Menopause is the natural decline in women’s reproductive hormones as she reaches her 40s or 50s. Menopause is typically marked by the stopping of the menstrual cycle. As you near menopause, your periods start becoming more and more erratic before stopping. Alongside this, you will also witness a number of other changes in your health and body. Although each woman is different, menopause symptoms such as mood changes, hot flashes, weight gain, and trouble sleeping are typically experienced by all women. There is also a certain percentage of postmenopausal women who report having painful sex after menopause. Let us look at how common this is, what are the causes of painful sex after menopause, and can it be treated.
Causes of Painful Sex After Menopause
Nearly 30 to 45 percent of postmenopausal women report experiencing pain during sex. (1) It is believed that sex becomes painful during or after menopause because of a lack of estrogen. Estrogen is the hormone that is responsible for stimulating the release of natural lubricants and also replenishes the lining of the vagina by growing new cells. However, when you enter the phase of menopause, your body starts to gradually cut down on the production of estrogen.
Without estrogen, the lining of the vagina remains thin, shrinks, and may even dry out. The vaginal lining also loses its natural elasticity. This condition is known as vulvovaginal atrophy.
In such a condition, with the vaginal lining thinning out, penetration during sex can be quite painful. The condition of experiencing pain during sex is known as dyspareunia. This pain can feel like a sharp, stabbing pain, or a burning pain. Sometimes if the vaginal lining becomes too thin, then it can also tear or bleed during sex.
Painful sex can be a cause of anxiety and worry. Anxiety is known to decrease lubrication further, causing you to clench the vaginal muscles, which may make sex even more painful. When sex becomes too painful, you will ultimately start to avoid it altogether, which could affect your relationship.
When you have intercourse, it stimulates the blood flow to the vagina, keeping the vaginal tissues healthy. When you start avoiding sex, the vaginal lining starts becoming even thinner and loses its elasticity.
In some cases, the pain eases once you have completed menopause, but in some women, it never truly goes away.
How to Relieve Painful Sex After Menopause?
There are many treatments available nowadays to make sex more comfortable and relieve pain after menopause. Some of these treatments can even help you enjoy sex again after menopause. However, it is best if you consult with your gynecologist to understand which of these options will be the right choice for you.
Lubricants are the first line of treatment that doctors prescribe to prevent painful sex after menopause. Lubricants are available in the form of a liquid or a gel, and they are effective in helping with mild vaginal dryness.
Lubricants reduce friction, thus preventing or reducing pain. You can apply the lubricant directly to your vagina or to your partner’s penis right before having intercourse.
If you are still not completely reached menopause, or if you use condoms, then you may consider using a water-based lubricant. Oil-based lubricants can cause damage to the condoms, reducing their effectiveness.
Moisturizers also work in a similar manner to lubricants, by reducing friction during sex. However, because moisturizers penetrate into your skin, they remain effective for a longer time. A moisturizer such as Replens can even keep working for three to four days.
Low Dose Vaginal Estrogen
When you are suffering from more severe dryness and pain that is not improving even after using a lubricant or a moisturizer, then your doctor may recommend that you use low-dose topical estrogen.
Estrogen helps improve the flexibility and thickness of vaginal tissues and also boosts blood flow to the vagina. Since estrogen goes directly into the vagina, it avoids causing the body-wide side effects that are commonly associated with estrogen pills. Low-dose estrogen is available in the form of tablets, cream, flexible ring, or an insert.
Vaginal estrogen cream is commonly sold under the brand names of Estrace and Premarin (2), which is supposed to be applied to the vagina two or three times in a week. (3)
Low-dose estrogen is also available as the vaginal ring sold under the brand name Estring. This is to be inserted into the vagina where it can stay inside for up to three months. (4)
There is also a vaginal tablet that you can take, available under the brand name of Vagifem. This is placed inside the vagina two times in a week with your finger or with an applicator. (5)
It has been observed that most women prefer to use the tablet or the ring to use the cream because they are less messy. The majority of women using low-dose vaginal estrogen say that it reduces their pain during sex quite significantly.
The US Food and Drug Administration (FDA) has only approved Ospemifene (brand names Osphena and Senshio) as a non-hormonal treatment for painful sex because of menopause. Ospemifene works similar to estrogen and thickens the lining of the vagina. However, ospemifene does not increase your risk for uterine or breast cancer like estrogen pills can.
Studies (6) have shown that ospemifene helps improve both pain and dryness due to menopause. It has also been found to work better than or as well as a topical estrogen. (7)
Ospemifene comes in a pill form, and you need to take it once a day. The significant side effect of the medication is hot flashes, and it may also increase the risk of stroke and blood clots.
If you do not get any relief with estrogen inserts and creams, then your doctor may recommend that you take estrogen pills. This is known as hormone therapy, and it can also help in relieving some of the other symptoms of menopause, including hot flashes.
However, estrogen pills are not without risks. They can cause many side effects, including:
Long-term use of estrogen pills is known to increase the risk of breast and uterine cancer. If you know that there is a history of these cancers in your family, then do ask your doctor whether it will be safe for you to take estrogen pills.
Other Conditions That Can Cause Pain During Sex
Menopause is not the only reason that can cause pain during sex. Pain during sex can also be a sign of the following conditions:
Vulvodynia: This is a condition that causes burning or pain in the vulva without any apparent reason. Nearly 60 percent of women who have vulvodynia is not able to have sex due to the pain. (8) Treatments for vulvodynia include physical therapy, topical anesthetics, as well as mental health counseling.
Vestibulodynia: The area where the vulva connects with the vagina is known as the vestibule. The vulva includes the outer parts of the vagina, including the labia, the clitoris, and the clitoral hood. In many women, the vestibule area becomes extremely sensitive to touch, and having sex or even inserting a tampon can be a very painful activity. Doctors treat vestibulodynia with physical therapy, local anesthetic gels or creams, and mental health counseling.
Cystitis: Inflammation of the bladder can also cause you to feel pain during sex. This happens because your bladder is sitting right on top of your vagina. Approximately 90 percent of women who were surveyed by the International Cystitis Association (ICA) (9), said that interstitial cystitis has negatively affected their sex life. Treatments for cystitis include nerve blocks, medication, and physical therapy. Relaxation techniques, hot or cold applications may also help alleviate the discomfort.
Vaginismus: Women who have vaginismus experience painful contraction of the muscles around the vagina during sex. It can also contract painfully when anything is inserted into the vagina, such as a tampon. (10) Vaginismus can be triggered by fear after a traumatic experience. Treatments for vaginismus include a dilator for widening and relaxing the vagina combined with physical therapy. (11)
Dryness and thinning of the lining of the vagina can lead to painful sex when you are going through menopause. If you experience pain during sex, then you should consult your physician or gynecologist for advice. Moisturizers, lubricants, and several types of estrogen therapy are available for treating vaginal dryness, which causes painful sex.
Your doctor will also evaluate your overall health to determine whether there is another underlying condition causing the pain.
- Forevher.healthywomen.org. (2019). When Sex Hurts. [online] Available at: https://forevher.healthywomen.org/facts-to-know-questions-to-ask/when-sex-hurts/ [Accessed 18 Nov. 2019].
- Archer, D.F., 1992. Estrace vs Premarin for treatment of menopausal symptoms: dosage comparison study. Advance in Therapy, 9, pp.21-31.
- Nachtigall, L., 1998. Use of low-dose premarin, estrace, and estring vaginally. Obstetrical & Gynecological Survey, 53(10S), pp.62S-65S.
- Weisberg, E., Ayton, R., Darling, G., Farrell, E., Murkies, A., O’Neill, S., Kirkegard, Y. and Fraser, I.S., 2005. Endometrial and vaginal effects of low-dose estradiol delivered by vaginal ring or vaginal tablet. Climacteric, 8(1), pp.83-93.
- Chollet, J.A., 2011. Efficacy and safety of ultra-low-dose Vagifem (10 mcg). Patient preference and adherence, 5, p.571.
- Bachmann, G.A., Komi, J.O. and Ospemifene Study Group, 2010. Ospemifene effectively treats vulvovaginal atrophy in postmenopausal women: results from a pivotal phase 3 study. Menopause, 17(3), pp.480-486.
- Bruyniks, N., Biglia, N., Palacios, S. and Mueck, A.O., 2017. Systematic indirect comparison of ospemifene versus local estrogens for vulvar and vaginal atrophy. Climacteric, 20(3), pp.195-204.
- HealthyWomen. (2019). Vulvodynia | HealthyWomen. [online] Available at: https://www.healthywomen.org/condition/vulvodynia [Accessed 19 Nov. 2019].
- Interstitial Cystitis Association. (2019). Intimacy & IC – Interstitial Cystitis Association. [online] Available at: https://www.ichelp.org/about-ic/women/icandintimacy/ [Accessed 19 Nov. 2019].
- Lamont, J.A., 1978. Vaginismus. American Journal of Obstetrics & Gynecology, 131(6), pp.632-636.
- McGuire, H. and Hawton, K.K., 2001. Interventions for vaginismus. Cochrane Database of Systematic Reviews, (2).
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