By Allison Danish, MPH

While aging is a gift, menopause doesn’t always feel like one. With hot flashes, sleep disturbances, and mood changes—it’s no walk in the park. Not to mention, with those hallmark hormonal shifts, sex can be painful for 20-59% of peri- and postmenopausal people. Aaaaand because we as a society don’t talk very much about sexual health—especially when it comes to people over the age of 40 who have vaginas—we certainly rarely talk about painful sex and menopause.

So why can sex be painful during and after menopause—and what can you do about it? We get the answers from Dr. Lauren Streicher, MD, board certified OBGYN and founder/director of the Northwestern Medicine Center for Menopause and the Northwestern Medicine Center for Sexual Health (among maaaany many other things because Dr. Streicher is an absolute powerhouse).

What is menopause?

Menopause can be split into three distinct groups: perimenopause, menopause, and postmenopause. 

Perimenopause

Perimenopause is often compared to puberty—but, according to Dr. Streicher, this isn’t quite right; while these transitions bookend the reproductive phase of a person’s life, it’s not a perfect analogy (unless postmenopausal people Benjamin Button back into children, but alas, this is not the case). 

Instead of hormones steadily ramping up, perimenopause is the period of time in which the ovaries are still making estrogen—but unreliably so. This is why Dr. Streicher refers to it as the “perimenopause rollercoaster.” Estrogen levels are fluctuating, so the menstrual cycle (if you have one) is often irregular, and people may start experiencing symptoms like hot flashes, sleep disturbances, and vaginal dryness. On average, perimenopause lasts for about 4 years. 

Menopause

Menopause is traditionally described as when someone hasn’t had a period in 12 consecutive months—buuuuut Dr. Streicher disagrees with this definition because at least 50% of people who were born with uteruses in the United States don’t have periods pre-menopause. So what’s a better definition? Dr. Streicher says menopause is when the ovaries have stopped producing estrogen—either because the ovaries have been removed (this is called an oophorectomy) or because the ovaries have decided it’s time to retire. 

Postmenopause

Postmenopause is exactly what it sounds like! It’s the time after menopause—and it usually means those major menopause symptoms peter off. But, as Dr. Streicher says, “You’re never done with menopause. You might be done with hot flashes, but the effects of lack of estrogen continue to escalate throughout your life.” And this isn’t meant to be daunting—postmenopause isn’t a disease, it’s just a new life stage that brings some new challenges.

Why is sex painful during/after menopause?

Great question! Iiiiiit could be a lot of things. For many people, sexual pain around menopause is just a continuation of discomfort experienced earlier in life—like vestibulodynia and pelvic floor muscle dysfunction. But for others, the pain begins during this new stage of life—and that’s what we’ll be talking about here. 

Genitourinary Syndrome of Menopause 

For most people, painful sex that starts around menopause is caused by something called genitourinary syndrome of menopause. This is a pretty new name for a constellation of symptoms that are associated with lack of estrogen, and it affects around 50-70% of postmenopausal people. These signs and symptoms range from vaginal dryness and discomfort, to decreased sexual desire and arousal, to painful and frequent urination. 

But why? In a word: estrogen. The vulva, vagina, and lower urinary tract (think bladder and urethra) are sensitive to and regulated by estrogen. So post-menopause, when the body is making less of this lil hormone, there’s less blood flow, the tissues thin and lose elasticity, smooth muscles aren’t quite as buff as they were before, and the microbiome shifts (which can result in a higher vaginal pH). TLDR; these changes can all mean dryness and irritation, as well less-than-optimal bladder function. 

Sexual desire, arousal, and orgasm can also all be affected. This is in part because of hormones as well. The ovaries make estrogen, but they also make progesterone and testosterone—all of which have a hand in sexual function! Around menopause, we know estrogen pretty dramatically declines but progesterone decreases too. Testosterone also peters off, but this is more of a function of age rather than menopause itself. Anyway. Decreasing hormones = decreasing desire to participate in the horizontal mambo. On top of that, all those signs and symptoms we mentioned above can make it hard to feel sexy—pain and discomfort, leakage, and even the concept of aging itself can affect your bedroom headspace. 

Dermatologic Conditions

People of any age can develop vulvar/vaginal skin conditions, but there are a few that are more common for peri- and post-menopausal people. 

Lichen sclerosus + Lichen planus

Lichen (pronounced “liken”) sclerosus is a vulvar skin condition where the tissue becomes thinner, oftentimes with hallmark white splotches. This can cause soreness and itchiness, bleeding, and pain during sex. 

Lichen planus is similar to lichen sclerosus, except it more often appears inside and around the entrance to the vagina and the spots may appear more purple-ish (though this can really vary). This can also cause soreness and pain.

Scientists aren’t sure what causes these conditions, but they do know they aren’t contagious and occur more often in middle-aged people.

Dermatitis

Postmenopausal people may be more affected by vulvar skin irritants (like some soaps). Lower estrogen can mean urinary incontinence and a compromised skin barrier, both of which can leave the vulva more susceptible to irritation. 

Yeast infection

Yeast infections are generally less common when estrogen is low, but if you’re taking HRT (hormone replacement therapy), then these infections can become more common.

Pelvic Organ Prolapse

Pelvic organ prolapse is when one or more of the pelvic organs (bladder, rectum, uterus) isn’t getting the support it needs and starts to slump downwards. This may occur in anywhere from 3 to 97% of postmenopausal people (wide range, we know lol), with pregnancy and birth being the biggest risk factors. 

For some people, this is a cause of pain or discomfort during penetrative sex because the pelvic organs might be experiencing a bit more “turbulence” since they’re hanging a little closer to the vagina.

How do you treat painful sex during/after menopause?

First thing’s first, Dr. Streicher says you need to have an exam from a clinician who’s well-versed in sexual pain/sexual medicine. This will help you figure out what exactly is causing the pain so you can pursue the right treatment for you. There are a loooooot of different options out there, so it’s important to know what will actually be helpful for your unique body. Here’s a directory of menopause practitioners that may be helpful for finding a clinician near you. If you’ve been to a health care practitioner before, but haven’t received any good treatment options, Dr. Streicher reassures, “Just because someone hasn’t given you a solution doesn’t mean there isn’t one.” 

So what are some potential treatments for painful sex during/after menopause?

Hormones

Hormones are a very common treatment option for addressing unpleasant changes surrounding menopause. When it comes to pain with sex, clinicians will often prescribe an estrogen cream, ring, or suppository, etc. This works to treat vaginal dryness associated with loss of estrogen (and it works well and is very safe)—but it’s not the solution for all pain during sex associated with menopause, hence why it’s so important to get an exam by a qualified clinician.

Pelvic Floor Physical Therapy

Pelvic floor muscle dysfunction is super common for people pre-menopause—but it can also crop up around menopause too. If sex has started to become painful later in life, your body remembers—specifically, your pelvic floor remembers. A complex hammock of muscles that support your pelvic organs, the pelvic floor relaxes during arousal to accommodate penetration. But if sexy time has been less-than-comfy, those muscles may be reluctant to relax, which can then cause more pain around the opening of the vagina and further back inside the pelvis. 

This is where pelvic floor physical therapy comes in. Armed with a diverse knowledge of exercises, hands-on techniques, and tools like dilators, pelvic PTs can be incredibly helpful for treating pain associated with pelvic floor muscle dysfunction. 

Lubes + Moisturizers

So simple, yet so profound. Lube is a really powerful tool for reducing friction in any bedroom—and it’s important to find lubes that are safe for your nethers, particularly if you’re in Menopause Town. Current research recommends silicone lube and water-based lubes that are near “iso-osmolar.” This is basically a fancy schmancy way of saying the lube isn’t going to pump water out of the cells (think: raisin). Lots of lubes are “hyperosmolar,” which can damage or even kill cells (EZ Jelly, K-Y Jelly, and Astroglide Liquid are examples of hyperosmolar lubes). 

The World Health Organization generally recommends vaginal lubes that are below 1200 mOsm/kg, have a pH of 4.5, and don’t contain the spermicide N9. We also recommend staying away from lubes that contain glycerin, parabens, propylene glycol, or ingredients that claim to be warming/cooling. Uberlube and Oh Naturale Aloe-Based Lube are great examples of lubes that meet these WHO recommendations. 

The same goes for vaginal moisturizers, a more everyday way to increase moisture (whereas lube is more of an as-the-situation-arises kind of tool). Unfortunately there isn’t a lot of data on vaginal moisturizers, so the general recommendation is to patch-test the product on your body before using it intravaginally. 

Ohnut

If pain with deep penetration is uncomfortable, we always recommend seeing a health care practitioner! And we also recognize that people still want to have sex while in treatment (or maybe deep pain will always be a reality). Wherever you’re at, Ohnut is a helpful tool for reducing the depth of penetration, so you and your partner can both relax and enjoy the moment without worry.

Beyond these common noninvasive treatments, there are other tools and treatments that people may find useful, from weed (very little research has been done to figure out whether marijuana can help with menopause symptoms) to laser therapy (very new, requires more studies to assess safety and efficacy) to hyaluronic acid. 

Wherever you are on the menopause journey, know that you’re not alone in your symptoms and you don’t just need to put up with them for the rest of your life. There are solutions and there are healthcare professionals who can help you do what you love (and who you love—wink wink) with comfort and confidence.