Menopause, Vaginal Dryness, and Painful Intercourse

For many women, talking about menopause and all the ways that it affects their lives is an awkward and uncomfortable topic in the best of times. So when it comes to talking about how menopause affects your sex life, the conversation might never be brought up at all.

But because it can be such an awkward topic, many women don’t seek help for menopausal vaginal dryness and, as a result, they suffer in silence.

It’s time to break that stigma: yes, menopause can lead to vaginal dryness and, subsequently, painful intercourse. But that doesn’t have to be the end of the story.

How Menopause Can Lead to Painful Sex

As you approach menopause, the hormones that control your reproductive cycle (estrogen, progesterone, and testosterone) begin to fluctuate and eventually decline, signaling the end of your ability to reproduce naturally. But because those hormones are responsible for everything to do with reproduction, it also means that your body begins to go through subsequent changes that can make it really hard on your sex life.

Vaginal discomfort is a very common symptom for menopausal women. The combination of vaginal symptoms, together with other changes happening in the vulva and bladder, has a name: genitourinary syndrome of menopause (GSM). It’s incredibly common: anywhere from 50-70% of postmenopausal women report experiencing GSM to some degree. However, it’s likely underdiagnosed because of how sensitive the subject is and how reluctant some women may be to bring it up with their healthcare providers.

The most common symptom of GSM is vaginal atrophy. This is a condition where the lining of your vagina, and the delicate skin of your vulva, become up to two thirds thinner. This means they can easily become irritated, inflamed and dry, due to a cascade of changes caused primarily by your decreasing estrogen levels.

In your fertile years, estrogen encourages blood flow to the vagina to support reproduction. This blood flow is important in keeping our vaginas healthy, stretchy, and lubricated. It also encourages glycogen deposition in the cells lining the vaginal walls: glycogen is a storage sugar that acts as food for lactobacillus bacteria that colonise a healthy vagina. This bacteria is really important to our vaginal health: it produces lactic acid, making our vagina a slightly acidic environment which discourages the over-growth of bacteria that might cause infections.

As you approach menopause, however, things start to change. Your estrogen levels can fluctuate wildly before eventually decreasing. This reduces blood sent to the area, making the vaginal tissues dryer, thinner, and more susceptible to inflammation and even microtraumas, like in the case of sexual intercourse. It also means we store less glycogen in our vaginal cells - so the lactobacillus numbers fall, increasing the vaginal pH and making us more prone to things like infections.

These changes can lead to itching and burning sensations in the vagina and vulva, and a change in our vaginal odour. Some of the other aspects of GSM include changes in the bladder: these can lead to incontinence and recurrent urinary infections. Some women find that urine leak can even occur during sex.

It’s not just the dryness, either: the vagina becomes less stretchy, too. Older women also have less sensory nerves in this area, and they are less able to respond to sexual touch: this means we may need more intense stimulus to respond to sexual touch like we used to. If we don’t do something about all this, over time, the erectile tissues of the clitoris can shrink too.

There are also other factors that could be at play decreasing pleasure during this life stage. For many women, the decrease in hormones also affects their libido. This doesn’t happen to all women, though: studies show that for some women, menopause brings a liberation and more sexual desire. The problem is though, that issues with pain tend to have a domino effect on ability to get aroused and climax - and if we stop expecting to enjoy sex, we pretty soon find we dont feel much like having it.

As if that’s not enough already, aging can also bring about other health issues like decreased mobility, aches, and pains. Many women also begin taking more medications to combat these health issues, which doesn’t help matters either: some medications can actually further reduce our libido and sexual response.

All of these factors combined can be hugely disruptive to having a healthy sex life.

Healthy Sex Lives During Menopause

It might seem like menopause has all the cards stacked against you when it comes to sexual intercourse. After all, there are so many other symptoms to contend with - mood swings, anxiety, and depression aren’t uncommon - and on top of that the physical realities of a decreased sex drive and vaginal dryness.

It’s no wonder that so many women feel hopeless and put off of sex for good.

It does not have to be the end of the story, though. Vaginal dryness, while painful and downright discouraging, can be addressed. If it’s getting in the way of your health and wellness, it’s always a good idea to check in with a doctor. It may be an awkward topic to bring up, but a medical professional can take a look at your particular symptoms, rule out other more serious conditions, and help you find ways to cope so that it doesn’t get in the way of your relationships and sex life.

The physical problems of GSM come about due to loss of oestrogen. So often the best way to prevent or reverse these changes is by considering using vaginal estrogen: it comes in many forms, from gels and rings to creams and pessaries. It has an excellent safety record and may even be suitable for some women with a personal history of breast cancer - your doctor can advise you further. Using estrogen locally helps to encourage improved blood flow back to the vagina and vulva, and also results in the return of the microbiome that is responsible for reducing the vaginal pH and preventing infection.

Not everybody wants to go down this route though, and that’s ok. There are other things you can do which can also help a little too.

These include

Check your diet

Certain vitamins can play a role in maintaining a healthy vagina, including Vitamins D and E. Foods and herbs with phytoestrogens, a plant-based compound similar to estrogen, may also help with less severe forms of vaginal atrophy.

There’s also evidence that some supplements can be helpful for vaginal dryness. DHEA, for example, is a hormone that can be taken orally or as a suppository or cream, and there’s evidence that it can help fight vaginal discomfort both in and out of the bedroom.

Using lubrication during sex

Some women find that using a personal water-based lubricant can greatly increase comfort and pleasure during sex. Oil based lubricants are another option: they can help trap moisture, and work well with water based on top during sex, providing a “double glide” effect.

Remember though, that oil based lubes rot condoms, so this isn’t an option if you are using these to prevent infection. It’s also worth knowing that sexually transmitted infections are easier to catch in the dryer, less infection-resistant, post menopausal vagina. So, if you’re in a new partnership, you mustn’t forget the condoms even though you may have stopped your periods and enjoying not worrying about contraception.

Lubricants can be a good solution for those who experience milder forms of vaginal dryness or discomfort, but it may not be a long-term solution for anyone whose discomfort extends beyond their sex life: this is where oestrogen or newer options like vaginal laser can work best.

Using vaginal moisturizers. Besides using lubrication when you’re actually having sex, you may also benefit from using other topical solutions. There are creams that you can apply to your vagina to keep it hydrated. It is also important to wash with cleansers rather than soaps, to avoid drying the delicate skin out further. Emollients are a good option for washing, even though it can feel strange when you’re used to lather!

Having regular sex

Having regular sex can be important for keeping your vagina healthy, even during menopause. This doesn’t have to mean sex with a partner - solo pleasure works fine here too. It’s also important to remember that good sex with a partner doesnt always need to include vaginal penetration to give you both satisfaction.

Regular sex and orgasms increase blood flow to your vagina. This can help to combat the effects of vaginal atrophy and keep the pleasure tissues in the clitoris healthy.

Don’t push it if it’s too uncomfortable, but do experiment to figure out what works best for you so that you can enjoy sex, not avoid it. Widen the definition of what “counts” as sex and intimacy. Consider toys which may help with arousal if you find you’re not as sensitive as you once were. Keep talking with your partner, and try to avoid gritting your teeth through pain - this can just set up a cycle of muscle spasm called vaginismus, which makes things even harder. Talk to your healthcare provider if you are struggling.

Final Thoughts On Menopause and Vaginal Dryness

Though lots of challenges can occur with menopause, it is important not to lose hope - if you are forewarned about what might happen, you can start to do something straight away. You don’t have to suffer. The first step to combatting vaginal dryness and painful sex is to open up and seek help. Vaginal atrophy is incredibly common, and there are a ton of remedies out there that can help bring relief.