What Happens When You Want to Have Sex, But It Hurts?

Dear HealthyWomen,

I'm a healthy 45-year-old woman, starting to approach menopause. Some days I feel fine, yet on other days I'm moody and get hot flashes. My periods are becoming erratic, too.

Sex with my husband used to be pleasurable. But ever since I started going into menopause, it has become quite uncomfortable and even painful. And I find myself fearing it—or worse, avoiding it—because, frankly, the pain it causes takes away any pleasure.

I think it's interfering with my relationship. I no longer feel sexy or desirable. Although my husband is sweet and seems to be understanding, I think he's losing patience with me, and I don't want to give up this important part of our relationship and let this problem come between us.

I've heard the term "vaginal atrophy," and people talking about how the vagina "shrinks." Is that what's going on here?

Signed,
Want Sex But Afraid

Dear WSBA,

Sex shouldn't hurt, nor does it need to. But you're not alone. For many women, sex can become painful and difficult around menopause.

The main culprit is estrogen loss, making the tissues of the vagina dry and thinner. Without moisture, the friction of sex can certainly cause pain. The vagina also loses some of its elasticity, which can make it feel tight and make penetration painful.

This condition used to be called vaginal atrophy, but in the last few years was updated to genitourinary syndrome of menopause, or GSM, because the changes that happen encompass more than just the dryness, irritation and burning of your vagina. They also include urinary symptoms, too. Learn more about what happens to your vagina during menopause.

But let's get back to your question of painful sex. The timing of your question is good, because there was an informative article just published in The New York Times called "Treating the Incredible Shrinking Vagina."

In it, the author, Dr. Jen Gunter, says that while these symptoms are distressing for many women, they can almost always be treated. So, there's hope here.

Dr. Gunter writes that besides loss of lubrication during sex, women may experience "an uncomfortable sandpaper-like sensation, pain, difficulties achieving orgasm and even tearing of the vagina or vulva." Your risk of urinary tract infections can climb, too, during this time and under these conditions.

Estrogen, which declines around menopause, is crucial to maintaining the bacterial colonies of the vagina. Changing levels can also affect the type of bacteria in your vagina and the typical odor of it, she writes.

During perimenopause—the period leading up to menopause—up to 15 percent of women deal with GSM, with that number climbing to about 50 percent by three years after menopause. (Menopause is defined as when you have gone 12 consecutive months without a period.)

Conversely, some women might never feel any symptoms at all. It is variable for everyone.

But, for women who experience problems, there are treatments to help—both over-the-counter and prescription products.

A lubricant (like Astroglide) can help make sex less painful and more comfortable. Some data suggests that a silicone-based one will be more effective than one that is water-based. If your partner uses a condom (yes, you can get pregnant during perimenopause!), beware that some oil-based lubricants can degrade condoms.

A moisturizer, used two to three times a week, can ease a dry vagina by mimicking the actions of vaginal fluid. One example is Replens, but there are many on the aisle of your drugstore.

And then there are prescription options. Vaginal estrogen is considered to be the gold standard to replace your missing estrogen after menopause. It's available as estradiol or conjugated equine estrogen and comes in different formulations including vaginal tablets, gel caps, creams or in a vaginal ring. This type of estrogen is low-dose and considered very safe. It is not associated with risks like breast cancer or stroke when used as prescribed.

There's also a newer option called intravaginal DHEA, which is a hormone that's converted in the vaginal tissues to estradiol and testosterone. Because it is newer, it hasn't been as well-studied as vaginal estrogen, so you might want to try the other options first. Keep in mind that some women might find it messy, because it requires daily application.

Then there's a pill, called Osphena, which contains the drug ospemifene, which acts like estrogen on the lining of your vagina (as well as your bones). While it doesn't seem to have the potential harmful effects of estrogen on your breasts or uterine lining, be aware that it can cause hot flashes and has a potential risk of stroke and blood clots, according to the Mayo Clinic.

Besides these treatments, it's recommended that you give your vagina some special care during this time. Wash your vulva with an unscented cleanser rather than soap, which can be drying and aggravate the already-dry vagina you're dealing with.

If you're dealing with other symptoms of GSM like urinary incontinence, don't use menstrual pads, but use incontinence pads instead. They work differently: menstrual pads retain moisture and will hold the wetness of the urine against your skin, further irritating the vulvar region.

Another thing that many experts recommend (and something that may make your husband very happy) is to have more sex. Sounds counterintuitive, right? If having sex hurts, how can you have more of it? But eventually it will help, because sex improves blood flow and can increase moisture in your vagina, as well as help stretch and strengthen your pelvic floor muscles.

As with any medical problem, be sure and talk with your health care professional. You may want to see a certified menopause practitioner, who specializes in these issues. Here's a site to search for one in your area.