Why Does Sex Hurt During and After Menopause?

Menopause can be split into three distinct groups: perimenopause, menopause, and postmenopause. 

Perimenopause is often compared to puberty—but, according to Dr. Streicher, this isn’t quite right; while these transitions bookend the reproductive phase of a person’s life, it’s not a perfect analogy (unless postmenopausal people Benjamin Button back into children, but alas, this is not the case). 

Instead of hormones steadily ramping up, perimenopause is the period of time in which the ovaries are still making estrogen—but unreliably so. This is why Dr. Streicher refers to it as the “perimenopause rollercoaster.” Estrogen levels are fluctuating, so the menstrual cycle (if you have one) is often irregular, and people may start experiencing a variety of symptoms:

• Hot flashes

• Sleep disturbances

• Vaginal dryness

• Mood changes

On average, perimenopause lasts for about 4 years. 

Menopause is traditionally described as when someone hasn’t had a period in  12 consecutive months—buuuuut Dr. Streicher disagrees with this definition because at least 50% of people who were born with uteruses in the United States  don’t have periods pre-menopause. So what’s a better definition? Dr. Streicher says menopause is when the ovaries have stopped producing estrogen—either because the ovaries have been removed (this is called an oophorectomy) or because the ovaries have decided it’s time to retire. 

Postmenopause is exactly what it sounds like! It’s the time after menopause—and it usually means those major menopause symptoms peter off. But, as Dr. Streicher says, “You’re never done with menopause. You might be done with hot flashes, but the effects of lack of estrogen continue to escalate throughout your life.” And this isn’t meant to be daunting—postmenopause isn’t a disease, it’s just a new life stage that brings some new challenges.

Great question! Iiiiiit could be a lot of things. For many people, sexual pain around menopause is just a continuation of discomfort  experienced earlier in life—like vestibulodynia and pelvic floor muscle dysfunction. But for others, the pain begins during this new stage of life—and that’s what we’ll be talking about here. 

Sexual desire, arousal, and orgasm can also all be affected. This is in part because of hormones as well. The ovaries make estrogen, but they also make progesterone and testosterone—all of which have a hand in sexual function! Around menopause, we know estrogen pretty dramatically declines but progesterone decreases too. 

Testosterone also peters off, but this is more of a function of age rather than menopause itself. Anyway. Decreasing hormones = decreasing desire to participate in the horizontal mambo. On top of that, all those signs and symptoms we mentioned above can make it hard to feel sexy—pain and discomfort, leakage, and even the concept of aging itself can affect your bedroom headspace. 

People of any age can develop vulvar/vaginal skin conditions, but there are a few that are more common for peri- and post-menopausal people. 

Lichen (pronounced “liken”) sclerosus is a vulvar skin condition where the tissue becomes thinner, oftentimes with hallmark white splotches. This can cause soreness and itchiness, bleeding, and pain during sex. 

Lichen planus is similar to lichen sclerosus, except it more often appears inside and around the entrance to the vagina and the spots may appear more purple-ish (though this can really vary). This can also cause soreness and pain.

Scientists aren’t sure what causes these conditions, but they do know they aren’t contagious and occur more often in middle-aged people.

Postmenopausal people may be more affected by vulvar skin irritants (like some soaps). Lower estrogen can mean urinary incontinence and a compromised skin barrier, both of which can leave the vulva more susceptible to irritation.

Yeast infections are generally less common when estrogen is low, but if you’re taking HRT (hormone replacement therapy), then these infections can become more common.

Pelvic organ prolapse is when one or more of the pelvic organs (bladder, rectum, uterus) isn’t getting the support it needs and starts to slump downwards. This may occur in anywhere from  3 to  97% of postmenopausal people (wide range, we know lol), with pregnancy and birth being the biggest risk factors. 

For some people, this is a cause of pain or discomfort during penetrative sex because the pelvic organs might be experiencing a bit more “turbulence” since they’re hanging a little closer to the vagina.

First thing’s first, Dr. Streicher says you need to have an exam from a clinician who’s well-versed in sexual pain/sexual medicine. This will help you figure out what exactly is causing the pain so you can pursue the right treatment for you. There are a loooooot of different options out there, so it’s important to know what will actually be helpful for your unique body. 

Here’s a  directory of menopause practitioners that may be helpful for finding a clinician near you. If you’ve been to a health care practitioner before, but haven’t received any good treatment options, Dr. Streicher reassures, “Just because someone hasn’t given you a solution doesn’t mean there isn’t one.” 

So what are some potential  treatments for painful sex during/after menopause?

Hormones are a very common treatment option for addressing unpleasant changes surrounding menopause. When it comes to pain with sex, clinicians often recommend one or more of the following: 

• Estrogen cream: Applied directly to the vaginal tissues to restore moisture and reduce dryness.

• Vaginal rings: Slowly release estrogen over time for ongoing relief.

• Suppositories: Deliver estrogen intravaginally for targeted effects.

• Combination approaches: Often paired with dilators, lubricants, or pelvic floor therapy depending on symptoms.

These all work to treat vaginal dryness associated with loss of estrogen (and it work well and are very safe)—but it’s not the solution for all pain during sex associated with menopause, hence why it’s so important to get an exam by a qualified clinician.

Pelvic floor muscle dysfunction is super common for people pre-menopause—but it can also crop up around menopause too. If sex has started to become painful later in life, your body remembers—specifically, your pelvic floor remembers. A complex hammock of muscles that support your pelvic organs, the pelvic floor relaxes during arousal to accommodate penetration. But if sexy time has been less-than-comfy, those muscles may be reluctant to relax, which can then cause more pain around the opening of the vagina and further back inside the pelvis. 

This is where pelvic floor physical therapy comes in. Armed with a diverse knowledge of exercises, hands-on techniques, and tools like dilators, pelvic PTs can be incredibly helpful for treating pain associated with pelvic floor muscle dysfunction. 

Unfortunately there isn’t a lot of data on vaginal moisturizers, so the general recommendation is to patch-test the product on your body before using it intravaginally.