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Why does it hurt? The Problems Behind Painful Sex

Why does sex hurt? As a urogynecologist, or a specialty physician who cares for women with gynecologic, sexual, pelvic support or bladder problems, I hear this question many times a day.


Women, standing with her legs crossed and a 'help' sign on her shirt

After menopause, the gradual decline in estrogen levels can impact the elasticity, moisture and resilience of the vaginal tissues. These hormonal changes can affect sex, exercising, or even bladder function!

Little did you know, the lower half of the bladder is right next to the vagina and is affected by the changes of menopause. In addition to painful intercourse and vaginal dryness, you may have:

  • Frequent urgency to urinate
  • Dribbles or leakage of urine
  • Urges to get up and go at night

This is what we call the genitourinary syndrome of menopause, or GSM, and it happens to nearly half of postmenopausal women. For many (lucky!) women, using lubricants improves these symptoms.

Lube eases the pain of sex.

When intercourse is uncomfortable or dry, lubricants can help. One of our favorite lubricants to recommend to patients is coconut oil — yes that oil from the kitchen. Move it to the bedroom! It is a convenient solid at room temperature and liquifies when you scoop it up. And it's safe for both partners.

Astroglide liquid or simple water-based lubricants can also be used with or without condoms. Avoid anything scented, flavored or with obvious chemical additives. Check out the ingredients list online before going to the store (much less embarrassing!).

Chemicals make problems worse.

Vaginal dryness and irritation from chemical additives can be a significant problem starting in perimenopause, the transition time leading up to menopause. Minimize your use of any soaps, lotions, wipes, creams, or sprays on the vulva. They are too harsh for such delicate skin. I am not a fan of any over-the-counter “moisturizers.” They all have long lists of chemical ingredients that can irritate this sensitive area.

Wear liners or pads only when necessary, not “just in case.” If you feel like you need pads all the time because of persistent irritation or leakage of urine, see your provider. You may need further evaluation or a skin biopsy.

Serious pain requires serious treatment.

When lubricants and moisturizers are not enough — and pain, stretching, pulling, or burning after intercourse persist — it's time to see a provider. A history of your problem and a pelvic exam is usually enough to determine if menopause is the cause of painful intercourse.

Even if you are up-to-date with your yearly examination, a detailed vaginal and vulvar exam is necessary to check for other problems in this area. Simple microscopic testing for vaginal pH, STD, or vaginal support problems can pinpoint specific ways to help. Rarely are these issues serious, and almost all are improved with simple treatments.

Estrogen Cream

Vaginally-inserted estrogen cream is the most direct treatment for painful sex caused by vaginal dryness. In small doses, it's a safe, simple, and direct way to improve your symptoms with minimal risk and few side effects.

Cost can be an issue. Estrogen cream is not covered well by insurance. Some women don't like having to insert the cream long-term. Others don't want to use any hormones in their menopausal transition. All hormone use should be guided by a licensed provider so that you get the most recent information to protect your health. Estrogen cream is generally not recommended if you have breast cancer.

Vaginal Inserts

IntraRosa and Prasterone are sex steroids that can improve the symptoms of menopause. Newly approved by the FDA, these vaginal inserts have to be placed inside the vagina at bedtime. You must use them nightly for at least three months before your provider can evaluate your dose. After that, you have to use them long-term to maintain the benefits.

Like with estrogen cream, cost may be an issue with vaginal inserts. Although this treatment also uses hormones, studies show that it's a safe and effective option if you don't want to use estrogen. But it's not yet recommended for women with breast cancer.

Selective Estrogen Receptor Modulator

If you're hoping to avoid hormone use, there's a pill called Osphena. It's a selective estrogen receptor modulator, or a SERM, that gradually works at the same receptors as estrogen to mimic the effects on the vaginal tissue. Osphena is also not for women with breast cancer. It's only for healthy women because it can increase your risk of hot flashes, blood clots, or uterine cancer.

MonaLisa Touch® Procedure

Many patients ask me about vaginal laser procedures for painful sex and vaginal dryness. They're not interested in using a long-term vaginal or oral medication. Though there is a great deal of information online about laser options, you should always discuss them with a board-certified provider.

From all the options in this area, I selected MonaLisa Touch. It's the most promising laser treatment to improve symptoms of GSM. In three office visits scheduled six weeks apart, you receive a five-minute internal and external laser treatment. The gentle vaginal and vulvar laser treatment stimulates the return of normal vaginal pH and moisture at the cellular level. This improves lubrication and relieves the symptoms of GSM without the tissue trauma seen with other lasers.

Improvement starts after your first treatment, but maximizes after your second and third. Research shows that Mona Lisa Touch is a safe, tolerable treatment that improves dryness, moisture, and comfort during sex. Further studies are needed to document whether urinary symptoms improve. Mona Lisa Touch is not covered by insurance, so cost may be an issue.

Patients ask me, “Why does it hurt?” But the question really is, “What can we do about it?” Pain during sex is not a new reality after menopause. You have plenty of options to improve your vaginal health — and have a healthy, happy sex life.

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