Why does sex after menopause hurt?

The hormone estrogen helps keep tissue in the vagina elastic and lubricated. As a woman’s estrogen levels decline with age, her vaginal walls become thinner and dryer — just like the skin on her hands. 

“Women tell me it can feel like sandpaper during intercourse,” Dr. Kagan says. And because the vagina and bladder share a common wall of tissue, some women also develop a leaking bladder or painful urination.

This problem is called the genitourinary syndrome of menopause (GSM). And while hot flashes usually go away after menopause, GSM only gets worse if left untreated.

How can a woman avoid painful sex?

“There are so many good options. GSM is totally reversable,” says Dr. Kagan. Try these tips to make sex more enjoyable.

• Talk with your doctor to make sure you don’t have an infection or another problem.
• Keep your vagina moist and lubricated during intercourse. Some women use a vaginal moisturizer like hyaluronic acid once or twice a week for general comfort. Dr. Kagan suggests using a silicon-based lubricant before sex. They last longer and rarely cause irritation.
• Consider taking vaginal estrogen, like low-dose estrogen creams, tablets or rings. While many women are understandably wary about taking estrogen after menopause, vaginal estrogen is safe because it doesn't travel to other areas of the body. The landmark Nurses' Health Study found that vaginal estrogen didn't increase the risk of heart disease or cancer.

Are there any homemade solutions?

Coconut oil is popular with many women, Dr. Kagan says. It’s a thicker, pasty oil. Women can apply it to their vagina or make little suppositories from it, freeze them and later insert them into their vaginas. The body’s natural warmth thaws them.  

Why don’t more women know about these solutions?

“Women don’t bring it up and clinicians don’t ask about it,” says Dr. Kagan. Women may be embarrassed to discuss painful sex. Too many clinicians focus primarily on hot flashes. Yet “it’s rare that a woman doesn’t have any symptoms of GSM,” she says. 

Dr. Kagan would like to see every gynecologist and general practitioner educate women about this issue before a woman’s last menstrual period. 

“The burden’s on us,” she says. Doctors routinely ask about a patient’s diet and exercise. “It’s time to start having open conversations about aging sex. There’s no reason people can’t have sex for as long as they live.”