How to End Painful Sex and Dryness During Menopause

Menopause happens. It is inevitable.

At some point in your 40s or 50s, your period will stop and your reproductive hormone levels will drop. This drop in hormone levels causes changes in your body. Some of these changes are silent like bone loss. Other changes are more obvious and symptomatic like hot flashes. Lying somewhere in between these two extremes are the changes that happen below your belt.

Although menopause causes changes to your vulva, vagina, urethra, and bladder that cause you significant discomfort and distress, you may not feel comfortable talking about it. And worse, your healthcare provider may not ask you.

The symptoms associated with the changes of menopause in these parts of your body are collectively called the genitourinary syndrome of menopause (GSM). The evidence suggests that up to 50 percent of menopausal women experience GSM although this number is likely higher due to underreporting.

A woman talking to her doctor
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So, What's Going on Down There?

Your vulva, vagina, urethra, and bladder (your lower genitourinary tract) are very sensitive to the drop in your hormone levels that come with menopause. Specifically, it is the drop in your estrogen level that causes changes in how your lower genital tract looks, feels and functions.

Your Vulva

Interestingly enough, it is thought that the origin of the word vulva is from Latin meaning "wrapper" or "a covering". Your vulva, which is often mistakenly referred to as your vagina, is an entirely separate part of your anatomy. It is made up of several distinct structures including your labia, your clitoris, the opening of your urethra and the opening of your vagina.

You have two separate labia or skin folds that function to protect the more delicate structures of your vulva. The outer labia majora is larger and contains fat cells or adipose tissue as well as hair follicles and acts as a protective cushion for the more delicate structures of your vulva. The labia minora lies just inside the labia majora. It contains multiple glands that produce secretions that provide lubrication adding to the protective function of this structure.

One of the (very) sensitive structures protected by your labia is your clitoris. As you hopefully know, your clitoris has one, and only one important function in your body. Containing around 8,000 nerve endings, touch sensation typically results in sexual pleasure. In other words, your clitoris plays a vital role in your sexual functioning. Your clitoris is protected by your labia and also an additional layer of skin known as the clitoral hood or prepuce.

Now let's look at your menopausal vulva.

The drop in estrogen levels or the hypoestrogenic state of menopause causes some pretty significant changes to your vulva. First, you lose the fat pad in your labia majora causing a decrease in the volume or size of your labia. Without adequate estrogen, there is also a thinning and shrinkage of the labia minora which then fuses to your labia majora. As the labia minora thins out it also produces less protective secretions.

This loss of padding and lubrication exposes the more sensitive underlying structures like your clitoris and the opening of your vagina to chaffing, irritation, and trauma.

And if that isn't bad enough, in some women the clitoral hood can also thin out, shrink or even fuse together. These changes often cause sex to be painful and can lead to a decreased interest in sex. But in some women, these changes are so significant that it causes an increased sensitivity and chronic clitoral pain not associated with sex.

Your Vagina

Like your vulva, menopause brings unpleasant changes to your vagina as well.

For starters, your vagina is lined with a special type of skin tissue that is composed of three layers. The top most or superficial layer is very sensitive to estrogen. During your reproductive years, normal estrogen levels keep your vaginal lining thick and well lubricated by building up this superficial layer and promoting normal secretions. This allows the vagina to resist trauma and promotes elasticity or the ability of the vagina to stretch and recover. Think childbirth.

With the drop in estrogen or the hypoestrogenic state of menopause, the vagina begins to atrophy. Vaginal atrophy causes the walls of the vagina to become thin and dry losing their elasticity and lubrication. This atrophic vaginal lining may cause itching or burning. Sex may become painful. These changes can also cause your vagina to tear easily even from normal minor trauma like sex or a pelvic exam. Vaginal atrophy leads to a narrowing of the vaginal opening and eventually can result in narrowing of your entire vagina.

Your Bladder

There is some debate over whether the menopausal changes to your lower urinary tract (bladder and urethra) are hormone or age-related. But there is evidence to support that low estrogen levels do contribute to the urinary tract problems of menopause.

Your bladder and urethra ( the tube that carries urine out of your bladder) are rich in estrogen receptors. Just like your vulva and vagina when your estrogen levels drop in menopause, these tissues lose their volume and elasticity. Your bladder may not expand like it used to, and you may find yourself needing to go to the bathroom more frequently. You also may notice that you dribble or drip urine occasionally just when you finish urinating.

Urinary tract infections can also be more common in menopause. The low estrogen levels create changes in the vagina that increase the concentration of UTI-causing bacteria. Also, the thinned-out lining of your urethra makes it easier for the bacteria to get into your bladder.

Soothe the Symptoms

If you have mild symptoms of GSM or if you want to avoid using any hormone-based treatments, you could consider using a vaginal lubricant or moisturizer. These products are available over the counter at your pharmacy, online or at specialty stores.

Vaginal lubricants are the best choice if you are having pain with sex. Since your vagina does not self-lubricate as well as it did before menopause, using a vaginal lubricant will help decrease the friction, pain, and trauma that can be associated with sexual activity. They work immediately. Their effect is short acting and may need to be reapplied as necessary. There are three types of vaginal lubricants:

  • Water-based - Water-based lubricants are safe to use with latex condoms and are non-staining. However, some water based lubricants contain glycerin which can be irritating and may increase your risk of yeast infections. If you choose a water-based lubricant, avoid those containing glycerin.
  • Silicone-based - Silicone-based lubricants are safe to use with latex condoms but they can stain fabric. They are longer acting than water-based lubricants and maintain their effect in the water.
  • Oil-based - Oil-based lubricants are not safe to use with latex condoms as they can cause the latex condom to break down increasing the risk of exposure to sexually transmitted infections. You should not use petroleum jelly, baby oil, or regular body lotion as a lubricant as they contain potentially irritating and harmful chemicals and have been shown to increase your risk of vaginal infections. However, you could try using a more natural oil like olive oil or coconut oil as a lubricant especially if you are sensitive to additives or dyes.

Unlike vaginal lubricants, vaginal moisturizers are used to improve some of the symptoms of GSM not related to sex. These moisturizers work by trapping moisture in the tissues and providing longer relief of your symptoms. Vaginal moisturizers are usually applied daily to improve the dryness and irritation caused by vulvovaginal atrophy. Olive oil and coconut oil may also be used as vaginal moisturizers.

Replace What's Missing

Where lubricants and moisturizers soothe the symptoms of GSM, hormone-containing products actually improve the blood flow and return thickness and elasticity to your vagina. In other words, they correct the problem rather than just treat the symptoms of GSM. Although taking systemic hormones in the form of the pill or the patch can reduce vaginal atrophy, most products with the best results are applied directly into the vagina.

Estrogen-containing products: Applying estrogen directly to the vaginal tissues is a very effective treatment for GSM. Usually, you will see significant improvement in your symptoms within a few weeks. There are a few different formulations of topical estrogen for vaginal use which include:

  • Vaginal cream - Typically, vaginal creams are used once a day for a few weeks then one to two times a week for maintenance treatment.
  • Vaginal ring - Vaginal rings are sustained release and are placed in the vagina for 3 months at a time.
  • Vaginal tablet - Vaginal tablets are used on a schedule much like vaginal creams but tend to be a bit less messy.

Selective Estrogen Receptor Modulator: SERMs are a class of synthetic hormones that both act like estrogen and block estrogen activity in different parts of your body. An example of a SERM is tamoxifen which is a powerful anti-estrogen used to treat breast cancer but also causes hot flashes and vaginal dryness. A newer SERM ospemifene has been shown to be an effective treatment for GSM and has FDA approval to treat the symptom of painful sex associated with GSM. However, even though early studies suggest an anti-estrogen effect in breast tissue similar to tamoxifen, there is not enough data to recommended its use in women with a history of breast cancer.

Vaginal DHEA: Another option for the treatment of GSM is a hormonal precursor to estrogen called prasterone. Prasterone or DHEA is FDA approved to treat the symptoms of GSM. It is a vaginal insert that is used daily. Once in the vagina, the hormone DHEA is converted into estrogen by the cells in your vagina. Early studies suggest that because estrogen is produced inside and then used directly by your vaginal cells, there is no absorption of estrogen into your bloodstream. This is an important point for women in whom estrogen may not be safe to use.

Your Vagina: Use It or Lose It

Believe it or not, staying sexually active in menopause helps maintain a healthy vagina.

Regular sexual activity actually increases blood flow to your vaginal tissues. This increase in blood flow helps to promote vaginal health and maintain some of the elasticity and thickness of the vagina. And, you shouldn't be afraid to take things into your own hands, literally. Direct clitoral stimulation through masturbation or use of a vibrator is an excellent way to encourage blood flow.

Even if you are taking a break from having sex, you need to maintain your vaginal health. When it comes to your vagina you really do need to use it or you will lose it.

A Word From Verywell

The menopausal drop in estrogen brings many changes to your body. Some of these changes are unpleasant and you may choose to seek treatment for them, like the symptoms associated with the genitourinary syndrome of menopause. These symptoms are common and easily treated with a variety of options available. Don't be ashamed to discuss these symptoms with your healthcare provider. Together, you and your healthcare provider can make a treatment plan that will help you live well during your menopausal years.

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3 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Merck Manual Consumer Version. Menopause. Updated December 2019

  2. Kagan R, Kellogg-spadt S, Parish SJ. Practical Treatment Considerations in the Management of Genitourinary Syndrome of Menopause. Drugs Aging. 2019;36(10):897-908. doi:10.3109/13697137.2015.1124259

  3. Kagan R, Kellogg-spadt S, Parish SJ. Practical Treatment Considerations in the Management of Genitourinary Syndrome of Menopause. Drugs Aging. 2019;36(10):897-908. doi:10.1007/s40266-019-00700-w

Additional Reading
  • Management of Menopausal Symptoms. Practice Bulletin No. 141. American College Of Obstetricians and Gynecologists. Obstet and Gynecol 2014; 123: 202-216.