Why Is Intercourse Painful During Menopause? A Clinical Guide to Relief

Painful sex in menopause, clinically termed dyspareunia, is primarily caused by vulvovaginal atrophy, otherwise known as Genitourinary Syndrome of Menopause (GSM) and  due to declining estrogen levels. Other causes of pain can include vulvar dermatoses, infections, nerve hypersensitivity  or pelvic floor tension. Diagnosis involves a thorough history and trauma-informed pelvic exam. While common treatments range from topical hormone therapies and pelvic floor physical therapy, there can sometimes be a need for specialized medical care.

Understanding the Prevalence of Menopausal Dyspareunia

Pain with sexual activity, or dyspareunia, affects about 8-10.4% of those who are sexually active in their late 50s and beyond.1,2 However, true dyspareunia rates are likely even higher as up to 38% of those over 57 have not had sexual activity in the past year, thus excluding them from being counted  even though for many their abstinence is the pain  their whole adult life, and it just eventually worsened to the point of inability to have penetrative intercourse. For others, it is a relatively new problem. In both situations, having pain instead of anticipated pleasure with sexual activity can be highly traumatizing and leave one feeling “broken” and hopeless. It also can be, understandably, very scary to set up that first appointment for evaluation and treatment. You may be wondering:  What is causing this pain? or What kind of exam will I have and will it hurt? So, I’d like to take this opportunity to give you some idea of what conditions cause sexual pain and what to expect for a typical evaluation to ease your fears ad hopefully encourage you to seek help!

Common Causes of Painful Intercourse During Menopause

Vulvovaginal Atrophy and Genitourinary Syndrome of Menopause (GSM)

This almost universal condition in menopause, even in those taking systemic hormone therapy, happens due to a drop in estrogen levels that leads to thinning or atrophy of the vulvar and vaginal tissues. These thin tissues are less well lubricated and painful when there is pressure and especially friction against them which causes sensations of stinging or burning, tearing, rawness and/or  swelling. A visual exam and sometimes a swab done for evaluation of the pH or a look at the vaginal cells under the microscope is all that is needed for diagnosis. First line treatment is use of a topical estradiol cream, vaginal ring or suppositories, or DHEA suppositories which are all locally acting. These topical hormones are generally very  safe as they do not increase the risk for blood clots or breast cancer. Local hormone therapy can take 8-12 weeks to correct the condition, but some relief can often be appreciable  in as soon as a few weeks of use. Alternatively, over the counter moisturizers can help with tissue comfort and reduce friction during sex, but do not correct the atrophic tissues.

Vulvar Dermatoses and Skin Conditions

There are dermatological conditions impacting the vulvar and vaginal skin, causing inflammation with either hyperplastic or atrophic changes. These dermatoses, like lichen sclerosus et atrophicus, are more common in menopause and can have associated itching and burning. There may be visible changes to the vulvar skin, like pallor, white patches, or scarring. Severe forms can cause loss of labial anatomy, clitoral phimosis or stenosis/narrowing of the vaginal entrance which can lead to additional symptoms of tearing or feeling like there is a blockage with penetrative intercourse. A biopsy may be needed for diagnosis and treatment involves use of prescription medications, typically topical steroids, to treat the specific condition diagnosed.

Vulvovaginitis and Inflammatory Conditions

Infectious conditions like yeast or trichomonas vulvovaginitis, allergy mediated reactions to local products, or even semen, or an autoimmune condition called desquamative inflammatory vaginitis (DIV), can all cause inflammation and swelling of the vulvar and vaginal tissues. This makes penetrative intercourse or even just external touch very painful. Itching, swelling, rawness, stinging and burning are often reported and often there is a discharge or odor noted as well. A swab or multiple swabs will be taken to confirm the diagnosis with a microscopic exam and laboratory testing.

Vulvodynia and Vaginismus 

Sensitivity to touch out of proportion to the pressure applied is a hallmark of a neurologic hypersensitivity pain syndrome called vulvodynia. Vulvodynia can be lifelong or acquired later in life and can be “provoked” only in response to direct touch, or “essential”, meaning it’s just there all the time. Vaginismus is a condition in which there is minimal or no pain to external touch, but vaginal penetration is limited and painful, which can be due to pelvic floor muscle tension and/or extreme fear of pain with  penetration. There can be much overlap in these two diagnoses. Swabs may be taken to rule out other conditions or infections, like yeast. However, a good history and thorough exam will often identify these two conditions and working with a gynecologic specialist in vulvar or pelvic pain for prescription topical and oral medications, a pelvic floor physical therapist, and a sex therapist is ideal.

Understanding Deep Dyspareunia and Pelvic Floor Tension

Pain deeper inside the vagina with penetration can be caused by pain from organs like the uterus, ovaries, bowel, bladder or from pain due to pressure on tense pelvic floor muscles. Tense pelvic floor muscles can also become a secondary cause of pain due to the reflex guarding that occurs following pain caused by any of the conditions already discussed. An exam is critical for diagnosis in order to palpate tense muscles or any pelvic masses, but often imaging, like a pelvic ultrasound, will also be advised by your doctor. Treatment would then be determined based on the specific condition diagnosed.

Table: Clinical Comparison of Menopausal Sexual Pain Causes

What to Expect During a Medical Evaluation for Sexual Pain

So, as you can see, there are many different causes of painful sex with vulvar touch and vaginal penetration. However, given how common vulvovaginal atrophy or GSM is in menopausal women, this can often be determined at a problem visit or well woman visit and treatment offered right away. If your doctor tells you that vulvovaginal pain or pain with sex is just part of normal aging or that sex shouldn’t really be important to you at your age – please find another doctor.

If the situation seems more complex or is not improving with initial treatment for vulvovaginal atrophy, a more comprehensive evaluation will be needed. As a gynecologist and sexual health expert, I can confirm that it takes time to do a detailed history and thorough trauma informed exam, so this should not be lumped into your well woman visit.

Factors Your Doctor Will Want to Know

• Pain Location: Is your pain superficial (vulva or vaginal opening) vs. deep (inner vagina due to pelvic floor muscles or internal organs).

• Triggers: Does the pain occur only with penetrative intercourse or also with tampons or vulvar touch or activities like biking? Is the pain always present and does not require direct touch to trigger?

• Duration: Is the pain lifelong or recent? Was it suddenly there or gradually worsening? 

• Trauma History: Did the pain follow a prior traumatic event? Past traumatic experiences, both sexual and medical, may exacerbate these conditions and affect the physical and emotional responses to the exam or testing needed.

Preparing for a Trauma-Informed Pelvic Examination

With any evaluation for dyspareunia, but particularly if you have reported a history of past medical or sexual trauma, your doctor should perform a trauma-informed pelvic examination. Why? Because these exams, if not done sensitively and carefully, can sometimes re-traumatize someone who has had painful sex for whatever reason. You have the right to stop an examination at any point if you feel uncomfortable with the speed, level of discomfort, or for any reason at all.

During the exam, your doctor should gently look at the external vulvar skin and may do a test called a “Q-tip touch test.” With this a lubricated or moistened, sterile Q-tip is touched to various pressure points around the outer and inner labia, perineum and the vaginal entrance, or vestibule. Next a vaginal swab may be obtained with or without a speculum inserted, to check a pH reading and to do a microscopic exam. Culture swabs may be obtained for testing for bacterial vaginosis, yeast or sexually transmitted infections that can sometimes contribute to pain during intercourse. Last a bimanual palpation exam is done with a gloved finger inside the vagina to assess for tension in the pelvic floor muscles at the entrance and deeper in the vagina, as well as to see if there are pelvic masses or pain with pressure on the bladder, cervix, uterus or the rectum.

During the exam, there may be the need to reproduce the pain to determine where it is coming from and the severity. This discomfort is usually never as bad as the pain you’ve already been feeling and can be mitigated by using some breathing and grounding techniques that I have shared with you in the Patient Toolkit.

How to Seek Specialist Help for Menopausal Sexual Health

I hope reading this gives you the inspiration and strength to seek help. The sooner we can try to figure this out and provide treatment options, the better the chance for recovery. That’s not to say that if you have been unable to have sex due to pain for 10, 20 or even 50 years that you can’t get better, but it definitely becomes harder to overcome. The longer you wait to address this problem, there is the layering effect of trauma from additional painful sexual experiences and the contribution of “top down” or descending pain modulation coming from the brain, which is wired to anticipate and avoid pain and emotional harm. It is very important to not feel embarrassed about this situation and to bring it up to your doctor. Ideally they will inquire about your sexual health, but with time pressured appointments, asking about problems in the bedroom is often first on the chopping block. Or your clinician may not feel comfortable treating these conditions, so they don’t ask. You may have to advocate for yourself again, and it can be frustrating. I get it. If you have not been supported or gotten a thorough history and exam by your gynecologist when bringing this problem up, please ask for a referral to see a specialist in vulvar or pelvic pain or search for a sexual health expert on the ISSWSH.org or vulvodynia.org websites. You deserve to enjoy sexual activity without pain!

Patient Toolkit: Breathing and Grounding Techniques

Use your senses, mental engagement and breathing to calm your nerves.

• Use aromatherapy or music to help calm your nerves while waiting for your visit.

• Bring a textured item, like a stone, to hold and feel during the visit and exam. 

• Look around the room and identify all the items you see that are a certain color.

• Count backwards from 100 by three.

• “Box Breathing”: Inhale for 4 counts, hold for 4 counts, exhale for 4 counts, and pause for 4 counts.

Frequently Asked Questions (FAQs)

1. Is it normal to experience painful sex during menopause?

While common—affecting over 10% of sexually active post-menopausal women—it is not a "normal" part of aging that you must accept. It is a treatable medical condition, often related to hormonal changes.

2. What is the Q-tip touch test used for?

This test involves touching pressure points around the labia and vaginal entrance with a moistened sterile Q-tip to identify specific locations of neurologic hypersensitivity to diagnose conditions like vulvodynia.

3. Are topical hormone  treatments safe for treating vaginal atrophy?

Yes, topical estradiol creams and rings, as well as estradiol and DHEA suppositories,, are locally acting and generally considered safe as they do not significantly increase the risk for blood clots or breast cancer.

4. What is the difference between superficial and deep dyspareunia?

Superficial pain occurs at the entry point (vulva or hymen), often feeling like burning, rawnesss or tearing. Deep pain is felt further inside the vagina as pressure or tearing  and may involve pelvic organs, the bladder, or tense pelvic floor muscles.

References

Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999. Feb 10;281(6):537–44. Erratum in: JAMA 1999 Apr 7;281(13):1174. 

Mitchell KR, Geary R, Graham CA, Datta J, Wellings K, Sonnenberg P, Field N, Nunns D, Bancroft J, Jones KG, Johnson AM, Mercer CH. Painful sex (dyspareunia) in women: prevalence and associated factors in a British population probability survey. BJOG. 2017. Oct;124(11):1689–1697.