Q. Can I have comfortable intercourse again?
A. You say you're four years past menopause, and, in addition to hot flashes and other symptoms, you have dryness and have had vaginal atrophy—a decrease in the size of your vaginal opening.
This is a classic symptom of genitourinary syndrome of menopause (GSM, earlier called vulvovaginal atrophy). Without estrogen, the vaginal tissues become thin and fragile, and the vagina can shorten and narrow.
Read more about how your vagina changes at midlife.
Vaginal moisturizers, which you say you're using, are of some benefit. They're better at prevention, though—started during perimenopause or early in menopause. Once atrophy is advanced, they're less helpful and may be irritating, as you've experienced.
The most likely effective treatment is localized estrogens like the most recently approved lmvexxy, which is a vaginal insert. There are also localized estrogens available in cream, ring, or tablet form. Something like Osphena (oral and non-estrogen) or Intrarosa may also be used. You say you like to avoid chemicals, and I understand that; estrogen is a natural chemical, and the local application is to replace what your body used to produce naturally in the way that has the fewest side effects. Osphena and Intrarosa work like a hormone, even though they aren't one.
These are all prescription therapies and a necessary component of your plan to counter the effects of vulvovaginal atrophy, which is chronic and progressive.
Once the tissues are healthier, you may need to use vaginal dilators to regain increased "capacity" (patency, in medical terms) of the vagina.
Whenever there is pain involved, that problem needs to be addressed first. Once you've achieved physical comfort, you may find a sex therapist helpful if issues remain, as your gynecologist suggested. In the meantime, no one should blame you for not wanting to have painful sex!
A number of the things you say are very familiar to me: you've had plenty of natural lubrication and you've never had issues with intercourse.
The unfortunate reality is that menopause changes the game, more dramatically for some of us than others. What was true for the younger you is no longer the case (ask me about menopausal weight gain!). But! I know how important intimacy is to relationships, and if you're willing to make the effort, it's almost always possible to regain function and comfort.
Read Blogger Judy Freedman's take on Drying Up in Menopause.
Barb DePree, MD, has been a gynecologist for 30 years, specializing in menopause care for the past 10. Dr. DePree was named the Certified Menopause Practitioner of the Year in 2013 by the North American Menopause Society. The award particularly recognized the outreach, communication and education she does through MiddlesexMD, a website she founded and where this blog first appeared. She also is director of the Women's Midlife Services at Holland Hospital, Holland, Michigan.
