ease any pain during intercourse. In therapy, you might learn exercises that strengthen the pelvic floor muscles and help with coordination and control. But it’s not just about strengthening; it also emphasizes relaxation and releasing tension. This is especially important for those who experience tight or overactive pelvic floor muscles that can lead to discomfort.

Your pelvic floor physical therapist may use various techniques, including manual therapy or biofeedback, to help find and correct any muscle imbalances. Manual therapy involves gentle pressure and stretching to improve flexibility and reduce pain, while biofeedback utilizes sensors that provide real-time feedback on muscle activity, allowing you to learn how to contract and relax these muscles effectively.

Pelvic floor therapy can also help with related concerns like urinary incontinence, pelvic pain, and reduced sexual sensation, making it a well-rounded approach to enhancing sexual health and overall well-being during menopause. Regular sessions with a pelvic floor therapist can help you build strength, boost blood circulation, and improve muscle function, leading to a more comfortable and enjoyable sex life.

6. Give penetration a pass

Despite what we’ve been led to believe, penetrative sex isn’t the be-all and end-all of a pleasurable sex life. There’s nothing wrong with skipping penetration entirely, especially if it’s causing you physical discomfort. 

“Foreplay” can be the main event. Focus on clitoral stimulation via manual or oral stimulation, and explore other forms of physical touch — nipple play, for example, can be incredibly satisfying. 

Final thoughts

Painful sex during menopause is a common but manageable issue. Understanding the causes behind it and taking proactive steps can make a significant difference. Whether through lubricants, vaginal moisturizers, hormone therapy, or pelvic floor exercises, there are multiple options to explore. There’s no reason menopause should limit your comfort or intimacy, the key is finding what works best for you and seeking guidance from healthcare providers when necessary.