When Sex Gives You More Pain Than Pleasure

As menopause hits, estrogen levels drop, and what often follows is dryness and thinning of the vaginal tissues. The uncomfortable symptoms can include a sensation of tightness, dryness and severe pain or burning—hardly a sexy scenario.

A dry vagina is not only bothersome but can mean painful sex, a common complaint of as many as 46 percent of postmenopausal women. And the numbers are likely higher, because many women feel a stigma or are too embarrassed to talk about it.

Medically known as dyspareunia, this pain—which can happen before, during and after sex—may develop as a result of the vaginal dryness, known as vulvovaginal atrophy. It also may have other psychological or physical causes, including vaginismus or genital injury. Vulvovaginal atrophy—the thinning, drying and inflammation of vaginal tissues—is common around menopause, due to declining levels of estrogen.

Whatever the cause, vaginal pain can put a strain on the best of relationships, sap self-esteem and affect a woman's quality of life.

The consequences can reach far beyond painful sex itself. Fearing pain, women may involuntarily tense their vaginal muscles or avoid or refrain from sex altogether, further complicating matters.

Fortunately, there are treatments, which sometimes require a multifaceted approach.

1. Low-dose vaginal estrogen. Vaginal estrogens are also known as estradiol and contain the same type of estrogen your body makes. It helps by restoring vaginal blood flow and improving the vaginal tissue's thickness and elasticity. Because the estrogen goes directly into the vagina, there's less risk of side effects than with oral estrogen, as it won't raise the circulating blood levels of estrogen significantly. Vaginal estrogen is available in two creams (Estrace Vaginal Cream and Neo-Estrone or Premarin Vaginal Cream), a tablet (Vagifem), or a vaginal ring (Estring). Newest to the market is Imvexxy, an applicator-free vaginal insert that comes in two doses. The North American Menopause Society advises using the lowest effective dose to limit side effects, which are rare but can include headache, nausea, breast pain or vaginal burning or pain. Although the American College of Obstetricians and Gynecologists (ACOG) says that there's no increased risk of cancer recurrence among women who are being treated for breast cancer or those with a history of it, this group of women is still advised to discuss the risks and benefits with their health care professionals.
2. Lubricants. These come in liquid or gel form and are applied directly to the vagina or vulva (the outer part of the vagina) before or after sex to ease pain from dryness. Lubricants work by reducing friction and can also be applied to a partner's penis prior to intercourse. Lubricants go to work immediately and are not absorbed into the skin, providing temporary relief from dryness and painful sex. Lubricants are available over-the-counter and may be water-, silicone- or oil-based. Be aware that oil-based lubricants like petroleum jelly or baby oil can cause vaginal irritation and may cause breaks in latex condoms.
3. Moisturizers. Designed to be applied regularly (not just prior to sex), moisturizers have longer-term effects than lubricants and can last for up to four days. They're absorbed into the skin and cling to the vaginal lining, which helps with vaginal comfort because they mimic its natural moisture and acidity.
4. Pelvic floor physical therapy. Although this is relatively new and hasn't been studied extensively, experts point to its safety and effectiveness. Physical therapists can noninvasively loosen tight tissues in the pelvic area using massage and gentle pressure and teach exercises to strengthen pelvic floor muscles.

Other strategies that can help manage dyspareunia include counseling and self-care. Treat your vagina gently: Use mild soap or plain water to wash yourself and pat, rather than rub, dry. Steer clear of products that contain perfumes (like bubble baths or douches) that may be irritating. Wear combatable-fitting cotton underwear, which is more breathable and wicks away moisture, and avoid tight-fitting clothing.