Painful Intercourse in Menopause: Why Sex Hurts and What to Do

Key Takeaways:

• Painful intercourse, or dyspareunia, is common during and after menopause. It’s often linked to decreased estrogen, which can lead to vaginal atrophy and genitourinary syndrome of menopause (GSM).

• In addition to discomfort during or after sex, GSM may cause vaginal dryness, burning, and irritation.

• Effective treatment options include over-the-counter lubricants and moisturizers, prescription hormonal or non-hormonal therapies, pelvic floor therapy, and open communication with your partner.
  

Menopause often brings changes to vaginal comfort and natural lubrication, which can make intercourse painful. While this experience can feel distressing, many strategies — ranging from lifestyle adjustments and over-the-counter products to effective medical treatments — can help you enjoy intimacy comfortably again.

Below, we’ll explore why sex might hurt and how to deal with painful intercourse during menopause and beyond.

Menopause is a natural stage in life that marks the end of your reproductive years, though the transition often begins earlier, during perimenopause, when hormone levels start to fluctuate. 

For many women, these shifting estrogen levels can contribute to irritation, soreness, and other changes that affect sexual comfort and lead to painful intercourse (also known as dyspareunia).

Here’s a closer look at what’s happening:

1. Hormonal Changes and GSM

Estrogen helps keep vaginal tissue healthy, elastic, and well-lubricated. As your body produces less estrogen during perimenopause and menopause, the tissues in your vagina and vulva can become thinner, drier, and less flexible. If left untreated, these symptoms can lead to a condition called genitourinary syndrome of menopause (GSM). 

GSM can involve a range of interconnected symptoms, many of which contribute to painful intercourse. Common signs include:

• Vaginal dryness, which can lead to tightness or a tearing feeling during penetration

• Burning or irritation in the vaginal area, which may occur before, during, or after sex

• Soreness or irritation that lingers for hours or even days after intercourse

• Bleeding after sex, caused by more fragile vaginal tissues

• Reduced blood flow to the clitoris, which can make arousal harder

• Urinary urgency or painful urination

• Recurrent urinary tract infections (UTIs)

By understanding how GSM affects the vagina and vulva, you can explore targeted strategies to restore comfort and intimacy.

2. Pelvic Floor Changes

The pelvic floor is a group of muscles that support the bladder, uterus, and bowel. A strong pelvic floor is closely linked to sexual function.

Pelvic floor disorders tend to become more common during midlife and may increase after menopause. These changes can contribute to painful intercourse in a few ways:

• Tightness or spasms: Overly tight muscles can make penetration extremely painful.

• Weakness: Weak pelvic floor muscles can lead to discomfort and a feeling of instability.

Learning to recognize and address pelvic floor dysfunction — often with the help of a pelvic floor physical therapist — can play a key role in restoring comfort and pleasure.

3. Psychological and Emotional Factors

Menopause brings not only physical changes but also emotional and psychological shifts — and these can have a significant effect on sexual well-being.

Your emotional health might influence your sex life in a few different ways:

• Anxiety or fear of pain. If sex has been painful, anticipating discomfort can create a cycle of anxiety that makes relaxation and arousal more difficult.

• Body image concerns. Changes in your body during menopause can affect how you feel about yourself and your desire for intimacy.

• Stress, sleep, and relationship challenges. Hot flashes, mood swings, and night sweats can disrupt sleep and increase stress, leaving you with less energy or interest in sex. Relationship strain from sexual difficulties may also amplify discomfort or worries.

Taking a holistic approach and addressing both the physical and emotional aspects of sexual health can help break the cycle of pain and make intimacy more enjoyable again.

The good news is that treating painful intercourse during menopause and perimenopause is totally possible. There are several approaches you can explore, and knowing your options can help you feel more in control and confident about intimacy.

Let’s dive into the most common and effective ones below.

Over-the-Counter Solutions

For many women, simple, non-prescription vaginal lubricants and moisturizers can make a big difference in sexual comfort.

For example, water-based or silicone-based lubricants can help increase vaginal lubrication and reduce friction during sexual activity, making penetration more comfortable. While there are oil-based lubricants out there, these can sometimes irritate sensitive tissues or affect condoms. So when in doubt, opt for fragrance-free water- or silicone-based options.

You can also look for vaginal moisturizers. Unlike lubricants, which are used during sex, moisturizers are applied regularly (every few days) to keep vaginal tissues hydrated and healthy. Over time, they can help restore a more natural moisture balance.

Prescription Medications

If over-the-counter options aren’t enough, your doctor can guide you toward more targeted prescription treatments, including:

• Local hormone replacement therapy (HRT). Often the most effective solution for relieving pain and restoring comfort during sex, local vaginal estrogen HRT works by replenishing estrogen directly in the vaginal tissues. Because it’s applied locally, very little estrogen enters the bloodstream. It comes in several forms, including creams, tablets, rings, and suppositories.

• Systemic HRT. For those experiencing a broader range of menopausal symptoms — such as hot flashes, night sweats, and mood changes — systemic HRT may also improve vaginal health as part of its overall benefits. This form of HRT delivers estrogen (and sometimes progesterone) throughout the body via pills, patches, or sprays. Your healthcare provider can help weigh the risks and benefits based on your personal health profile.

• Ospemifene. This oral medication is a non-hormonal alternative. It works similarly to estrogen in vaginal tissues to increase thickness and reduce discomfort, making it a good option for women who prefer or require a non-hormonal treatment.

Here’s a quick side-by-side glance at these treatment options:

Lifestyle Adjustments

In addition to medical treatments, small changes in your daily routine can make a meaningful difference in comfort and sexual health during menopause. Here are some things to try:

• Pelvic floor physical therapy. A specialized therapist can help identify and address issues with pelvic floor muscles — whether they’re tight, weak, or uncoordinated. Through targeted exercises (like Kegels) and advice, therapy can improve muscle function and reduce pain during intercourse.

• Regular sexual activity (when comfortable). Maintaining sexual activity, whether with a partner or solo, helps maintain vaginal blood flow and tissue elasticity. The key is to keep it comfortable and pleasurable, not painful.

• Focus on foreplay and explore alternatives. Allowing extra time for arousal and natural lubrication before penetration can reduce discomfort and improve sexual enjoyment. Also, painful penetration doesn't mean the end of intimacy. You can explore other forms of sexual expression and touch that are pleasurable and comfortable for both of you.

• Communicate with your partner, if you have one. Open communication with your partner is an important part of managing painful sex. In fact, couples who talk openly about sexual needs often report better experiences overall.

• Consider talk therapy. Individual therapy can help process emotions around menopause and painful intercourse, while couples counseling can guide communication and intimacy if sexual challenges affect your relationship.

At the end of the day, the best treatment for dyspareunia often includes a multi-faceted approach that addresses all the physical, emotional, and behavioral elements of the condition. It could include a mix of professionals, from a gynecologist and physical therapist to a sex therapist.

It’s normal to feel hesitant or embarrassed talking about sexual pain, but your healthcare provider is there to help you feel your best. You don’t have to just live with it — there are effective treatments for this common symptom of menopause.

It might be time to seek professional advice if:

• Pain is persistent, severe, or affecting your quality of life

• Over-the-counter lubricants or moisturizers haven’t helped

• You experience bleeding after intercourse

• You notice new or worsening urinary symptoms

• The pain is causing emotional distress or affecting your relationship

A healthcare professional can provide an accurate diagnosis and guide you toward treatments tailored to your needs, helping you regain comfort and confidence in your sexual health.

Painful sex during menopause is common — but you don’t have to just accept it and live with it. Understanding the hormonal changes your body is going through and working with your healthcare provider can help you find relief. With lifestyle strategies, therapies, and medical treatments like low-dose vaginal estrogen, comfort and intimacy are within reach.

What is dyspareunia?

Dyspareunia is the medical term for recurrent or persistent pain during sexual intercourse. It can range from mild discomfort to sharp pain, and may occur at the vaginal entrance, deep in the pelvis, during penetration (known as entry pain), or right after sex.

Is painful sex during menopause permanent?

No, painful sex during or after menopause doesn’t have to be permanent. With the right treatments and management strategies, such as over-the-counter lubricants and vaginal hormone replacement therapy, most women can experience significant relief and restore comfortable intimacy.

Can stress make painful intercourse worse?

Yes, it’s possible for anxiety and fear of pain to increase pelvic floor muscle tension and lower natural arousal and lubrication, which can make intercourse more uncomfortable. Research also shows that everyday stress can get in the way of feeling in the mood for intimacy for women during menopause, which could play a role in the issue, too.

How long does it take for treatments like vaginal estrogen to work?

Some women notice improvements within a few weeks, but it typically takes eight to 12 weeks of consistent use to experience the full benefits of vaginal estrogen therapy. Try to be gentle with yourself and give your body time to adjust. In the meantime, things like pelvic floor exercises and over-the-counter lubricants may help.