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 menopause symptoms are more obvious, like hot flashes. Lying somewhere between these two extremes are the changes that happen below your belt.

Although menopause causes changes to your vulva, vagina, urethra, and bladder, potentially causing 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% of menopausal women experience GSM, although this percentage is likely higher due to underreporting.

GSM may affect your sex life, hindering your natural ability to self-lubricate, which can lead to vaginal dryness and painful intercourse. But don't worry; there are things that you can do to ease such symptoms. This article discusses how menopause affects your body and what you can do to alleviate symptoms of GSM.

A woman talking to her doctor
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Menopausal Changes

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, the drop in your estrogen, also known as the hypoestrogenic state of menopause or hypoestrogenism, 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." The vulva is often referred to as your vagina, but it is actually its own separate 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. It 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 to protect the area from dryness and irritation.

One of the (very) sensitive structures protected by your labia is your clitoris. As you may know, your clitoris, which contains 8,000 nerve endings that respond to touch sensation, has one particular function in your body: sexual pleasure.

In other words, your clitoris plays a vital role in your sexual functioning, or the stages of sexual desire, arousal, and orgasm. 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 causes 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. Rarely, it may fuse to your labia majora. As the labia minora thins out, it also produces less protective secretions. In some women, the clitoral hood can also thin out, shrink, or even fuse together.

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.

These changes often cause sex to be painful and can lead to a decreased interest in sex. Sometimes, changes can be so significant that it causes 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 topmost or superficial layer is very sensitive to estrogen. During your reproductive years, normal estrogen levels keep your vaginal lining thick and well lubricated.

This allows the vagina to resist trauma and promotes elasticity (i.e., the ability of the vagina to stretch and recover), which can be helpful in childbirth and sex.

The drop in estrogen can cause the walls of the vagina to become thin and dry (referred to as vaginal atrophy), losing their elasticity and lubrication, which may make sex painful. Vaginal atrophy can also lead to a narrowing of the vaginal opening. These changes may cause the vagina to tear easily from normal minor trauma like sex or a pelvic exam.

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. Like your vulva and vagina, these tissues lose their volume and elasticity when your estrogen levels drop in menopause.

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 (UTIs) 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.

Vaginal Dryness Treatments

If you have mild symptoms of GSM or if you want to avoid using hormone therapy, you could consider using a vaginal lubricant or moisturizer. These products are available over the counter at your pharmacy, online, or in 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 they 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 effectiveness in water.
  • Oil-based: Oil-based lubricants are not safe to use with latex condoms as they can cause the latex to break down, increasing the risk of exposure to sexually transmitted infections. You should not use petroleum jelly, baby oil, or regular body lotion products as a lubricant. These products contain potentially irritating and harmful chemicals 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 vaginal atrophy. Olive oil and coconut oil may also be used as vaginal moisturizers.

Menopausal Hormone Therapy

Although lubricants and moisturizers soothe the symptoms of GSM, hormone-containing products can improve vaginal blood flow and estrogen production, returning 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 in the vagina.

Estrogen-containing products: Applying estrogen directly to the vaginal tissues is an 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 two 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 three months at a time.
  • Vaginal tablet: Typically, vaginal tablets are inserted into the vagina once daily for two weeks. After the initial two weeks, one tablet is inserted twice a week for maintenance treatment.

Estrogen and Cancer

Research suggests that taking oral estrogen alone increases the risk of endometrial cancer (cancer of the uterus) for women who have a uterus, in addition to ovarian cancer. There is also an increased risk of breast cancer if estrogen is taken in combination with progestin.

But research shows that forms of hormonal therapy inserted in or applied to the vagina can decrease such risks as estrogen is not absorbed into the bloodstream.

More research in this area is needed, but this is an important point for women for whom estrogen pills may not be safe to use, such as those with a prior history of breast cancer.

Selective estrogen receptor modulators (SERMs): SERMs are a class of synthetic hormones that both act like estrogen and block estrogen activity in different parts of your body. These hormones are emerging as an alternative to estrogen. An example of a SERM is tamoxifen, which is a powerful anti-estrogen used to treat breast cancer but that also causes hot flashes and vaginal dryness.

Specifically, a newer SERM known as ospemifene is an effective treatment for GSM and is FDA-approved to treat the symptom of painful sex associated with GSM.

However, although early studies suggest an anti-estrogen effect in breast tissue similar to tamoxifen, there is not enough data to recommend its use in women with a history of breast cancer.

Vaginal DHEA: Prasterone is a manmade version of the hormone that produces estrogen, known as dehydroepiandrosterone (DHEA). Prasterone, often referred to as vaginal DHEA, is FDA-approved to treat GSM symptoms. 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.

Using Your Vagina Helps

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

Regular sexual activity increases blood flow to your vaginal tissues and can maintain some of the elasticity of the vagina. And, you shouldn't be afraid to take things into your own hands, literally.

Direct clitoral stimulation through masturbation or the use of a vibrator is an excellent way to encourage blood flow. Kegel exercises can strengthen your pelvic floor muscles and encourage vaginal blood flow as well. Even if you are taking a break from having sex, there are ways to maintain your vaginal health.

Summary

Many women experience menopausal symptoms like vaginal dryness, itchiness, and irritation that can make sex painful. Vaginal lubricants are common products used to reduce dryness and friction and ease such symptoms.

Hormonal-based pills, creams, and inserts like topical estrogen and vaginal DHEA can be a more effective measure of treatment to improves vaginal blood flow and estrogen production.

A Word From Verywell

Don't be ashamed to discuss symptoms of GSM with your healthcare provider. These symptoms are common and easily treated with a variety of options available. Together, you and your healthcare provider can make a treatment plan to help you live well during your menopausal years.

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