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    Why is sex after menopause sometimes more painful?

a middle-aged couple in bed with their backs to each other, sleeping or maybe upset, angry, frustratedDEAR MAYO CLINIC: I am in my late 50s and have recently found that sex is becoming quite uncomfortable. I am assuming this is because I’m past menopause, but what’s the best way to make sex less painful?

ANSWER: Dyspareunia, the term for painful vaginal sex, is quite common. Estimates vary, but surveys of postmenopausal women not on hormone therapy report dyspareunia in as many as 20 to 30 percent. It’s often divided into three categories: superficial pain, deep pain or both. Most women complain of superficial pain, which occurs upon vaginal penetration. Often, the pain has a sharp or burning quality. Deep pain occurs with deep penetration or thrusting. For some women, dyspareunia is temporary. For others, it can become chronic.

After menopause, painful intercourse often is associated with changes due to decreased estrogen levels. The vaginal tissues tend to become less elastic, more fragile, and more susceptible to bleeding, tearing or pain during sexual activity or during a pelvic exam. It can make sex painful or even impossible. The loss of estrogen can cause urinary problems, which also can make sex uncomfortable. Lack of sexual activity contributes to loss of tissue health and elasticity.

Sometimes, other factors are at play, including injury or trauma, such as from childbirth, pelvic surgery or an accident. Skin conditions like eczema or lichen sclerosus, or an infection in your genital area or urinary tract also can cause sex to be painful. Involuntary spasms of the vaginal wall muscles (vaginismus) can make attempts at penetration painful or impossible. Certain medications, such as antidepressants, high blood pressure medications and others, can contribute to vaginal dryness. In addition, stress, fear of intimacy, and concerns about body image or relationship difficulties can make pleasurable sex a challenge.

Pain associated with deep penetration or certain positions may be caused by inadequate relaxation of pelvic muscles or conditions that affect the pelvic area, such as pelvic floor dysfunction, endometriosis and uterine fibroids. Scarring from pelvic surgery or treatments such as pelvic radiation can cause changes that make sex painful. 

Fortunately, you don’t have to forgo sex altogether to avoid pain. The first step is talking to your health care provider, who can refer you to an appropriate specialist. He or she may ask when your pain began, where it hurts and if it happens every time you have sex. Your health care provider also may ask about your history of surgery, childbirth and sexual relationships.

Examination of the genital area and pelvic muscles can help identify the location of your pain and possibly the cause. If there are physical conditions contributing to your pain, treating the underlying cause may help resolve the pain. Your health care provider also may suggest medication changes if they may be affecting your sexual health.

There also are a number of other treatment options. Vaginal lubricants help decrease pain during sex and can be applied as often as needed. Keep in mind that oil-based lubricants may degrade condoms. Vaginal moisturizers used every two to three days can help maintain vaginal moisture.

When estrogen levels are low, the first choice for treatment is usually low-dose vaginal estrogen therapy. This typically comes in the form of a cream, vaginal tablet or flexible vaginal ring. A once-daily vaginal insert, prasterone, is also available. Estrogen doses in these forms are low enough to minimize risks of overall systemic estrogen exposure. Unlike moisturizers and lubricants, low-dose vaginal estrogen therapy actually helps reverse vaginal tissue changes related to loss of estrogen with menopause.

Some women prefer the convenience of swallowing a pill rather than relying on topical therapies. The drug ospemifene acts like estrogen on the vaginal lining and bone but doesn’t seem to have estrogen’s potentially harmful effects on the breasts or the lining of the uterus. Unfortunately, the drug may cause hot flashes. And, like estrogen, ospemifen has a potential risk of stroke and blood clots.

Topical creams also are prescribed to treat skin conditions such as lichen sclerosus. Skin conditions may worsen the symptoms of dryness associated with decreased estrogen levels. These creams, which may include topical steroids, are prescribed after a detailed exam and diagnosis by your health care provider. He or she also may recommend treatment with antibiotics for proven infections.

Another option is pelvic floor physical therapy, which may relieve pain when tight, tender pelvic floor muscles contribute to painful sex. Pelvic floor physical therapy, which is performed by a therapist who specializes in this treatment, can relax the pelvic floor muscles and may relieve pain. Your therapist also may educate you about vaginal dilation exercises with a lubricated dilator to help stretch the tissues.

Finally, a counselor or sex therapist can help you identify specific stressors that may be negatively affecting your sex life. Sex therapy can help you improve communication with your partner, address body image problems, and learn how to decrease anxiety and better enjoy intimacy. (adapted from Mayo Clinic Health Letter) — Beatriz Stamps, M.D., Gynecology, Mayo Clinic, Phoenix