[6 min read]
In this article:
- After menopause, changes in the vagina can cause sex to become uncomfortable or even extremely painful for some.
- It's a common experience that often goes undiscussed between patients and their providers.
- A Swedish gynecology, menopause and sexual health expert discusses treatments, and ways to approach the subject with your provider and your partner.
- Learn about how Swedish women's wellness services can help you.
Menopause can be a complicated time of life. It is different for every person and is often accompanied by a broad range of physical and emotional changes. One change that is far more common than we may understand is painful sex after menopause—so painful, in fact, that some people abandon sexual intercourse altogether, assuming that menopause has put an end to their sex lives. The pain many people experience is called dyspareunia, which is vaginal dryness caused by menopausal hormone changes. It’s a symptom of what’s clinically known as genitourinary syndrome of menopause (GSM). Unfortunately, dyspareunia often goes unaddressed and undiscussed because, sometimes, neither patients nor doctors bring it up during exams. To learn more, we spoke with Ashley Fuller, M.D., a gynecology, menopause and sexual medicine expert at Swedish Women’s Wellness and Specialty GYN Care, about managing the condition and how to talk about it with your doctor and partner.
Why does sex become painful for some people after menopause?
This happens because of the drop in estrogen. Early in menopause, we often have symptoms including, sleep issues, weight gain and mood issues. These often improve with time or over the first few years of menopause. Vaginal dryness, or GSM, is a progressive disease of menopause causing progressive dryness and tightness.
I agree with the findings of a recent paper on the subject, that it often is the vestibule that is the source of pain. The vestibule is a small strip of tissue right at the opening of the vagina that has a lot of nerve endings and hormone receptors. When we have low estrogen levels this tissue gets overly sensitive. When attempting penetrative sex, if this tissue is painful, we tend to tense our pelvic floor muscles when we feel this pain at the opening; this causes the whole experience to be painful. Our brain remembers the pain and next time we attempt sex, we tense up earlier in anticipation of the pain and it is often worse. We often have less sex because of this—which is understandable, because why would we want to do something that is painful?
Unfortunately, this drives a cycle that results in less stretching of this increasingly tight tissue (by penetration), making having sex even more painful. It is quite often that when I see these patients in clinic, this is the reason they have not been able to successfully have penetrative sex in several years.
Can it be prevented?
Lubricants, moisturizers, and vaginal estrogen are the solutions here. I am always a fan of lubricants. There is hardly anyone I would not recommend lubricant for! They can prevent some pain. I do not generally recommend vaginal estrogen preventatively. We all have enough to do in life, it feels like an extra task to be putting vaginal inserts in at night before bed before we need it! It is also not cheap, unfortunately. The way I recommend patients prevent this is to come to their provider as soon as they start feeling discomfort. The earlier the better. Then we can start vaginal estrogen and they can treat this pain right away. It is much easier to treat pain when it first starts rather than two years later.
What are some common treatments you recommend for patients who are experiencing pain?
I recommend trying lubricants, but ultimately, it is vaginal estrogen that helps the most. I like the preparations that get the estrogen to the vestibule, these are vaginal estrogen creams or gel caps that are inserted and placed near the opening of the vagina so that they coat the opening and improve the sensitivity of the vestibule. I do not generally find that vaginal pills or the vaginal ring are as helpful because they do not treat the vestibule.
Vaginal estrogen is safe and has few contraindications. Unfortunately, the U.S. Food and Drug Administration puts a black box warning on the box about increased risk of heart disease and breast cancer. This is not true and is referring to systemic (oral or transdermal) estrogen. There could be a larger conversation here about how this is inaccurate for systemic estrogen also, because the guidance is based on old studies. Patients should speak with their doctors, but it is understood that having a family history of breast cancer or a personal history of a blood clot is not a contraindication for vaginal estrogen.
I also find vaginal dilators to be helpful. They help stretch the tissue which helps it stretch more easily but it also gives the patient confidence and helps overcome that mind body connection that tells her to tense up in anticipation of pain. It can help her work through some of that instinctual pelvic floor tightening. And sometimes, I also recommend pelvic floor physical therapy to help with this.
What might you tell a patient who was feeling embarrassment or shame?
There is nothing to be embarrassed about! This is very common. The estimates vary but in general three out of four women experience pain with sex at some point in their lives and it is most common when we are postmenopausal.
What are some strategies for talking with a partner about painful sex during menopause?
It is important for a partner to know about this so that they can be on board with how to improve things. Most of my patients have expressed that their partners are very supportive and go out of their way to not hurt them. But there is no way this does not affect a couple's intimacy and can also affect their partner's sexual function. If communication is too difficult, sometimes a sex therapist is helpful.
Learn more and find a provider
If you have questions about menopause or reproductive health issues, contact Swedish Obstetrics and Gynecology and learn about their full spectrum of gynecological care.
Swedish Virtual Care connects you face-to-face with a nurse practitioner who can review your symptoms, provide instruction, and follow up as needed. If you need to find a provider, you can use our provider directory.
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This information is not intended as a substitute for professional medical care. Always follow your health care professional’s instructions.
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