After you’ve officially made the transition into menopause, you may assume that your symptoms are behind you. And sure, hot flashes and night sweats can subside, but there’s one change that might linger for good: painful sex.
During menopause, your body loses estrogen, a hormone that helps keep the vaginal tissues healthy, says Mary Jane Minkin, MD, a clinical professor of obstetrics, gynecology, and reproductive sciences at the Yale University School of Medicine, in New Haven, Connecticut. When your estrogen levels decline, you can also experience vaginal dryness, which can lead to painful sex.
Vaginal dryness and soreness or burning during penetration “often occur further out from menopause,” says Dr. Minkin. “Whereas a woman may experience hot flashes that get better, vaginal dryness tends to get worse over the years.”
Left untreated, the problem can become so severe that some women give up intercourse entirely because it’s too dry and uncomfortable to be pleasurable. Compounding the confusion, “since it occurs later, many women don’t associate this with menopause at all, and they think dryness is inevitable with aging,” says Minkin.
The good news is that there are many things you can do to improve vaginal lubrication, reduce pain, and make sex feel good again. Here are five options to try.
1. Get a Vaginal Moisturizer
Polycarbophil gel, which is available over the counter, is a good first remedy, says Minkin. The product works mainly by adding water to the tissues, she says, and because it’s applied two or three times per week, you don’t have to remember to use it every time you’re intimate. The gel can be applied with an applicator into the vagina.
You can also apply some vaginal moisturizers externally. The labia can become dry, too, explains Minkin, which can make intercourse uncomfortable.
2. Try a Lubricant During Sex
Intimacy can be even better if you combine polycarbophil gel with a lubricant during sex, says Minkin. There are plenty of lubricants available on the market, and finding the right one can take some trial and error.
“I tell patients not to go out and buy the giant, economy size bottle until you know it will agree with you,” says Minkin. Many contain fragrances, which can irritate especially sensitive vaginal and vulval tissues. Also, if you’re using condoms to protect against sexually transmitted infections, be aware that an oil-based lubricant can degrade the latex; in that case, choose a water-based or silicone lubricant.
3. Get Into Foreplay
A quickie might not work for you anymore. “The more foreplay the better, whether you’re pre- or postmenopausal,” says Minkin. “It gets the [vaginal] tissue revved up.”
Similarly, it may also help revamp your definition of sex. If intercourse is painful because of dryness, you might find that oral sex (which, yes, is still sex) is more pleasurable and allows you to be intimate with your partner.
4. Try a Toy
One word: vibrator. “I’m a big fan of recommending vibrators to my patients,” says Minkin. “Anything that will increase pelvic blood flow will increase moisture to the vagina.”
There are many styles and functions of vibrators on the market, ranging from base models with a few different intensities to those with multiple speeds, patterns, and extra features. Don’t know where to start? Try female-friendly online retailers like Babeland, Lelo, or Bellesa Boutique.
5. Ask About an Rx
For some women, all it takes to relieve dryness is a good vaginal moisturizer and some lifestyle changes. Others might need a prescription. If that’s the case for you, talk to your doctor about vaginal estrogen.
“Almost everyone can use vaginal estrogen,” says Minkin. “It’s really quite safe.” Vaginal estrogens work by increasing moisture to the tissue via vaginal suppositories, rings, or creams, based on personal preference, she says.
A vaginal suppository with the hormone DHEA, which is converted into estrogen and testosterone, may be another Rx option for you, she says. One study found that women using DHEA suppositories reported an improvement in vaginal dryness and pain during sex compared with those who used a placebo.
Finally, ospemifene tablets are a once-daily nonhormonal prescription medication that treats both vaginal dryness and painful intercourse due to menopause by increasing certain cells (and decreasing others) in the vaginal tissue.
Keep in mind that pain during sex can have other causes beyond vaginal dryness, such as a vaginal infection. It can also be a symptom of ovarian cancer — as can bloating, pelvic or abdominal pain, and feeling the urge to urinate more often, notes the American Cancer Society — or vulvodynia, a chronic pain condition.
The bottom line: Be up front with your doctor about your discomfort. A good sex life is one part of being in good health.
Vaginal Hormone Therapy
Vaginal estrogen
If you do not get sufficient relief from lubricants and moisturizers, your healthcare provider could prescribe you low-dose vaginal estrogen. These products do a very good job at treating the vaginal dryness and irritation that causes sex to hurt. Vaginal estrogen will make the tissue in your vagina moister and thicker. The tissue will be less pale, as more blood will flow to your vagina.
It’s very important to consult your healthcare provider before using estrogen. For some people, estrogen use can increase your risk for stroke, blood clots high blood pressure, and heart attack.
You can choose from a number of different vaginal estrogen products. You may notice relief after a few weeks of use, but depending on how bad your symptoms are, it may take several months.
- Vaginal cream– You can put a pea-size amount of estrogen cream into the vagina using your finger or an applicator. If the vaginal opening is also affected, you may apply a very small amount to this area as well. You will put estrogen cream in your vagina one time, each day for two weeks, and then one time, two days per week.
- Vaginal tablet– If you find the cream to be messy, you can put a small tablet into the vagina using your finger or an applicator. You will put this tablet in your vagina one time, each day for two weeks, and then one time, two days per week.
- Vaginal ring– You can put a small flexible plastic ring in your vagina for 3 months and then remove and replace with a new one every 3 months. You do not need to remove the ring to have sex or bathe. If you choose to remove it to have sex, make sure to put it back inside the vagina afterwards.
Which vaginal estrogen form is better? The cream, the tablet or the ring?
All three forms do a very good job at treating vaginal dryness and pain with sex. Choose the estrogen form you are more comfortable with or the one that is more convenient to you. Talk to your insurance company and explore the costs of all your options. Cost and affordability may also be a factor to take into consideration. Note that estrogen is only available with a prescription and you should only take it after carefully discussing and learning the risks and benefits of estrogen for you.
Non-Estrogen Treatments
- DHEA- This is a hormone which works like estrogen on the vagina. It is a suppository that is placed in the vagina at bedtime.
- Ospemifene- Ospemifene is the only oral non-hormone treatment available to treat vaginal dryness and pain with sex during menopause. You can take the pill by mouth one time, each day. This medication is not estrogen, but it works like estrogen to help improve the tissue in your vagina. It also helps with your bones. If you don’t want to use any vaginal product, or have a hard time putting products inside your vagina, ospemifene may be a good option for you. Relief may be noticed after using the medication for 12 weeks.
- Vaginal prasterone- You can put a suppository inside your vagina using an applicator one time, each day, at bedtime. The vaginal suppository contains prasterone, an ingredient that is changed in your body to estrogen. If you do not want to use estrogen, this may be a good option for you. However, keep in mind that vaginal prasterone was recently approved by the FDA and we know less about this therapy option as compared to vaginal estrogen.
Other Treatments
Vaginal Laser
Laser therapy appears to be a safe and potentially good option to treat vaginal dryness and pain with sex during and after menopause. During this procedure, a numbing cream is applied to the vulva and vagina, and a probe is carefully inserted into the vagina by your healthcare provider. This probe delivers laser energy to all your vaginal walls, and to your vulvar area or vaginal opening, if necessary. Multiple sessions may be needed. The laser works by creating many small punctures in your vagina which help stimulate the growth of new, healthy vaginal tissue. Currently, there are not enough data to recommend this treatment over other therapies, such as vaginal estrogen. More research needs to be done. However, vaginal laser treatment holds promise for women who cannot use estrogen, cannot tolerate hormone treatment, cannot afford long-term hormone treatment, or are not willing to use products with hormone.
Physical therapy
Many women who experience pain with sex have tight muscles in the pelvis. With the help of a physical therapist, you can be taught how to identify and relax the muscles of your pelvic floor (pelvis). This treatment occurs over a number of sessions. Learning how to relax the muscles of your pelvis may help you have easier, less painful sex.
Vaginal dilators
If your vagina narrows and shortens, or you have been contracting your pelvic muscles in such a way that you are unable to have sex (such as in anticipation of the pain that is usually felt), a set of vaginal dilators could help you. You will gently stretch your vagina with well-lubricated dilators starting with the smallest one, and gradually increasing the size of the dilator until you are able to have sex. Your health care provider or therapist can guide you during this process.
Behavior Changes
There are some things you can do to potentially reduce pain during sex. The most common recommendations are:
- Empty your bladder before having sex
- Increase the amount of time spent in foreplay as this may improve natural lubrication
- Change positions during sex- don’t be afraid to speak about what feels right or wrong
- Choose positions that allow you to have control of the depth of penetration
- Place ice packs around a towel and apply to your vulva if you feel discomfort after sex
- As long as there is no major pain, try staying sexually active- sex itself keeps the vaginal tissue healthy and maintains the vagina soft and stretchable.
- Practice yoga- Yoga has many benefits! Some yoga poses work by strengthening and relaxing the muscles of your belly and pelvis. This exercise may help increase sensation during sex, and may even help ease pain during penetration. Practicing yoga can help you improve your sexual function.