What is the most common complaint of women* in my office?
Sex hurts.
What is the most common reason that women have pain with sex?
Menopause.
What is the most common reason that I get frustrated and enraged on a daily basis?
Untreated pain with menopause!
Up to 87% of women will experience pain with sex after menopause. Basically, most women are gonna feel this change, whether it affects their sex life or not. But most women seem to have never heard anything about this.
Why is menopause such a problem for women’s sex lives? The vulva, clitoris, are vagina are all dependent on estrogen. Estrogen causes these tissues to develop in puberty and is necessary to maintain vulvovaginal health.
Menopause means the end of the menstrual cycle and therefore the end of estrogen.
No estrogen = mo’ vulvovaginal problems.
If you still have your period, maybe you won’t have any issues at all at menopause, some women don’t. If you are in menopause already, maybe you feel fine.
But these changes (called genitourinary syndrome of menopause to be precise) are something you should know about, because it explains a lot about how the vulva and vagina works. It’s also important because the changes that start at menopause can get worse over time.
I lay out the whys and wherefores of the effects of estrogen or the lack thereof on the vulva, vagina and clitoris here.
This may all sound a bit dire. But the real problem with these menopausal changes is only that people don’t know about it. Because, for the most part, treatment is straightforward.
Let’s review the 5 tips for pain free sex after menopause.
Tip 1: Get an exam
While hormonal changes are the most common cause of pain with sex after menopause, they aren’t the only ones.
It’s a good idea to have someone examine your vulva and vagina to rule out other causes of pain.
I don’t recommend an exam lightly. I am well aware that the medical establishment doesn’t have a record of treating women all that well during genital exams. It’s a common source of trauma for women.
If I were in charge, I would decree that all women should have access to qualified and compassionate medical providers. Every exam would be trauma-informed (link to trauma informed exam info), meaning that the patient’s experience would be the guide, not provider convenience. And while we are at, no one shall be asked to have an important conversation while in a paper gown with their butt hanging out! And no more stirrups!
Until my queendom begins, I hope that you can find an excellent provider to help you with an exam and support you in working with any sexual pain that you may have. If you live near me, come on in for an appointment (link to booking a consult)! Finding a provider that is listed on this website or this website would be a great place to start.
Your local gynecologist or primary care provider may also do a great job. But if you don’t feel comfortable during your exam in any way, I encourage you to let your provider know. If that doesn’t feel possible for you, seek out someone else to work with. There are great folks out there and you deserve to feel supported during this essential exam.
Tip 2: To use hormones or not to use hormones
Since loss of estrogen is often the only cause of pain with sex after menopause, it would stand to reason that replacing this lost estrogen would be the most effective treatment. And it is.
Fortunately, there are several hormonal options available. The most frequently prescribed one is local vaginal estradiol. Estrogen actually refers to three hormones that the body makes, estradiol, estrone and estriol. Estradiol is one of the these and is the most abundant and most potent one the body makes. Local vaginal estradiol products come in the form of creams, tablets, ovules and rings.
If you like working with integrative or alternative practitioners, you will find that they are more likely to prescribe estriol for GSM. This is also one of the three estrogens that the body makes, but it is much more rare in the body and also a very weak estrogen. The reasoning for the use of estriol is that it is safer because it is a weaker estrogen. It is also thought to be safer because it only attaches to receptors in the vulvovaginal tissue and not breast tissue, theoretically leading to decrease risk of activating breast cancer. Overall, estriol seems safe and effective but there much fewer studies on estriol compared to estradiol. Estriol is also only available from a compounding pharmacy; depending on how you feel about compounding, this is either a pro or a con.
Another effective hormonal option is DHEA suppositories (prasterone). DHEA is a hormone that the body makes that is a precursor to the three types of estrogen. The cells of the vulvovaginal tissue can convert DHEA to an estrogen. They can also convert DHEA to testosterone, which may make it work better for some women (link to article about why sex hurts after menopause).
An older product, Premarin, is still on the market. It is a conjugated equine estrogen. Yes, equine – made from the urine of female horses. This was the way that estrogen was first produced for women. Though it is effective it does contain lots of other horse hormones that may not be every woman’s cup tea. That being said, the product has been around for decades and is safe based on the research.
Lots of choices out there!
But maybe you are wondering, “Hey Lori! I heard these hormones aren’t safe!! Are you trying to kill me or what??”
I got you! I hear this all the time from women. And women have good reason to think these treatments may not be safe because there is a lot of misinformation out there, even coming straight from the FDA.
Yes, these hormones are safe – maybe even for women with a history of breast cancer. If you doubt me, check out this post for more information.
But even if you decide that hormones aren’t right for you, you can still get relief with non-hormonal options, namely moisturizers. Moisturizers are like the lotion that you put on the rest of your body. And just like on the rest of your body, vaginal moisturizers can plump the tissues and increase moisture.
There is actually some good new data that moisturizers can work just as well as estradiol for decreasing symptoms related to genitourinary syndrome of menopause (let’s just call it GSM).
So, if you can’t get on board with hormones for whatever reason, use a good vaginal moisturizer 3-5 times a week. Check out this article for more information.
Whatever treatment you decide on, choosing the right product for you can be a bit of a process of trial and error. Each product has its own pros and cons in terms of dosing, effectiveness, packaging etc.
Cost is a big thing to consider. Moisturizers cost about $20-$40 a month. Hormonal treatments are often cheaper if you have Insurance coverage. But each company covers these medications differently and never in a predictable manner. Women without insurance may have a hard time affording them at all (that’s a whole other thing worth ranting about! If men had this kind of trouble with their penis, testosterone would be available for free in every bathroom in America!)
The goal with treatment for GSM is to find what works for you and stick with it. Unfortunately, the changes that happen after menopause are chronic and progressive. These symptoms don’t go away without treatment.
Care of the vulvovaginal tissue should become part of your routine self-care after menopause. Brush your teeth, floss, use sunscreen…do something to take care of your vulva and vagina to keep things happy and healthy.
Tip 3: Use an awesome lubricant every time!
Hormonal treatments or moisturizers used a few times a week are the backbone of treatment for GSM.
But the next best way to decrease pain with sex and INCREASE PLEASURE is to use a great lubricant every single time for sexual play.
The number one reason anyone has pain with sexual penetration of any kind is simply related to friction. Dry fingers or toys or penises dragging against delicate vulovaginal tissue is gonna hurt. And at no time is this more true than after menopause.
Women often feel some shame around the use of lubricants and I think we just have to blow this whole idea out of the water. There is nothing wrong with you if you want to use a lubricant, it’s the most basic and probably the most essential aide to sexual pleasure out there.
I strongly recommend that you take some time to pick out a couple of lubricants that you love. As a quick and easy recommendation, silicone (uberlube) or oil-based lubricants (coconut oil) work well for menopausal women. Check out this article for more information.
Tip #4: Keep if flexible
The loss of estrogen at menopause (or any other time) causes the vulvovaginal tissue to become tighter and stiffer. The opening of the vagina be a particular problem because even subtle loss in flexibility here can make penetrative sex very painful.
Applying moisturizers or local hormonal treatments can go a long way towards hydrating and loosening up the tissues. But these tissues also need to be mobilized, just like every other part of your body.
What, you may ask, are good ways to mobilize the vulvovaginal tissues?
Well, my friend. Let your imagination be your guide!
The goal would be to engage in some sort of regular vaginal penetration, hopefully of the pleasurable variety when possible. You can do this alone or with a partner. It can be approached like a type of physical therapy but I think adding in pleasure improves vulvovaginal health even more and is also….well, pleasurable!
If you do not have bothersome symptoms, there is no need to purchase any special equipment. However, some women may pain and restriction at the opening of the vagina who cannot tolerate penetration well may benefit from using dilators. Dilators are cylinder shaped and come in varying sizes. They are used to slowly help release the opening of the vagina and increase flexibility.
How often should you do this? There is no strict consensus on this. It also depends on whether you currently have pain or are just hoping to maintain vaginal health.
If you are having trouble with pain with sex, especially if you are unable to tolerate penetration at all, I would strongly recommend that you find a good pelvic floor physical therapist. Did I say strongly recommend? I mean really, really strongly recommend! For more information about why pelvic PT can be essential for overcoming painful sex, check out this article.
Tip # 5: Keep the focus on PLEASURE
When pain becomes a problem, either in actuality or as something you may be anticipating as part of menopause now, it is easy to lose sight of the fact that, no matter what, pleasure is also always possible.
Your body is built for pleasure. Even when there are changes to the body and mind which lead to pain. Pleasure is still always available to you.
In many ways, I view pleasure as an antidote to pain.
In the most literal sense, sexual pleasure does heal the tissues of the vulva and vagina. Sexual pleasure leads to arousal. Arousal increases blood flow, this is how clitorises (and penises) swell and become erect when you get turned on.
Improved blood flow heals tissue by bringing oxygen to tissues and taking away waste products. Think of how wounds need good blood flow to heal, for instance.
So, arousal is great for healing the vulvovaginal tissue. Another way to augment blood flow is to add vibration into the mix (yes, that kind of vibration!) to increase arousal and even further increase blood flow. And bonus! You can get a vibrator that you can also use to mobilize those vaginal tissues with regular penetration. I love efficiency! ☺
But pleasure doesn’t just heal the body but it also heals the mind. Pleasure, joy, comfort, intimacy – these are the basic resources of life. Your whole body, all your five senses, have the capacity to bring in this pleasure if only you take the time to tune into it. Sexual pleasure is one form of this sensual pleasure that connects us to our fundamental selves and to our partners. Leaning into sexual pleasure even when there may also be sexual pain helps to maintain this connection and provides much needed refuge.
Sex is after all about pleasure – so regardless of the ability to tolerate penetration – that pleasure is still possible.
Lean into pleasure as much as possible as often as possible. I give you full permission. Don’t believe me, well…then here is a prescription to make it official.
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The sad truth is that all of this should be common knowledge. But women tell me all the time that they have never heard this story. Maybe the same is true for you.
The unnecessary suffering causes is unacceptable as far as I am concerned.
If any of this this is news to you, I’m glad you found it. Pass it on. Tell anyone who needs to know.
Here’s to women living long, happy sex lives without pain!
* *In this article, the term “woman” or “women” will refer to people that are born with a vulva and vagina. As we know, there are women who are not born with this genitalia and other genders who do have a vulva and vagina. Language is somewhat inept in its ability to elegantly capture this beautiful complexity. I encourage you to use the information in this article as it applies to you or your loved ones.
