Sex After Menopause Doesn't Have to Hurt

Genitourinary Syndrome of Menopause — or GSM — is the current medical term for the collection of vaginal, vulvar, and urinary symptoms caused by estrogen loss after menopause. It replaced the older term "vulvovaginal atrophy" in 2014 because the condition affects far more than just the vagina.

GSM affects up to 84% of postmenopausal women, yet fewer than half seek treatment — many because they don't realize it's a medical condition with effective solutions, or because they're embarrassed to bring it up.

When estrogen drops, the tissues of the vagina, vulva, and lower urinary tract undergo significant changes. The vaginal walls become thinner (sometimes just a few cells thick, compared to the healthy 20–40 cell layers of premenopausal tissue), less elastic, and more fragile. Natural lubrication decreases dramatically. The vaginal pH rises from its normal acidic range (3.5–4.5) to above 5.0, which disrupts the protective lactobacillus bacteria and increases susceptibility to infections.

Symptoms include vaginal dryness, burning, and irritation; pain during intercourse (dyspareunia); light bleeding after sex; reduced vaginal elasticity; urinary urgency, frequency, and recurrent UTIs; and changes in the external appearance of the vulva.

The critical difference between GSM and other menopausal symptoms: hot flashes and night sweats typically peak and then gradually improve over years. GSM does the opposite — it's progressive. Without treatment, symptoms worsen over time as the tissues continue to thin and lose blood supply. This makes early intervention particularly important.

Treatment for GSM follows a stepped approach, from over-the-counter options to prescription therapies, and many women benefit from combining strategies.

For mild symptoms, start with over-the-counter vaginal moisturizers used regularly (2–3 times per week, not just during sex). Products like Replens, Hyalo GYN, or other hyaluronic acid-based moisturizers rehydrate vaginal tissue and help maintain a healthier pH. These are different from lubricants — moisturizers are used routinely for tissue health, while lubricants are used during sexual activity.

Water-based or silicone-based lubricants during intercourse reduce friction and discomfort. Avoid products with glycerin, parabens, or warming/cooling additives, which can irritate sensitive postmenopausal tissue. Silicone-based lubricants tend to last longer and don't dry out.

For moderate to severe symptoms, vaginal estrogen is considered the gold standard. Available as a cream (Estrace, Premarin), tablet (Vagifem/Yuvafem), ring (Estring), or insert (Imvexxy), vaginal estrogen restores tissue thickness, elasticity, lubrication, and healthy pH. The key reassurance: vaginal estrogen acts locally with minimal systemic absorption. Blood estrogen levels remain in the normal postmenopausal range, making it safe for most women.

Prasterone (Intrarosa), a vaginal DHEA insert, is a newer prescription option that works by converting to both estrogen and testosterone locally in vaginal tissue. It's an alternative for women who prefer not to use estrogen directly.

The most important thing: these symptoms are not something you need to "just live with." Treatment works, and the sooner you start, the easier it is to restore tissue health.

Vaginal estrogen has an excellent safety profile and is fundamentally different from systemic hormone therapy. This distinction matters because many women — and some healthcare providers — conflate the two, leading to unnecessary avoidance of an effective treatment.

When you apply estrogen vaginally (cream, tablet, ring, or insert), the vast majority stays in the local tissue. Studies consistently show that blood estrogen levels in women using low-dose vaginal estrogen remain within the normal postmenopausal range. This means the systemic risks associated with oral or transdermal HRT (such as blood clots or breast cancer concerns) do not apply in the same way.

The FDA still requires a black box warning on vaginal estrogen products — the same warning used for systemic HRT — but both NAMS and ACOG have stated that this warning is not supported by the evidence for low-dose vaginal preparations. In 2023, an FDA advisory committee voted to recommend reclassifying some low-dose vaginal estrogen products for over-the-counter access.

For women with a history of breast cancer, the situation is more nuanced. Many oncologists now allow ultra-low-dose vaginal estrogen (especially the ring or 10-mcg tablet) for breast cancer survivors, particularly those not on aromatase inhibitors. However, this should always be an individual discussion between you, your oncologist, and your gynecologist.

Vaginal estrogen can be used indefinitely — there's no recommended time limit. Benefits persist as long as treatment continues, and symptoms return when it's stopped. Most women notice improvement within 2–4 weeks, with full benefits by 12 weeks.

Yes — pelvic floor physical therapy (PFPT) is one of the most underutilized and effective treatments for painful sex after menopause, and it addresses components that estrogen alone doesn't fix.

During and after menopause, the pelvic floor muscles can become hypertonic (overly tight) as an involuntary guarding response to pain or discomfort during intercourse. This creates a cycle: pain causes muscle tension, muscle tension makes penetration more painful, and increased pain triggers even more guarding. Over time, some women develop vaginismus — an involuntary tightening of the vaginal muscles that makes penetration extremely difficult or impossible.

A pelvic floor physical therapist can assess your muscle tone, identify trigger points, and develop a treatment plan that may include manual therapy (internal and external), myofascial release, progressive vaginal dilator training, biofeedback to retrain muscle coordination, breathing and relaxation techniques, and home exercises.

PFPT is particularly valuable in combination with vaginal estrogen. While estrogen restores tissue health, physical therapy addresses the muscular and neuromuscular components of pain. Many women find that combining both treatments produces better results than either alone.

To find a qualified pelvic floor PT, look for one with specific training in pelvic health (often listed as WCS — Women's Health Clinical Specialist or CAPP-Pelvic certification). Your gynecologist can provide a referral, and many states allow direct access without a referral. Insurance increasingly covers pelvic floor PT, though coverage varies.

You deserve pain-free intimacy. This is a medical issue with medical solutions, not an inevitable consequence of aging.

Yes — regular sexual activity (with a partner or solo) has been shown to help maintain vaginal health after menopause, and the science behind this is straightforward.

Sexual arousal increases blood flow to the vaginal tissues, which supports oxygenation, nutrient delivery, and tissue elasticity. Regular activity also helps maintain vaginal muscle tone and flexibility. Studies have found that sexually active postmenopausal women have thicker vaginal walls, better lubrication, and lower rates of vaginal atrophy compared to those who are not active.

This doesn't mean you should push through painful sex — that's counterproductive and can worsen the guarding response described above. The goal is comfortable, pleasurable activity. If intercourse is painful, start with other forms of intimacy and use lubricants, moisturizers, or vaginal estrogen to restore comfort first.

Solo sexual activity (masturbation with or without a vibrator) provides the same tissue-health benefits as partnered sex. Vibrators can be particularly helpful for increasing blood flow to the area and maintaining sensitivity, especially when used with a lubricant.

Vaginal dilators are another option — medical-grade graduated dilators used gently and progressively can help maintain or restore vaginal capacity and elasticity, particularly if you've had a long gap without sexual activity.

The key principle: your vaginal tissues respond to the "use it" signal the same way your muscles respond to exercise. Regular, gentle engagement maintains function. But if pain has already set in, treat the underlying cause first (atrophy, pelvic floor tension, or both) before expecting activity alone to resolve the issue.

Bringing up sexual pain can feel vulnerable, but remember: your doctor has had this conversation many times, and they need you to raise the topic because most won't ask first. A 2016 survey found that only 40% of ob-gyns routinely ask postmenopausal patients about sexual function.

Here's a straightforward way to start: "I've been experiencing pain (or dryness, or discomfort) during sex since menopause, and I'd like to discuss treatment options." That single sentence gives your doctor the clinical framing they need. You can also write it on your intake form if saying it feels difficult.

Be specific about your symptoms: When did they start? Is the pain at the vaginal opening, deeper inside, or both? Is it during penetration, with movement, or after? Do you have dryness, burning, or itching outside of sex? Have you tried any over-the-counter products? This information helps your doctor distinguish between GSM, pelvic floor dysfunction, and other potential causes.

If your doctor dismisses your concerns with "that's just part of aging" or seems uncomfortable discussing it, you have every right to advocate for yourself or seek another provider. A menopause specialist (look for NAMS-certified practitioners at menopause.org) or a sexual medicine specialist will be well-versed in these treatments.

Important: painful sex after menopause is a medical symptom with evidence-based treatments. You are not being "high-maintenance" for wanting to address it. Sexual well-being is a recognized component of overall health by the WHO, and you deserve a provider who treats it that way.