Sexual Wellness Resource Center
For Adults over 50.

Vaginal Dryness & Painful Intercourse: Causes and Solutions

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By Michael Bates, M.D.

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"Doctor, sex has become painful and I'm just losing interest," said a recently menopausal patient in my office one day.

She wasn't alone. Between 17% and 45% of postmenopausal women find sex painful, according to The North American Menopause Society. A different study published by the American Academy of Family Physicians puts that number at up to 20% of American women. However, the numbers may be much higher, as many women don't seek treatment, and doctors too often do not bring up the topic.

In my OB/GYN practice, for the majority of patients this was a new problem. They had a history of comfortable sexual functioning before menopause. For others it came after a hysterectomy, radical pelvic surgery, or pelvic radiation. For still others it came with the resumption of sexual activity after many years of abstinence.

What causes this problem? In the majority of cases it is due to vaginal atrophy—the drying and thinning of vaginal tissues due to the fall of estrogen levels before, during and after the menopause.

The good news is that this is very treatable. Whether you are experiencing vaginal dryness and painful intercourse yourself, or your partner is, this article is meant to give you a deeper understanding, hope and, most importantly, a starting place to find the right solutions.

The most common cause of vaginal dryness: a drop in estrogen levels due to menopause

Estrogen is the female hormone produced by the ovaries. As the menopause (the last menstrual period) nears, hormone production declines. This decrease is gradual in some and abrupt in others, which explains why some women experience more symptoms than others.

Less estrogen causes the tissues of the vagina to become thinner, drier and less elastic. The vagina produces fewer secretions, resulting in decreased lubrication of the vaginal walls. This condition is called vaginal atrophy (atrophic vaginitis).

Possible symptoms include:

  • Vaginal itching, burning, soreness and irritation
  • More frequent bladder infections
  • Painful intercourse (dyspareunia)
  • Post coital (after sex) burning with urination
  • Post coital spotting or bleeding

Are there other potential causes of vaginal dryness?

Yes.

1. Not enough foreplay prior to intercourse

With sexual excitement and arousal, the vagina naturally produces lubrication in preparation for intercourse ("getting wet"). A lack of sufficient foreplay can result in inadequate lubrication. This can happen at any age, but it's important to remember that as we get older, it can become more common. This is due to reduced blood flow to the genitals, which makes them less sensitive. Longer, stronger stimulation is needed for arousal and orgasm—just at the time in our lives when fatigue and hand or wrist arthritis can make giving that stimulation more difficult!

Partners may need to adjust their sexual routines to include a longer warmup period before intercourse or even before touching the vulva. The use of personal lubricants can help a lot—I'll cover that in a bit. There are sexual aids (sex toys) that can help, too. Clitoral pumps draw more blood flow into the vulva area, increasing sensitivity. Vibrators provide the strong, consistent stimulation needed for arousal and orgasm, and relieve weakened or arthritic wrists and hands. Our article on Sex Toys for Women outlines the different types of vibrators and even gives recommendations.

2. Certain medications (prescription and over-the-counter)

There are also medications that can contribute to vaginal dryness, including some antidepressants, antihistamines and birth control pills. This is something to discuss with your doctor. He or she may be able to prescribe an alternate medication or adjust the dosage.

3. Surgery and certain cancer treatments

Surgery, hysterectomy, pelvic radiation, chemotherapy, and certain hormone therapies used in cancer treatment can cause vaginal dryness. So can anti-estrogen medications used after the diagnosis of breast cancer, endometriosis, and fibroid tumors. Let your doctor know that your sex life is important to you, and that you want to find a solution that will keep sex comfortable without interfering with the treatment of your underlying condition.

4. Smoking

5. Douching

Douching can dry out the vagina and flush out the good bacteria it needs to prevent infection. The vaginal canal is self-cleaning—douching is not necessary.

6. Stress

Don't underestimate the effect of stress. Stress can manifest itself in a number of physical symptoms, vaginal dryness being one.

More About Painful Intercourse (Dyspareunia)

"Dyspareunia" derives from the Greek word "dyspareunos," which means "badly mated!" Individuals with dyspareunia may experience pain either at the vaginal opening with initial penetration, or deep pain with full penetration. They may also experience pain not only inside the vagina, but on the clitoris and/or labia. Even touching the vaginal opening may cause pain.

Vaginal dryness and atrophy is one possible cause of painful intercourse, and the main focus of this article. In my OB/GYN practice, this was the cause in the majority of cases. However, there are other potential factors:

  • pelvic floor muscular relaxation (dropping of the bladder and/or the uterus)
  • involuntary pelvic floor muscular spasm (vaginismus), which can make penetration difficult, painful or impossible
  • vulvodynia (stinging, burning, irritation, rawness or pain of the tissue surrounding the vaginal entrance, with or without touch)
  • dermatological conditions
  • Sexually transmitted infection (STI)

Not all causes of painful intercourse are purely physical. Some are emotional, relational and/or psychological. There may be a combination of physical and psychological factors. For example, vaginismus can be caused by the fear of pain, shame or other negative feelings surrounding sex, sexual trauma, and other complex factors. Stress, anxiety and depression can put the damper on arousal and even contribute to vaginal dryness and vaginismus. Treatment typically involves both physical therapy (kegel exercises and/or the use of vaginal dilators) and counseling to address the underlying stressors, negative feelings and/or trauma.

Menopause may result in vaginal dryness, but that doesn't mean sex after menopause has to be uncomfortable or painful.

Here is the good news. Menopause does not mean the end of your sex life! Sex is not only possible but also pleasurable and healthy for the majority of women throughout their senior years. It does, however, require some changes.

Let's get back to my patient. She had taken the right first step—seeing her doctor. We talked about lack of lubrication, pain during insertion, post intercourse irritation and vaginal burning. She answered "yes" to all of the questions. The exam followed and the skin of the vaginal opening was pale, speculum insertion was uncomfortable, and the external and internal tissues appeared thin and dry—classic findings of vaginal atrophy.

Though it did not apply to this patient, who could be diagnosed via history and a pelvic exam, an ultrasound may be necessary if there is pain with deep penetration or if there is an abnormality (mass or unusual tenderness) discovered with the exam.

Vaginal atrophy is easily and successfully treated in the vast majority of patients. Estrogen is the gold standard of treatment, in either oral or topical form. If the symptoms are only vaginal (ie painful sex), topical estrogen in the form of creams, tablets, rings or suppositories can take care of the problem. Its targeted effect reverses vaginal atrophy, increases vaginal blood flow and promotes lubrication. Topical treatment releases little estrogen into the bloodstream, so it has minimal systemic effects. If there are also symptoms including hot flashes, night sweats or poor sleep, systemic treatment may be better. This can be done using pills, patches or skin creams. You and your doctor will come up with the right plan for you.

Other treatments for vaginal atrophy and/or painful intercourse, 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

After you have seen your doctor, what more can you do?

1. Share your problem with your partner and work together to find solutions.

With aging, it's normal to take longer to become aroused and reach orgasm. You both may need a longer warmup period before intercourse or genital touching. Practice foreplay, foreplay and more foreplay! Consider adding a sex toy to relieve tired fingers and hands, and to increase the intensity of stimulation. Our article on Sex Toys for Seniors offers a buying guide to make choosing your first toy (or second, or tenth!) easier.

2. Explore and enjoy outercourse.

"Outercourse" means sex that doesn't involve penetration, including "making out," caressing, manual stimulation and oral sex.

You and your partner may need to stick to non-penetrative sexual activity until the estrogen has had time to take effect or other therapies are working to permit comfortable, pain-free intercourse.

However, you'd do well to think of outercourse not as a temporary substitute for "real sex" but as real sex. Real, wonderful, intimate, satisfying sex! See our Beginner's Guide to Enjoying Outercourse.

Sex, both penetrative and non-penetrative, is also good for vaginal health. 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.

3. When comfortable, it is important to resume vaginal penetration.

Penetration helps keep the vaginal lining thicker, the vaginal opening from becoming smaller, and the vagina from becoming shorter and narrower. The penetration can be with a penis, a sex toy such as a dildo, or with vaginal dilators. Vaginal dilators can play a crucial role in helping maintain the vagina for comfortable sexual function. See our article here for more information.


Inspire Silicone Dilator Training Set (5 Piece)

from: Lovehoney Ltd

4. Lubricants are your friends.

Even if you are taking estrogen, you need to use personal lubricants, and use them generously. This goes for any kind of penetrative sexual activity, but lubricants can make masturbation, manual sex, and vibrators feel better, too. A dry vulva can make stimulation feel scratchy and irritating instead of pleasurable; lubricants take care of that problem by reducing friction. Feeling wet can also add to sexual excitement and arousal.

It is important to use personal lubricants that are designed for sexual activity. Oil-based lubricants like petroleum jelly, baby oil and mineral oil are not recommended for sexual use. They have a thick, greasy or oily feeling and can cause condom damage.

Sex lubricants come in two main categories: water-based and silicone-based. Silicone-based lubricants feel quite natural and stay slippery longer than water-based. That means they don't need to be reapplied as often. However, they can't be used with silicone sex toys, and sex toys of some other materials, too. The sex toy you buy will usually specify what kind of lubricant to use; if it doesn't, play it safe with a water-based lube.

Keep lubricant on hand during all sexual activity. Rather than thinking of applying lubricant as a chore before you can get to the fun, find ways to make the process itself fun.


Sliquid Organics Natural Lubricant 8.5 fl. oz

What is the take-home message?

  • Changes to your sex life and sexual functioning are normal with aging. If symptoms of vaginal dryness and painful intercourse develop, they can be successfully treated.
  • Keep having sex. Sexual stimulation promotes vaginal health.
  • The pleasure and intimacy of sex are important in relationships and they don't have to be discarded with age.
  • Finally, as we have talked about many times on these pages, sex is good for your health.

As per our Terms of Use, this article is for general educational and informational purposes only and is not meant to serve as a substitute for professional medical advice. Consult with your own physician or health care practitioner regarding the use of any information received here before using or relying on it. Your physician or health care practitioner should address any and all medical questions, concerns and decisions regarding the possible treatment of any medical condition.

References

Vaginismus, www.myclevelandclinic.org

Seehusen, Dean A., MD, MPH, Baird, Drew C., MD, Bode, David B., MD, Dyspareunia in women, www.aafp.org

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