Pain During Sex After Menopause: You're Not Alone
If sex has become uncomfortable or painful since perimenopause or menopause, you may be wondering why.
Perhaps intercourse used to be comfortable, but now you notice dryness, burning, irritation, or pain with penetration. You might also find that the discomfort continues afterwards.
It can be difficult to talk about, even with someone you trust.
Some women assume it's simply part of getting older. Others may avoid sex altogether because they're worried it will hurt.
But painful sex after menopause is common, and you don't have to simply put up with it.
There can be several reasons for the change, and understanding what's contributing to your symptoms is an important first step.
Why Can Sex Become Painful After Menopause?
One of the main reasons is the change in oestrogen that occurs during menopause.
Oestrogen helps maintain the health of the tissues around the vagina and urinary tract. As oestrogen levels decline, these tissues can become thinner, drier and less elastic.
This can make friction during sex more uncomfortable and may contribute to pain with penetration.
These changes are often described as genitourinary syndrome of menopause (GSM).
GSM is a term used to describe symptoms affecting the genital and urinary tissues associated with the hormonal changes of menopause. Symptoms can include vaginal dryness, irritation, discomfort and pain during sex.
However, hormonal changes aren't necessarily the whole story.
Pain During Sex Isn't Always Caused by Dryness
It's easy to assume that painful sex after menopause is simply a lubrication problem.
Sometimes dryness is an important factor.
But pain can have several contributing factors.
For example, the pelvic floor muscles may become tense or have difficulty relaxing. If these muscles are already sensitive or overactive, penetration may feel uncomfortable even when vaginal dryness isn't the main issue.
Previous experiences with pain can also influence how the body responds.
If sex has hurt several times, it's understandable to start anticipating that it will hurt again. You may unconsciously tense your pelvic floor muscles in response, which can contribute to further discomfort.
This doesn't mean the pain is "in your head".
The pain is real.
It simply means that pain is influenced by more than one part of the body.
What Might Pain During Sex Feel Like?
Pain can feel different from one woman to another.
You might notice:
Dryness or friction
Burning or irritation
Pain at the vaginal opening
Deeper pelvic pain during penetration
Tightness or difficulty with penetration
Pain that continues after sex
Discomfort when using tampons or undergoing a vaginal examination
Where you experience the pain can provide useful information, but it doesn't tell us the cause on its own.
That's why a detailed assessment is often more useful than trying to match your symptoms to something you've read online.
Could Your Pelvic Floor Be Contributing?
Your pelvic floor is a group of muscles at the base of your pelvis.
These muscles help support your pelvic organs and play an important role in bladder and bowel function. They also need to lengthen and relax during activities such as bowel movements and vaginal penetration.
Pelvic floor muscles can sometimes become overactive or remain tense when they should be relaxing.
For some women experiencing painful sex, this may be one factor contributing to their symptoms.
This is also why automatically doing more pelvic floor strengthening exercises isn't always the answer.
If your muscles are already tense, the goal may be to improve their ability to relax and coordinate rather than simply make them stronger.
What About Vaginal Dryness?
Vaginal dryness is a common symptom associated with menopause.
If the vaginal tissues are drier and less elastic, intercourse can become uncomfortable, particularly with penetration.
Using a suitable lubricant during sexual activity can help reduce friction.
Vaginal moisturisers may also help with ongoing dryness.
For women experiencing genitourinary symptoms associated with menopause, current NICE guidance recommends discussing vaginal oestrogen as a treatment option, with non-hormonal moisturisers or lubricants also options depending on individual circumstances and preferences.
It's important to speak with your GP or another appropriate healthcare professional about whether vaginal oestrogen is suitable for you, particularly if you have a history of breast cancer or other medical considerations.
What If Sex Still Hurts Despite Using Lubricant?
This is an important question.
If you've tried using lubricant and sex is still painful, it doesn't necessarily mean you're doing anything wrong.
It may simply mean that dryness isn't the only factor contributing to your symptoms.
There may be pelvic floor muscle tension, changes in the vaginal tissues, pain sensitivity, previous surgery or childbirth, or another condition that needs to be considered.
This is where an individual assessment can be helpful.
Instead of continuing to try different products or exercises without knowing what is contributing to the pain, you can have the symptoms assessed and develop a plan based on your specific situation.
What Can Help With Painful Sex After Menopause?
There isn't one treatment that works for every woman.
Depending on what's contributing to your symptoms, management may include several approaches.
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Lubricants can reduce friction during sexual activity and may make intercourse more comfortable when dryness is contributing.
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These are designed to provide ongoing moisture rather than being used only during sex. They may be useful for some women experiencing vaginal dryness.
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Your GP or menopause healthcare professional can discuss whether treatments such as vaginal oestrogen are appropriate for you.
Current NICE guidance recommends vaginal oestrogen for people experiencing genitourinary symptoms associated with menopause, where appropriate.
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Physiotherapy may be helpful when pelvic floor muscle tension, coordination, movement, or pain sensitivity is contributing to your symptoms.
Treatment isn't necessarily about strengthening.
Depending on your assessment, it may involve education, breathing and relaxation strategies, movement, pelvic floor muscle retraining, and other techniques tailored to your needs.
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If penetration is painful, you don't need to push through the pain.
You and your partner may want to explore other forms of intimacy while you work out what's contributing to your symptoms.
Pain is information, not something you need to prove you can tolerate.
Does Pain During Sex Mean Something Is Wrong?
Pain during sex deserves attention, particularly if it's new, persistent, worsening, or affecting your quality of life.
Menopause-related changes may be contributing, but painful sex can also have other causes.
For example, pelvic pain conditions, skin conditions, infections, pelvic floor dysfunction, previous surgery, and other gynaecological conditions can cause pain.
That is why it's important not to automatically assume that every new symptom is simply menopause.
If you experience new or unexplained vaginal bleeding, particularly bleeding after sex, speak with your GP or another appropriate healthcare professional for assessment.
How Pelvic Health Physiotherapy Can Help
Your appointment starts with a conversation about what's been happening and what you'd like help with.
We may discuss:
Where you experience pain
When the pain occurs
Whether dryness is present
Your pelvic floor muscle function
Your bladder and bowel symptoms
Your medical and gynaecological history
Previous pregnancies, childbirth or surgery
Your movement and musculoskeletal health
How the symptoms are affecting your life
An internal assessment isn't automatically required.
If one is clinically appropriate, your physiotherapist will explain why it may be useful and obtain your informed consent before proceeding. You can ask questions or choose not to have an internal examination.
Frequently Asked Questions
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Pain during sex is common after menopause, particularly when vaginal dryness and tissue changes are present. However, "common" doesn't mean you have to accept it as something you cannot address.
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Hormonal changes can affect the vaginal and surrounding tissues, making them drier, thinner and less elastic. Pelvic floor muscle tension and other factors may also contribute.
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Yes. Reduced lubrication can increase friction and make penetration uncomfortable. However, dryness isn't the only possible cause of painful sex.
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It can help when pelvic floor muscle tension, difficulty relaxing or coordinating the muscles, or other musculoskeletal factors are contributing to pain. The appropriate approach depends on your individual assessment.
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You don't need to push through pain. Continuing an activity that repeatedly causes pain may make the experience more difficult. Consider pausing penetration and discussing your symptoms with an appropriate healthcare professional.
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Not necessarily. Your physiotherapist will determine what assessment is appropriate based on your symptoms and goals. Any internal examination should only happen with your informed consent.
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There are several management options, depending on what's contributing to the pain. These may include lubricants, vaginal moisturisers, medical treatments such as vaginal oestrogen where appropriate, and pelvic health physiotherapy.
Key Takeaways
Pain during sex is a common symptom associated with menopause.
Lower oestrogen levels can affect vaginal and vulval tissues and contribute to dryness and discomfort.
Pelvic floor muscle tension can also contribute to painful penetration.
Lubricants and vaginal moisturisers may help with dryness, while medical treatments such as vaginal oestrogen may be appropriate for some women.
Pelvic health physiotherapy may help when pelvic floor or musculoskeletal factors are contributing.
Persistent, new or unexplained pain should be assessed rather than automatically attributed to menopause.
