With the menopause transition comes a change in estrogen levels. That change affects just about EVERYTHING, including sex. Estrogen is responsible for keeping the tissue of the vagina moist and well lubricated. It keeps this tissue plump and healthy and even helps keep the good bacteria in the vagina healthy! When estrogen levels decline, the tissue in the vagina can become dry, thin, less lubricated and less elastic, all of which can cause sex to feel painful or cause a burning or tearing sensation. For some, this pain can be significant enough to deter all interest in sexual activity. Fortunately, there are many things that can be done to protect this tissue and to keep sex (touch and/or penetration) comfortable.

Vaginal moisturizers and lubricants are the first options to consider but the two are quite different from each other.  We can think of vaginal moisturizer similarly to lotion that we use on the rest of our bodies when we have dry skin. The purpose of a vaginal moisturizer is simply to provide moisture to vaginal tissue and should be used on a regular, even daily basis. Lubricants are used to increase pleasure and decrease friction with sexual activity. They are typically made in a base of water, oil, or silicone but some brands can have some less desirable additives such as parabens and petroleum so make sure to read the labels, because there may be some undesirable short and long term effects of these two ingredients.


Ideally, your lubricant will have a pH that is similar to that of the vagina helping to keep your vagina healthy and balanced.  If vaginal moisturizers and lubricants are just not doing the job, we have other options!  Lose-dose, select hormones applied directly to the vagina and/or vulva can often provide substantial benefit to the local tissue.


Research strongly supports the use of either vaginal estrogen or DHEA (Dehydroepiandrosterone) low-dose hormones for the treatment of vaginal dryness. Fortunately, very little of these low-dose hormones are absorbed into the blood stream, which makes them a good option for a wide range of women. There are even vaginal estrogen products and vaginal DHEA products that are considered safe for some breast/endometrial/ovarian cancer patients. However, if you have a history of breast or other hormone sensitive cancer it is always best to speak with your doctor prior to attempting any hormone therapy. It is also important to note that there are numerous methods by which these hormones can be delivered including: suppositories (large and small), creams, tablets, and rings. Having this variety of options allows clinicians to individualize the treatment to find the best delivery method for you. Finally, regular sexual activity can help maintain healthy blood flow to the genitals, which diminishes with the loss of estrogen. Remember, sexual activity does not always have to be between two people and self-administered sexual activity also is relevant to the topic at hand.


We know that vulvo-vaginal changes with menopause are very common. Over 30 million women in the US have symptoms of vaginal dryness, irritation, and pain with sex.  But pain with sex isn’t always due to a feeling of dryness. The decrease in estrogen can lay the groundwork for noxious microbes to grow, which may lead to vaginal infection. Most commonly, women can develop bacterial vaginosis or yeast vaginitis both of which can have unique symptoms of discharge, irritation, and even odor. Infections like these can leave this already delicate tissue feeling raw and very irritated, making sex or even the thought of it, out of the question. If you feel you have a change in vaginal discharge or new vaginal irritation, it is best to see your provider for appropriate evaluation and treatment. Similarly, to the increased potential for vaginal infections with the menopause transition, there can also be an increase in urinary tract infections (UTIs). Estrogen therapy can be quite supportive to the urethral tissue, decreasing risk for UTIs and can even help prevent annoying urinary leakage.


Of course there are other causes of pain with sex, which may be the case for women who describe their pain with sex as deep pelvic pain. For starters, the muscles of the pelvic bowl are subject to “knots” or trigger points just like the muscles in our neck and shoulders when we are under stress. Penetrative sexual activity can further irritate these trigger points causing pain. Specialized physical therapists with training in pelvic floor physical therapy can often provide great relief to women in this situation. Additionally, pelvic organ prolapse (a feeling of the vaginal or rectum falling out) can cause sex to be uncomfortable. Pelvic organ prolapse is often noticed in the menopause years and is usually associated with prior pregnancy.  Depending on the severity, this displacement of tissue may be addressed by pelvic floor physical therapy but in some cases might require surgery. Other factors like vulvar skin disorders, scar tissue from previous abdominal surgeries, endometriosis, inflammatory bowel disease, chronic pain syndromes, or other medical condition may also contribute to pain with sex.


Of special note, psychosocial elements can most assuredly play a role in pain with sex. People who have a history of trauma may also have pain with sex. This pain should be evaluated just like any other reported pain and amongst other treatments may also benefit from counseling support.


Whatever the cause, if you are experiencing pain with sex, check-in with your women’s health provider so it may be appropriately assessed and treated.


A Woman’s Time Clinical Note:

At our clinic, we have not only special expertise in this area of gynecology/women’s health, but we offer both conventional and natural treatment options.

Dr. Erin Conlon is accepting new patients for this specialty area of women’s health.