What is dyspareunia

Painful intercourse can occur for reasons that range from structural problems to psychological concerns. Many women have painful intercourse at some point in their lives.

The medical term for painful intercourse is dyspareunia, defined as persistent or recurrent genital pain that occurs just before, during or after vaginal intercourse.

There are many causes of dyspareunia including physical ones like not enough lubrication, a skin infection, illness or surgery. Psychological causes like partner issues, stress and anxiety can contribute also and make it even worse. Talk to your doctor if you’re having painful intercourse. Getting a diagnosis of what is causing the pain can help you to know what treatment might be best for you. Treatments focus on the cause, and can help eliminate or lessen this common problem.

If you have dyspareunia or painful intercourse, you might feel:

• Pain only at sexual entry (penetration)
• Pain with every penetration, including putting in a tampon
• Deep pain during thrusting
• Burning pain or aching pain
• Throbbing pain, lasting hours after intercourse

Dyspareunia or painful sexual intercourse can be caused by many things, such as:

• illness
• infection
• a physical problem
• a psychological problem

If you get pain during or after sex, your body may be trying to tell you something is wrong, so don’t ignore it. See your doctor or go to a sexual health clinic.

If you find talking about it embarrassing, remember that doctors are used to dealing with problems like this.

Painful sexual intercourse can affect both men and women.

Painful intercourse in women

Women can experience pain during or after sex, either in the vagina or deeper in the pelvis (deep dyspareunia).

Pain in the vagina could be caused by:

• An infection: thrush or a sexually transmitted infection (STI), such as chlamydia, gonorrhea or genital herpes
• The menopause: changing hormone levels can make your vagina dry
• Lack of sexual arousal at any age
• Vaginismus: a condition where muscles in or around the vagina shut tightly, making sex painful or impossible
• Genital irritation or allergy caused by spermicides, latex condoms or products such as soap and shampoo

Pain felt inside the pelvis (deep dyspareunia) can be caused by conditions such as:

• Pelvic inflammatory disease (PID)
• Endometriosis
• Fibroids growing near your vagina or cervix
• Irritable bowel syndrome (IBS)
• Constipation

Painful intercourse in men

Some causes of dyspareunia for men are:

• Infections like thrush, which can cause soreness and itching, and some sexually transmitted infections (STIs), such as herpes
• If the foreskin is tight, penetration can be painful, as the foreskin is pushed back
• Small tears in the foreskin that can’t be seen but cause soreness and a sharp, stinging pain around the tear
• Inflammation of the prostate gland (prostatitis)
• Testicle pain and swelling can sometimes be caused by getting sexually aroused but not ejaculating (coming). It can also be a sign of an infection, such as chlamydia.

What to do

If you have pain during or after sex, you should get advice from your doctor or a sexual health clinic. They can assess what’s causing the problem and whether you need any treatment. For example:

• if you have pain, unusual discharge, itchiness or soreness around your genitals, they may recommend treatment for thrush or having an sexually transmitted infection (STI) test
• if your vagina is dry, you may be advised to try using a lubricating product – remember to use a water-based product if you’re using condoms, because oil-based lubricants can damage them and make them ineffective
• if you have an allergy or irritation around your genitals, you may be advised to avoid using products that could be causing it
• if there’s an emotional reason or anxiety that’s causing problems, a counselor or sex therapist may be able to help – your doctor or sexual health clinic can refer you to one

Types of dyspareunia

There are two main types of dyspareunia, which are classified according to where the pain is.

Superficial dyspareunia

This is pain on attempted penetration, which may be the result of:

• size disparity: the erect penis is too large for the vaginal entrance (as a result of menopausal changes or dermatological conditions)
• prolonged use of depot medroxyprogesterone acetate (‘Depo’) contraception (interferes with the body’s naturally produced oestrogen)
• an intact or thickened hymen (the membrane that partially covers the vaginal entrance)
• vaginismus: spasm of the pelvic floor muscles that causes temporary narrowing of the vagina
• sexual arousal disorders
• infections (Candidia ablicans, Trichomonas vaginalis, genital herpes)

Deep dyspareunia

This is pain at the top of the vagina often experienced with thrusting. Pain can include burning, tearing or aching sensations. This pain may be the result of a pelvic disease, such as endometriosis, ovarian cysts or pelvic inflammatory disease from sexually transmissible infections such as chlamydia or gonorrhea.

Dyspareunia causes

There are many physical and psychological causes of dyspareunia.

Physical causes of painful intercourse differ, depending on whether the pain occurs at entry or with deep thrusting.

Emotional factors might be associated with many types of painful intercourse.

Entry pain

Pain felt at the vaginal entry may be caused by:

• Not enough lubrication. This is often the result of not enough foreplay. A drop in estrogen levels after menopause or childbirth or during breast-feeding also can be a cause. Certain medications are known to affect sexual desire or arousal, which can decrease lubrication and make sex painful. These include antidepressants, high blood pressure medications, sedatives, antihistamines and certain birth control pills.
• Injury, trauma or irritation. This includes injury or irritation from an accident, pelvic surgery, female circumcision or a cut made during childbirth to enlarge the birth canal (episiotomy).
• Inflammation, infection or skin disorder. An infection in your genital area or urinary tract can cause painful intercourse. Eczema or other skin problems in your genital area also can be the problem.
• Vaginismus. These involuntary spasms of the muscles of the vaginal wall can make penetration painful.
• Congenital abnormality. A problem present at birth, such as the absence of a fully formed vagina (vaginal agenesis) or development of a membrane that blocks the vaginal opening (imperforate hymen), could cause dyspareunia.

Lubrication

When a woman is sufficiently aroused (‘turned on’), her vagina and glands around the vaginal entrance secrete fluids that reduce friction and allow penetration without pain. If you are not sufficiently aroused before attempting penetration, you may feel dry and experience a stinging, burning, tearing or throbbing sensation.

Inflammation, infection or skin disorder

The skin of the vulva (external parts of the female genitals) is extremely delicate, making it vulnerable to a wide range of conditions.

Sometimes part of the vulva, or sometimes the entire vulva, has some of the following:

• Redness
• Swelling
• Burning
• Itching
• Cracking
• Splitting (fissuring)
• Whitening of skin (leukoplakia)
• Discharge

Vaginismus (spasms)

Penetration may be painful for some women because the muscles in the vagina spasm. This creates a feeling of painful tightness that makes penetration painful, difficult and at times impossible.

Deep pain

Deep pain or deep dyspareunia usually occurs with deep penetration. It might be worse in certain positions. Causes include:

• Certain illnesses and conditions. The list includes endometriosis, pelvic inflammatory disease, uterine prolapse, retroverted uterus, uterine fibroids, cystitis, irritable bowel syndrome, constipation, hemorrhoids and ovarian cysts.
• Surgeries or medical treatments. Scarring from pelvic surgery, including hysterectomy, can cause painful intercourse. Medical treatments for cancer, such as radiation and chemotherapy, can cause changes that make sex painful.

Surgery or medical treatments

Scars from surgery in the pelvic area can cause painful sex.

Emotional factors

Sometimes dyspareunia begins as a physical problem but also affects your mental wellbeing and relationships, causing stress and anxiety.

Emotions are deeply intertwined with sexual activity, so they might play a role in sexual pain. Emotional factors include:

• Psychological issues. Anxiety, depression, concerns about your physical appearance, fear of intimacy or relationship problems can contribute to a low level of arousal and a resulting discomfort or pain.
• Stress. Your pelvic floor muscles tend to tighten in response to stress in your life. This can contribute to pain during intercourse.
• History of sexual abuse. Not every woman with dyspareunia has a history of sexual abuse, but if you have been abused, it can play a role.

It can be difficult to tell whether emotional factors are associated with dyspareunia. Initial pain can lead to fear of recurring pain, making it difficult to relax, which can lead to more pain. You might start avoiding sexual intercourse if you associate it with the pain.

Painful intercourse after menopause

The hormonal changes that occur at menopause result in a range of symptoms, including hot flushes, mood changes and sexual symptoms. While most of the symptoms of menopause are temporary, sexual symptoms such as low libido, pain during intercourse (dyspareunia) and vaginal dryness often persist if they are left untreated. Sexual symptoms are natural and normal, but they may cause distress for some women. They would benefit from speaking with their doctor about treatments to help them maintain or improve sexual function during and after menopause.

Most women report symptoms of menopause which have the potential to affect their sex life. The majority (75%) report problems with vaginal lubrication, 28% report dyspareunia (pain during sex) and 15% either vaginal itching, irritation or pain. The stage of menopause at which women experience these symptoms differs and they tend to be more common as the post-menopausal period increases. For example, 30% of women report vaginal symptoms in the early stages of menopause compared to 47% in the later stages of menopause.

Urogenital symptoms, including increased frequency or urgency of urination and pain when urinating may also be reported and indirectly affect women’s sexual function. Women are 2-3 times more likely than men to experience reduced libido as they age.

Most women experience changes in the way sex feels around the time of menopause. Changes to sexual feeling reported by menopausal women commonly include:

• Vaginal dryness;
• Dyspareunia (pain during sex);
• Vulvo-vaginal itching; and/or
• Vulvo-vaginal irritation.

Women may also experience a reduction in the size of their breasts and decreased nipple sensation.

Urogenital symptoms may make sex uncomfortable or painful or reduce a woman’s libido. While many women experience reduced libido following menopause, it is important to note that some feel sexier and freer about their sexual interactions.

It is also important to note that many women who do experience changed sexual feelings do not feel these changes affect the quality of their sex life, and many women continue to enjoy sex after menopause despite it feeling different. It is also important for menopausal women to be cognisant that sexual feelings change differently for each woman. While the majority report reduced sexual desire, a considerable proportion also report increasing desire post-menopause. For example, in one qualitative study, a quarter of participants reported that their libido increased after menopause.

Women may also experience changes in the way particular aspects of sex feel, for example the intensity with which they experience orgasm. However, the direction of change varies between women, with some women experiencing more intense and others less intense orgasms. It is important to note that in many cases these changed sexual feelings are not perceived by women as related to the hormonal and physiological changes of menopause. Rather women are more likely to perceive these changes occur as a result of changing sexual partners or techniques (e.g. masturbation rather than intercourse).

In around one third of couples, changes to the male partner’s sexual function (e.g. the woman’s partner may begin to experience erectile dysfunction as he ages) is the cause of female sexual dysfunction post-menopause.

There is clearly diversity in the changes women experience following menopause and many factors other than hormonal changes influence sexual feelings. Nevertheless, there is also considerable evidence that hormonal factors do influence the feeling of sex post-menopause.

Why do sexual feelings change after menopause?

Hormonal changes

Sexual feelings change in the peri-menopausal period and persist post-menopause due to hormonal changes. Prior to menopause, the ovaries produce the majority of estrogen, progesterone and testosterone in a woman’s body. As ovarian hormone production ceases post-menopause, estrogen, progesterone and testosterone levels decline.

Estrogen (and to a lesser degree progesterone) largely regulate vaginal function (in particular blood flow to the vagina in response to physical stimulation and vaginal lubrication), while testosterone affects the functioning of the vulva. Reduced hormone levels in the menopausal period therefore affect the function of the vagina and vulva.

Physiology of the vagina

The vagina is a complex structure, consisting of several layers, a fibrous outer layer or rough skin cells, a middle muscular layer and smooth inner layer of skin cells known as the epithelium. The majority of the body’s cells which utilize and have their function regulated by oestrogen and progesterone are found in the vagina. The cells of the vulva comprise the majority of the body’s cells which utilize and are regulated by testosterone.

In the pre-menopausal period when levels of estrogen and other hormones are high, the vagina is characterized by:

• Relatively high blood flow;
• A thicker epithelium, that is a thicker layer of smooth skin cells;
• Greater acidity; and
• Increased lubrication.

The changes to hormone production which occur at menopause, and particularly the rapid decline in estrogen production, cause the skin and muscles cells of the vagina and vulva to deteriorate.

The physiology of the vagina changes and the vaginal walls, which are often only a few cell layers thick, become thinner. Their appearance and texture also changes. Post-menopause, the vaginal walls become pale, smoother and less elastic due to degeneration of the connective tissue components of the vagina (e.g. collagen, smooth muscle) which usually give them their elasticity. In addition the vagina typically becomes shorter and narrower as a result of hormonal changes which occur at menopause.

Reduced estrogen levels may also affect a woman’s sexual response indirectly. In the post-menopausal period, many women experience vasomotor symptoms (e.g. hot flushes) which may cause insomnia, irritability and reduced skin sensitivity. These in turn, may affect a woman’s sexual desire.

Vaginal lubrication also reduces in the menopausal and post-menopausal period. The vagina produces less natural lubricant and also takes longer to begin producing lubrication in response to sexual stimulation. As a result of decreased lubrication the vagina is more likely to become dry, which increases the risk of trauma (e.g. cuts or grazes) during sexual activity.

Vaginal blood flow also reduces as a result of the hormonal changes which occur at menopause. Reduced blood flow causes the vulva to be less sensitive to touch. It also further affects vaginal lubrication as in the absence of adequate vaginal blood flow during sexual activity, the amount of lubricant which passes out of the vaginal membrane to lubricate the vaginal walls also decreases. This further increases the likelihood of vaginal dryness and trauma.

The vaginal environment becomes less acidic in the post-menopausal period as a result of physical changes (e.g. changes to the shape and texture of the vagina) and reduced glycogen production which occurs as a result of hormonal changes. This in turn reduces concentrations of lactic acid producing lactobacilli, microorganisms which colonise the vaginal tract pre-menopause and maintain an acidic vaginal environment. The acidity of the vaginal tract in the pre-menopausal period provides considerable protection against infection. With increasing alkalinity the vagina becomes more susceptible to infection, as microorganisms which could previously not survive in the acidic vaginal environment can more easily colonise the vaginal tract.

Non-hormonal factors

In addition to hormonal changes there are a range of other factors which may affect a woman’s sexual function at menopause. However, these factors are not specific to menopause and may also affect women’s sexuality at other stages of life.

A woman’s libido and sexual response are highly contextual and heavily influenced by psychosocial factors, that is, factors relating to the psychological health and social context. As a result, many women with biologically and physiologically normal genital systems experience sexual dysfunction. Such sexual dysfunctions may become more prevalent at menopause, because of the significant psychological and social changes which also occur in a woman’s life at this time. For example, a menopausal woman’s ageing partner may experience sexual dysfunction which can significantly affect the woman’s sexual function, or the woman may be coping with upheavals such as changes to her maternal role because of her children leaving home.

A woman’s satisfaction with her sexual relationship and her psychological wellbeing also have an important influence on her sexual desire in the menopausal period. One large study found that having positive feelings for their partner and good psychological health were more important predictors for a woman having a good libido in the post-menopausal period than hormone levels. A study of 438 Australian women also reported that psychosocial factors (including previous sexual function, partner change and satisfaction with sexual partner) had a more important influence on sexual response than estrogen levels (although estrogen levels were correlated with sexual function).

Other non-hormonal factors which may influence sexual function include:

• Emotional wellbeing, including the presence or absence of psychological disorders such as depression and anxiety;
• Emotional satisfaction with the relationship;
• Satisfaction with previous sexual encounters;
• Fatigue;
• Medication use, in particular use of antidepressant medications;
• Thyroid disorder;
• Hyperprolactinaemia (elevated blood prolactin levels).

Dyspareunia diagnosis

A medical evaluation for dyspareunia usually consists of:

A thorough medical history. Your doctor may ask when your pain began, exactly where it hurts, how it feels, and if it happens with every sexual partner and every sexual position. Your doctor may also inquire about your sexual history, surgical history and previous childbirth experiences.

Don’t let embarrassment stop you from giving candid answers. These questions provide clues to the cause of your pain.

A pelvic exam. During a pelvic exam, your doctor can check for signs of skin irritation, infection or anatomical problems. He or she may also try to identify the location of your pain by applying gentle pressure to your genitals and pelvic muscles.

A visual exam of your vagina, using an instrument called a speculum to separate the vaginal walls, may be performed as well. Some women who experience painful intercourse are also uncomfortable during a pelvic exam, no matter how gentle the doctor is. You can ask to stop the exam at any time if it’s too painful.

Other tests. If your doctor suspects certain causes of painful intercourse, he or she might also recommend a pelvic ultrasound.

Dyspareunia treatment

Treatment options vary depending on the cause of the pain.

Medications

If an infection or medical condition contributes to your pain, treating the cause might resolve your problem. Changing medications known to cause lubrication problems also might eliminate your symptoms.

For many postmenopausal women, dyspareunia is caused by inadequate lubrication resulting from low estrogen levels. Often, this can be treated with topical estrogen applied directly to the vagina.

The Food and Drug Administration approved the drug ospemifene (Osphena) to treat moderate to severe dyspareunia in women who have problems with vaginal lubrication. Ospemifene acts like estrogen on the vaginal lining, but doesn’t seem to have estrogen’s potentially harmful effects on the breasts.

Drawbacks are that the drug might cause hot flashes, and it carries a risk of stroke, blood clots and cancer of the lining of the uterus (endometrium).

Another drug to relieve painful intercourse is prasterone (Intrarosa). It’s a capsule you place inside the vagina daily.

Other treatments

Certain nonmedication therapies also might help with dyspareunia:

• Desensitization therapy. You learn vaginal relaxation exercises that can decrease pain.
• Counseling or sex therapy. If sex has been painful for some time, you might have a negative emotional response to sexual stimulation even after treatment. If you and your partner have avoided intimacy because of painful intercourse, you might also need help improving communication with your partner and restoring sexual intimacy. Talking to a counselor or sex therapist can help resolve these issues. Cognitive behavioral therapy can also be helpful in changing negative thought patterns and behaviors.

Painful intercourse after menopause treatment

Sexual functioning in the menopausal period, as at other times of life, is influenced by a broad range of factors, including:

• Biological factors: For example, characteristics of the woman’s physical body, hormone levels, and illness or medication use;
• Psychosocial factors: Including the quality of a woman’s intimate and social relationships, her psychological health, and social upheavals such as children leaving home; and
• Sexual factors: Such as the quality of the woman’s previous sexual experiences, and her partner’s sexual function.

There is convincing evidence that the hormonal changes that occur at menopause alter the physiology of the female sexual organs (such as the shape and texture of the vagina) and alter sexual response (the amount of vaginal lubrication produced when sexually aroused). But other factors also have an important influence on sexual function, such as the quality of an intimate relationship, previous sexual experience, mental wellbeing and satisfaction with her partner. Some studies have found that these factors are more important as predictors of whether or not a woman will experience menopausal sexual dysfunction than hormone levels.

There are several strategies that can help women overcome negative factors influencing their sexual function. Maintaining good physical health, addressing any emotional issues which may inhibit sexual function, and engaging in regular, varied sexual activity are some important aspects of maintaining sexual function after menopause.

Non-hormonal therapies

Non-hormonal vaginal lubricants

In many cases non-hormonal vaginal moisturizers (e.g. water based lubricants) are sufficient to relieve symptoms, in particular vaginal dryness. These products are usually recommended to relieve symptoms before other treatments, which involve greater side effects are trialed. Water-based lubricants are usually recommended as they are more effective than oil-based lubricants such as petroleum jelly.

Psychological therapies

Sexual dysfunctions can cause distress and other psychological problems including mood changes, depression and anxiety. Existing psychological problems (e.g. depression) may also contribute to difficulties with sexual function. It is therefore often useful to involve women’s partners in the treatment of post-menopausal sexual dysfunction, and it is recommended that both partners be interviewed alone and as a couple in the assessment of these problems.

Couples with interpersonal issues in their relationship may benefit from consulting a specialist for assessment and treatment (e.g. couples therapy or sex therapy). It may also be important to assess the male partner’s sexual function, as male sexual dysfunction often undermines the female partner’s functioning.

Psychological interventions may also assist menopausal women to cope with other stressors in their life which influence the severity of menopause symptoms, such as stress in the workplace, or dealing with children leaving home.

Sexual training

It may also be important for the couple to learn new sexual techniques. Learning and normalizing the use of non-penetrative sexual techniques can be important for women experiencing pain during intercourse, as pain typically worsens when women persist with intercourse when experiencing pain. In other cases, couples may benefit from increasing foreplay before vaginal penetration is attempted, and it may be important to learn sexual techniques which involve greater vulval and clitoral stimulation.

Sexual permissiveness training may also be important, to teach the couple to be happy about their sexuality. As ageing individuals are not typically perceived as sexual in many societies, couples may feel guilty about sex as they age, or not be aware that they can still have a fulfilling sex life.

Physical health

A healthy body is a good foundation for a healthy sex life. It is therefore important that menopausal women take measures to improve their overall health. Health professionals will be able to offer comprehensive advice about maintaining good physical health after menopause. Women should begin by ensuring that they:

• Eat a healthy balanced diet;
• Exercise regularly;
• Get enough sleep; and
• Avoid harmful substances, including nicotine and alcohol.

Psychosocial health

Psychosocial factors are factors relating to the individual’s psyche and social situation. They include things like a person’s emotional health, the support available to them, and the dominant values and beliefs of the society where they live. Psychosocial factors influence many aspects of an individual’s health.

Psychosocial factors also influence a woman’s sexual function. Menopause is a time when women experience significant social upheaval and are more likely to experience psychological issues. It is therefore important for women to consider how psychosocial factors may be affecting their sex life, and implement strategies to alleviate any negative influences on sexual function.

Take care of your mental health

Menopause is a time of significant social upheaval as well as bodily changes. It is also a time when women may be busy with work or family commitments, and some women may not take enough time out to relax and recuperate. Time for relaxation is important for emotional health. If you are having difficulty finding time to rest and relax, you may wish to try:

• Setting aside some time, just for yourself;
• Taking time out to do something special, either alone or with friends or family;
• Identify roles in life (such as being a mother, worker or friend) and whether these are important or fulfilling. It’s also important to think about any new roles you would like to take on in the menopausal period, for example becoming a volunteer or joining an interest group, if you have extra time on your hands;
• Surround yourself with family members and friends who you trust and whom you can talk to; and
• Consider talking to a health professional, especially if you feel depressed or anxious.

Address issues in your intimate relationship

Women who are satisfied with their intimate relationship and partner are less likely to experience sexual dysfunction during and after menopause. Relationship issues such as a lack of trust may contribute to sexual dysfunction. Women in long-term relationships are more likely to experience low sexual desire. It is therefore important that women with issues in their relationship address these, for example by seeing a relationship counselor.

Think about how other relationships may be affecting your sexual feelings

Menopause is a time when women may face significant changes in family relationships. For example, it is often a time when children leave home, or when more time is dedicated to caring for ageing parents. These may affect a woman’s libido or sexual desire. For instance, women caring for aged parents might experience reduced sexual desire because they are tired. Women whose children leave home may experience psychological issues such as reduced self-esteem because of their changing maternal role, which may in turn influence the woman’s sex life.

Have a positive attitude to menopause

Having a negative attitude towards menopause has been shown to increase the likelihood of menopausal symptoms. Women who see menopause as a crisis rather than the start of a new phase of life are more likely to experience symptoms.

Try to focus on the positive aspects of menopause. For instance, some women report a feeling of freedom after menopause, because they do not have to worry about menstrual bleeding.

Improve your self-esteem

Low self-esteem can affect libido and sexual function. It is important to address any issues of self-esteem. Try to:

• Focus on the good, not the bad;
• Identify achievements you have made throughout your life and focus on these if you feel low;
• Challenge unrealistic expectations, for example about your body shape or the ageing process;
• Set realistic goals;
• Join an interest group or do volunteer work.

Be positive about your body

Menopause is a time of significant physical changes, and women may feel uncomfortable or unconfident about the changes occurring in their bodies, particularly if they gain weight. Changes to body shape and weight gain are normal experiences for ageing women. Women should not compare themselves to unrealistic ideals (e.g. younger women’s bodies) and should be aware that the changes they are going through are normal.

Menopausal women can also take positive actions to ensure optimal physical health, for example engaging in regular, moderate-intensity exercise and eating healthy nutritious food.

Sexual factors

Menopausal women should therefore consider how a range of sexual factors might be influencing their sexual function in the menopausal period.

Investigate treatments to relieve sexual symptoms

There are a range of treatments for relieving the sexual symptoms of menopause. The safest and most effective treatment option depends on the range of menopausal symptoms the woman is experiencing. Discuss treatment options with your doctor.

Beware of sexually transmitted infections

Although women no longer have to worry about contraception after menopause, sexually transmitted infections (STIs) still present a risk. The vagina is more susceptible to small abrasions and grazes after menopause compared to before menopause, so the risk of sexually transmitted infections may also increase.

Consider the influence of your sexual partner

Women may experience reduced sexual function with menopause. As men age, their sexual function may also deteriorate. Conditions such as testosterone deficiency (hypogonadism) and erectile dysfunction are more common amongst older men. Having a great sex life takes two, and the sexual function of a woman’s partner influences her own sexual function.

Don’t blame yourself

Good sex takes two, and sexual problems may stem from one or both partners. Changes such as low libido are only issues if they are perceived to be such, so don’t feel bad simply because your sexual feelings have changed.

Assess your partner’s sexual function

Think about how it might influence your sexual function. Identify any factors such as health issues which may be affecting your partner’s sexual performance.

Involve your partner in treatment

Even if a partner has no obvious sexual dysfunction, they can be part of the solution. Involving your partner in the process of treating your sexual dysfunction can help them understand the changes you are going through.

Talk to your sexual partner

Partners are not mind readers and will not experience things in the same way as you. Some partners may even avoid sex for fear of hurting you. It’s important to let your partner know how you’re feeling, the changes you’re going through and how these affect your sex drive.

Talk to a health professional

Talking to a health professional, either alone or with your partner, can be an important part of resolving menopausal sexual difficulties for some women. Counseling can help women increase their awareness of menopause and provide reassurance that what’s happening to them is normal. Your doctor can ensure that there are no systemic health issues which may be causing the sexual symptoms. A sex therapist may also provide emotional support for couples wishing to improve their sex life.

Keep having sex

Regular sexual activity increases vaginal elasticity (which typically reduces in the menopausal period) and may reduce the sexual symptoms of menopause. If you don’t have a partner, don’t worry.! Self-stimulation (masturbation) is equally effective for increasing vaginal elasticity and lubrication.

Think about sex

The brain plays an important role in regulating sexual desire, and thinking about sex can make you feel like having sex.

Dedicate time to being intimate

Don’t wait for intimacy to occur spontaneously. Take a weekend away, or dedicate some time to being intimate with your partner.

Try something different

Engage in a range of sexual activities, including non-penetrative sex. Women who don’t feel like vaginal penetration or who experience pain on intercourse should think about a range of other ways they can obtain sexual pleasure. These might include:

• An intimate massage;
• Caressing;
• Oral sex;
• Using sexual lubricants;
• Using sexual enhancement products, including erotic films and sex toys.

Herbal or natural therapies

While herbal (often termed natural) therapies are more commonly applied to the treatment of hot flushes, they may also be used to treat menopause-related sexual dysfunction. However, there is currently insufficient evidence to determine whether or not these remedies are an effective treatment. Their use is not currently recommended for the treatment of sexual symptoms of menopause.

Red clover isoflavones (oestrogens which occur naturally in plants) have been used to treat sexual symptoms. It has shown a positive effect on vaginal tissue. However, further research regarding their effectiveness in relieving vaginal dryness or libido is warranted.

Lycopodium clavatum (also known as Wolf’s foot) is a homeopathic remedy used to treat sexual symptoms of menopause. There is little evidence available on its efficacy.

Hormonal therapies

There are numerous hormonal therapies which are highly effective in relieving sexual symptoms in menopausal and post-menopausal women. However, it is important to note that hormonal therapies are associated with adverse side effects and cannot be used by a substantial proportion of women due to side effects and health risks.

In addition it is important to be cognizant that many sexual dysfunctions result from complex interactions between biological, psychological and social factors. In the presence of psychological and social inhibitors of sexual function, biological therapies such as hormone replacement therapy, may be ineffective.

Estrogen therapy

Estrogen therapy is the standard second line treatment for sexual symptoms of menopause, that is, it is the treatment which is most likely to be instituted if a woman finds vaginal lubricants (first line treatment) are ineffective in relieving her symptoms. Estrogen therapy is effective in relieving sexual symptoms in 80-90% of women. It can be delivered locally to the vagina (e.g. via estrogen-containing vaginal lubricants which are absorbed locally and only affect the vaginal cells) or as low dose systemic therapy (e.g. as estrogen-containing tablets, the estrogen from which is distributed through and affects the entire body or has a systemic effect). As local modes of administration provide estrogen only to the vagina and not the entire body, they are associated with fewer side effects.

The most appropriate type of estrogen therapy depends on the causes of sexual dysfunction. For example, an estrogen-releasing ring is more effective than an estrogen releasing tablet in reducing vaginal rash, but less effective for relieving vaginal dryness, compared to an estrogen containing tablet. It is important that women discuss their symptoms openly and honestly with their doctor so they can determine which treatment is most appropriate.

Local estrogen therapy

Local therapies include estrogen-containing creams which are applied to the vagina and estrogen-releasing tablets and rings which are inserted into the vagina. In women who experience only vaginal symptoms and do not experience other symptoms of menopause (e.g. hot flushes) local estrogen-therapy is preferred over systemic therapy, as it raises systemic estrogen levels very little, and therefore is associated with fewer side effects.

Local estrogen therapies are suitable for most women, but those with hormone-dependent cancers should consult their oncologist before treatment is instituted. All local estrogen therapies have demonstrated similar efficacy, so the most appropriate product is selected based on the woman’s preference and availability. Therapy usually continues as long as symptoms persist.

While local therapy can effectively relieve vaginal symptoms of menopause, it is not an effective treatment for vasomotor symptoms and is not associated with a reduced risk of osteoporosis as is systemic therapy. Thus systemic therapy may be recommended for menopausal women who also experience vasomotor symptoms.

Systemic estrogen therapy

Systemic treatment is indicated for women with sexual and other (e.g. vasomotor) symptoms of menopause, but it is not indicated for the treatment of vaginal symptoms alone. It is contraindicated in a substantial proportion of women (e.g. those with a history of hormone dependent cancer) because it carries a number of health risks, including an increased risk of cancer.

Progesterone therapy

When estrogen therapy is systemic it is typically administered in conjunction with progesterone to reduce potential adverse estrogenic side effects, in particular the increased risk of endometrial cancer associated with sole-estrogen therapy. Progesterone is typically not necessary for women receiving local estrogen therapy, although it may be considered for women using frequent or high doses of local-estrogen products.

Progesterone therapy has not been tested as a treatment for sexual dysfunction associated with menopause. However, evidence from one study suggests that progesterone may inhibit sexual desire.

Testosterone therapy

Testosterone may also be administered in conjunction with estrogen. Limited available data suggests that combined testosterone-estrogen therapy is more effective in reducing menopause-related sexual dysfunction than estrogen therapy alone.

Tibolone

Tibolone is a synthetically produced hormone with estrogenic, progesterogenic and androgenic properties. It has been demonstrated effective in reducing some symptoms of menopause. Trials have shown this drug effective in reducing vaginal dryness, although results regarding its effect on libido are somewhat conflicting. One small trial found that women treated with tibolone experienced a greater number of sexual fantasies compared to women who did not receive tibolone, while other trials have reported no improvement in libido following tibolone therapy. Women considering this therapy should be aware that tibolone increases the risk of recurrence in patients who have been treated for breast cancer.

Treat hot flashes

In addition to sexual dysfunction, many women experience a range of other symptoms during menopause. These co-occurring symptoms may contribute to sexual dysfunction. Hot flashes, the most common menopausal symptom experienced by 70% of women who undergo natural menopause, may cause insomnia, irritability and reduced skin sensitivity, which may affect women’s sexual desire and responsiveness.

There are treatments that may help to relieve menopausal hot flushes, and in doing so, can have a positive effect on sexual function.

Lifestyle and home remedies

You and your partner might be able to minimize pain with a few changes to your sexual routine:

• Change positions. If you have sharp pain during thrusting, try different positions, such as being on top. In this position, you might be able to regulate penetration to a depth that feels good to you.
• Communicate. Talk about what feels good and what doesn’t. If you need your partner to go slow, say so.
• Don’t rush. Longer foreplay can help stimulate your natural lubrication. You might reduce pain by delaying penetration until you feel fully aroused.
• Use lubricants. A personal lubricant can make sex more comfortable. Try different brands until you find one you like.

Coping and support

Until vaginal penetration becomes less painful, you and your partner might find other ways to be intimate. Sensual massage, kissing and mutual masturbation offer alternatives to intercourse that might be more comfortable, more fulfilling and more fun than your regular routine.