What to Do About Painful Sex After Menopause
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Changes to the vagina can mess with your sex life. But there are solutions that work.
In a 2022 study that asked a few dozen postmenopausal women who experienced pain during penetrative sex to describe their experiences of intercourse, the most common response was “burning.” Other terms were “raw,” “dry,” “sharp,” “ripping,” “sandpaper” and “knives.”
What they were describing is known as dyspareunia, which is one of the more overlooked and under-treated symptoms of menopause, said Dr. Martha Goetsch, an emeritus assistant professor in the obstetrics and gynecology department at Oregon Health & Science University and a co-author of the paper.
Dyspareunia can occur at any life stage but it spikes after the menopausal transition, though signs can emerge during perimenopause too, said Dr. Lauren Streicher, clinical professor of obstetrics and gynecology at Northwestern University. Estimates about the prevalence of dyspareunia range between 13 and 84 percent of postmenopausal women — a highly inexact figure in large part because many women and doctors don’t broach the subject.
As a result, women often don’t receive the care they need for dyspareunia despite the fact that it is easily treatable, Dr. Streicher said. If left untreated, the condition can worsen to a point that it leads to a loss of self-esteem, reduced quality of life, depression and a significant shift in the relationship dynamic with a partner.
“They just think ‘OK, well, I guess my sex life is over,’” Dr. Streicher said.
Why does sex become painful in menopause?
The drastic drop in estrogen during and after menopause is the main reason sex can become a painful affair. Among its many functions, estrogen is responsible for keeping the vaginal walls elastic and lubricated, Dr. Streicher said. The accordionlike folds in the vaginal wall that enable them to stretch, called rugae, are plumped up by estrogen.
Without it, the vaginal walls thin out, the rugae all but disappear and lubrication becomes “history,” Dr. Streicher said. “When we look inside the vagina with the speculum, we can see it — we can see that these little folds in the skin are no longer there” and the lining is dry.
The loss of estrogen also alters the vestibule — the small, highly sensitive entryway to the vagina that is packed with nerve endings or, as Dr. Goetsch described it, “the two square inches that could wreck your life.” In fact, in her research and among her patients, she has found that a majority of women who complained about painful sex suffered from pain in the vestibule rather than inside the vagina. After menopause, those two square inches can become extremely tender. In her research, Dr. Goetsch has found that it might be because the drop in estrogen may stimulate a proliferation of new nerve endings in the area, which can signal pain.
“Quite a few animal studies show that when estrogen levels go low, the various nerves sprout new nerve endings,” she said, “and then when the estrogen levels go back up, those extra nerve endings are pruned back.”
Not all postmenopausal women will experience severe changes associated with the drop in estrogen, but even mild shifts in the vagina can make pain-free, pleasurable sex elusive, leading to irritation and possibly even cuts and tears of the brittle vaginal tissues, Dr. Goetsch said.
There are several other factors that can also contribute to dyspareunia among menopausal women. The hormonal changes alter acidity levels of the vagina, Dr. Streicher said, which can lead to recurrent urinary tract infections among menopausal women, creating discomfort in the area whether or not they are having sex. And some common health conditions among older people, like diabetes or cardiovascular disease, can also dry out the vagina, she added.
So what is the solution?
It all depends on the degree of changes to the vaginal area, Dr. Streicher said, and the safest way to determine what treatment you need is by seeking out an expert who will do a thorough exam. “There’s a big difference between ‘Oh, you know, I’m not as wet as I usually am’ versus it is so dry, so tight and so thin that the tissue literally splits.”
Here are a few of the treatment options:
Lubricants: This is a quick and easy solution for women who suffer only from dryness. Dr. Streicher recommends warming the lubricant because “cold is a vasoconstrictor, which will make you have even less natural lubrication, whereas heat is a vasodilator and will help the muscles relax,” she said. One option is placing a bottle of lubricant in a bowl of hot water for a few minutes before use.
Here are the lubes we have available at The Art of Loving:
Vaginal moisturizers: These creams and gels can be found over the counter. “What they actually do is increase water content in vaginal mucosal cells — the ones that are lining the wall,” Dr. Streicher said, helping restore their elasticity and lubrication, though they can also be helpful for those who have pain in the vestibule. Some moisturizers can also help lower vaginal pH levels, she said. Beware that many lubricants market themselves as moisturizers; the difference is that a moisturizer will have instructions to apply it inside the vagina on a regular basis, Dr. Streicher said, whereas a lubricant should be used during sex.
Estrogen creams: Studies have repeatedly found that this prescription option is highly effective at reducing pain, including in the vestibule area. They are generally low-dose, localized and come in different formulations that your doctor can help you choose among.
Lidocaine: This is an unconventional prescription option that Dr. Goetsch has recommended for many of her patients, particularly those who can’t use hormones, like breast cancer survivors. Liquid lidocaine is an anesthetic that numbs the nerve endings of the vestibule. In a small randomized trial in women with dyspareunia, lidocaine reduced pain substantially during intimacy for most participants, Dr. Goetsch said, and women who had sex while using lidocaine rarely reported residual pain after the anesthetic wore off. And, Dr. Goetsch added, application of liquid lidocaine didn’t numb the partner.
Written by: Alisha Haridasani Gupta on The New York Times