Sexual Wellness Resource Center
For Adults over 50.

Painful sex

By Michael Bates, M.D.

Painful intercourse is called dyspareunia. The word is derived from the Greek word dyspareunos, which means “badly mated!”

 Over my 35 years of practice, when menopausal patients talked to me about painful sex, it was mostly a problem of lack of lubrication and vaginal dryness. Other symptoms included:

  • pain when touching the vaginal opening.
  • pain, either at the vaginal opening with initial penetration, or deep pain with full penetration
  • post coital itching, burning, or soreness
  • post coital burning with urination
  • post coital spotting or bleeding

For the majority of the patients it was a new problem, they had had a history of comfortable sexual functioning before menopause. For others it came after hysterectomy, or pelvic reconstruction for a dropped bladder or uterus, or after pelvic radiation. For still others it came with resumption of sexual activity after many years of inactivity.

What causes this problem? For the majority of cases it is due to vaginal atrophy, the drying and thinning of vaginal tissues secondary to the fall of estrogen levels as women approach, experience and pass through the menopause, the last menstrual period. Other factors can be at play:

  • pelvic floor muscular relaxation (dropping of the bladder and/or the uterus)
  • pelvic floor muscular spasm (vaginismus) with worry about pain
  • vulvodynia (stinging, burning, irritation, rawness or pain on the tissue surrounding the vaginal entrance, with or without touch),
  • dermatological conditions

How common is this problem? Between 17% and 45% of postmenopausal women find sex painful, according to The North American Menopause Society, only 25% of these women seek treatment. In an international survey of 391 women by the Women’s Sexual Health Foundation, fewer that 9% of women said their doctor had ever asked if they had sexual problems. 

Diagnosis is via history and pelvic exam. This may be followed by an ultrasound, especially if the pain is with deep penetration, or if there is an abnormality (mass or unusual tenderness) discovered with the bimanual exam.

The good news is that dyspareunia caused by vaginal atrophy is very treatable and one of the best treatments doesn’t even involve medicine! The more often you have sex, the less likely you are to develop atrophy. That is because sex increases blood flow to the genitals, keeping them healthy. That is the same theory for the recommendation of the use of vibrators for sexual dysfunction treatment and for vaginal rehabilitation following radical gynecologic surgery or pelvic radiation therapy.

For medical treatment, topical low-dose vaginal estrogen is the gold standard, even if one is already taking systemic estrogen therapy. Its targeted effect reverses vaginal atrophy, increases vaginal blood flow and promotes lubrication. Topical treatment only releases little estrogen into the bloodstream, so it has minimal systemic effects.  With informed consent, patients with contraindications to systemic estrogen use (history of breast cancer or stroke) can also safely benefit from topical treatment.

Other treatments, depending on diagnosis:

  • Non hormonal lubricants (Replens) and moisturizers. Lubricants are applied just prior to sex, moisturizers are applied regularly.
  • Lidocaine, a numbing agent applied to the vaginal opening before and after sex.
  • Pelvic floor therapy, a relatively new tactic using physical therapy to reduce tightness and improve muscle function.

So what is the take-home message? Your vagina does not have to atrophy with age, painful sex is a very treatable problem. Talk to your partner. Talk to your doctor, if she or he is not knowledgeable in this area, ask for a referral to a specialist, usually an interested, sympathetic gynecologist or a urogynecologist.

 References

 Dolgen, Ellen, All pain, no gain? Put an end to painful sex during menopause, www.huffingtonpost.com

 Kao, Alina, PhD, Candidate, Binik, Yitzchak M, PhD, Kapuscinski, Anita, BA, Khalifé, Samir, MD, Dysparunia in postmenopausal women: A critical review, www.ncbi.nim.nih.gov

 Madsen, Pamela, Your vagina will not turn to stone, www.huffingtonpost.com

 Westbrook, Leslie A., How to deal with a new partner after a ‘dry spell,’http://www.nextavenue.org

 What causes painful sex after the menopause? www.healthywomen.org

 When sex gives more pain than pleasure, www.health.harvard.edu

 

 

 

 

About the Author

Michael Bates, M.D.

Dr Bates practiced obstetrics and gynecology for 34 years in Wichita, Kansas, until his retirement in 2011.

You might also enjoy...

Masturbation
Masturbation, facts, not myths

By Michael Bates, M.D.

woman and man
Why do women stop having sex?

By Michael Bates, M.D.