How Does Menopause Impact Sexual Health?

Menopause literally means the end of monthly cycles. Every woman experiencing menstruation eventually faces a period of 12 months without a menstrual period. This is a natural phenomenon that occurs with age and marks the end of your reproductive years. During menopause, ovaries reduce/stop producing eggs as well as estrogen which is responsible for the menstrual cycle and affects the urinary tract, heart and blood vessels, bones, etc.

Symptoms of menopause include:

• Irregular periods/changes in the blood flow
• Hot flashes & Night Sweats
• Intense pain during thrusting
• Cold flashes
• Difficulty sleeping
• Emotional changes (irritability or mood swings)
• Vaginal dryness
• Urinary urgency
• Worsening of premenstrual syndrome (PMS)

The average age of women who experience menopause in Canada is 51 years old. Nevertheless, it is important to remember that each individual faces a unique set of symptoms at various ages.

Painful intercourse after menopause may be caused by some of the symptoms of it. This is why everyone going through menopause should be aware of what may cause pain and how to avoid/deal with it.

Why is Sex Painful after Menopause?

Hormonal Changes

Estrogen is a hormone that is produced by the ovaries. Amongst several other roles, it increases a normal clear discharge from the vagina that leads to a healthy vulva and urethra. It lessens dryness and soreness in the vagina. Due to menopause, estrogen levels are decreased thus resulting in itchiness, redness, or soreness of the vulva. Especially during sex, decreased lubrication of the vagina is observed.

Also Read: Estrogen and Progesterone: Options for Hormone Replacement Therapy

Decreased production of estrogen can also cause several other issues. Vulvo vaginal atrophy (VVA) is one of them. It is thinning, drying and inflammation of the vaginal walls. Another is atrophic vaginitis which is an inflammation of the vagina. Atrophic urethritis is an inflammation of the urethra that is also an effect of low estrogen.

Physical Factors

Some skin conditions for example eczema (dry and itchy patches of skin), vulvar lichen sclerosus (patchy, discolored, thin skin), or an infection that is caused in your genital area/urinary tract can lead to painful sex after menopause.

The dryness and thinning of the vagina can sometimes result in menopausal vaginismus which is an involuntary spasm of the vaginal wall when attempted penetration. Certain medications such as antidepressants, high blood pressure medications, etc. are taken in response to certain symptoms of menopause. These can at times cause vaginal dryness as well.

The vagina contains lactic acid which protects vaginal health by restricting the growth of fungi and unwanted bacteria. Estrogen maintains the pH level of the vagina, but when the estrogen levels go down, there are changes in the acidic level as well. With a higher pH scale, it is prone to vaginitis and other bacterial infections that make the vagina dry and sore.

Pelvic floor dysfunction is an inability to relax or coordinate your pelvic floor muscles. Women sometimes face pelvic floor disorders that bring about sexual dysfunction. Overactive pelvic floor muscles can be too tense, while underactive ones prove to be weak or loose for sex. Any of these two situations can result in lower arousal.

Psychological & Emotional Factors

Libido is the sex drive of people. During menopause, women face a significant loss of libido. It depends on the woman’s testosterone levels, and sexual history, including physiological and psychological reasons. Libido can be affected by dyspareunia (consistent pain during/after sex in the genital area). Dyspareunia may cause marital differences, which often decreases sex drive.

There are several psychological barriers that people could face originating from physiological changes. Many women face intense stress, depression, or body image issues. Anger between the couple can cause stress, depression or anxiety, and can decrease libido. In fact, some medications used to treat such ailments can worsen the libido as well. Some cultural beliefs that implant the idea that sexual intercourse mustn’t happen after a certain age set a sort of body image issue with the post-menopause body of the women. The askew view of your own body decreases the libido.

Common Symptoms of Painful Intercourse after Menopause

Painful sex after menopause has a set of common symptoms that can help you identify the issue.

• Pain only at sexual entry/penetration
• Pain with every penetration (including tampon)
• Intense pain during thrusting
• Burning/aching pain
• Throbbing pain that lasts hours after sex
• Cramping of the pelvic region
• Pelvic muscle tightness or spasms
• Itching at the vagina
• “sandpaper” feeling, i.e., penetration in a dry vagina can cause this feeling
• Extreme vaginal dryness can cause tearing of the vaginal muscles if anything is thrusted in it roughly
• Bleeding of the vagina caused by friction against thinner, sensitive skin post-reduction of estrogen

What other conditions can cause pain during sex?

Vaginismus

It is a type of sexual dysfunction. The vaginal muscles involuntarily or consistently contract, causing pain during sex. It doesn’t usually interfere with sexual arousal, yet since it causes vaginal pain, penetration becomes difficult. This pain can take place when anything is penetrated in the vagina, including a tampon.

There are two cases of vaginismus: primary vaginismus (never had a vaginal penetration) and secondary (it was once achieved but is no longer possible for a variety of reasons).

The connection between vaginismus and menopause is that when estrogen levels decrease, dryness and reduced elasticity result in painful intercourse.

Vulvodynia

This is a consistent pain or discomfort around the vulva, the outer part of the female genitals. To classify as vulvodynia, the pain must persist for 3 months without any clear cause. The symptoms are experienced in the vulva and can include the following: burning, irritation, stinging, soreness, rawness, sharp pain, etc. Along with these, there may be a lingering aching, throbbing or swelling.

The intensity and duration of these symptoms may vary from individual to individual. If the symptoms are severe, women are usually unable to even think of having sex. This condition can be prolonged over years.

Sexual responses of people, along with genital pain, are regulated by the gonadal hormones. In the case of women, it is estrogen’s role. As seen in menopause, the levels of estrogen dip, which is seen as a cause for vulvodynia along with many other ailments.

Skin Conditions

There are several skin conditions that impact sexual arousal. Certain physiological factors of painful sex after menopause show symptoms including dryness, redness, itchiness, etc. Apart from those, there are conditions like eczema that cause dry, itchy and patchy skin near the genital area. This leads to thin cracks, red patches and sort of a crust formation.

Vulvar eczema can be caused by soap/detergents, adult/baby wipes, panty liners, nylon underwear, sweat, lubricants/spermicides, fragrances, latex, and tea tree oil. This tends to pass on genetically and is treatable.

Vulvar lichen sclerosus is an inflammatory skin condition that affects sexual gratification. It has a tendency to affect the area surrounding the genitals. The cause is multifactorial, including genetic, autoimmune, and lifestyle factors. Symptoms may include irritation, bladder and bowel pain, painful sex, burning sensation, and vulvar scarring. The pain prevents women from experiencing arousal.

Menopuase Treatment options available

Non-Medical Interventions

Painful sex after menopause has natural remedies too. Communication with your partner is essential; if something causes you pain, it is always better to let them know and find alternate ways to have intercourse.

Lifestyle changes in the manner of consuming a well-balanced diet, consistent exercises, and healthily coping with stress are just a few examples of natural remedies for painful sex after menopause.

Over-the-Counter Solutions

Many women counter vaginal dryness by applying a water-based lubricant or moisturizer, which is available at most grocery stores or pharmacies. They reduce friction, thereby reducing any onset of pain. There are oil-based lubricants as well, but they sometimes damage the condoms and make them less efficient. The lubricant is applied to your vagina or your partner’s penis/penetration tool right before having sex. Some examples of lubricants are Astroglide, Jo, Sliquid, etc.

Moisturizers are known to reduce friction during sex as well. They can get absorbed into the skin and last much longer than a lubricant. For example, Replens can keep working for 3-4 days. There is also K-Y Liquibeads.

Prescription Treatment

If lubricants or moisturizers are not that effective, your doctor may prescribe low-dose topical estrogen therapy. Estrogen, as read above, increases the thickness and elasticity of vaginal wall muscles, as well as improves blood flow. Estrogen comes in a cream, tablet, ring or insert. Since it directly goes into the vagina, there are less body-wide side effects.

Learn more: A Complete Guide to Hormone Replacement Therapy for Menopausal Women

Vaginal estrogen cream has brands like Premarin or Estrace. To use it you must apply it to your vagina 2-3 times a week. On the other hand, the vaginal ring (Estring) is inserted into the vagina. You can go ahead for up to 3 months with it in your vagina. Vagifem, the vaginal tablet, is applied to the vagina twice a week using an applicator or your finger. Since a ring or tablet is less messy compared to a cream, many women prefer them.

For a higher dose, your doctor may switch to systemic hormone therapy. In this treatment, estrogen comes in a pill, skin patch, ring, gel, cream or spray. This is absorbed throughout the body and is used to tackle any symptom of menopause.

Topical estrogen therapy as well as systemic hormone therapy are all part of the Bioidentical Hormone Replacement Therapy (BHRT). BHRT is used to boost hormone levels. In the case of post-menopausal women, it is the flow of estrogen. Occasionally it is used to help reduce symptoms of cancer or to treat conditions like insulin resistance, adrenal and thyroid disorders, osteoporosis, and fibromyalgia.

These hormone replacements are derived from plants and are chemically identical to the ones that our human body produces. BHRT can be administered via pills, patches, creams, gels, or injections.

Side effects of BHRT

FDA has approved many bioidentical hormone products, but not the compounded ones. They are not yet regulated for safety or efficiency. Proper consultation with your doctor is advised before you plan for BHRT. It may increase the risk for conditions like:

• Blood clots
• Stroke/heart disease
• Gallbladder disease
• Breast cancer

Some common side effects include:

• Acne
• Bloating
• Weight gain
• Fatigue
• Mood swings

Also Read: The Connection Between BHRT and Cardiovascular Health

Non-Hormonal Medications

FDA has approved only one non-hormonal treatment for painful intercourse after menopause: ospemifene. It imitates estrogen and thickens the vaginal lining, without increasing the risk for breast or uterine cancer. It has been proven to reduce dryness along with pain, and function better than topical estrogen. Ospemifene is a pill you take once a day. There are a few side effects to it: hot flashes, a slightly increased risk of blood clots and strokes.

Alternative Therapies

Pelvic Floor Physical Therapy (PFPT) improves pelvic floor muscle. It increases its strength, endurance, power, relaxation or a combination depending on the individual muscle type. This is performed by specialized PFPT specialists, and can resolve a certain degree of pain involved in having sex.

For women who face severe stress or depression, mood swings, etc., it is advisable to undergo psychological counseling. It will help in dealing with the stress and can help find ways to balance and uplift your mood. Sex therapy is for individuals or couples who wish to work towards a pleasant intercourse experience for both of them. It is crucial to communicate, and at times a mediator can aid in that process.

Conclusion

Women facing menopause can opt for several treatment methods after consulting their doctors. Painful sex after menopause is normal, as are its treatments, therefore there are a variety of ways you and your partner can ensure that it is more pleasurable than painful. Bioidentical Hormone Replacement Therapy when done with trustworthy doctors can yield great results. Menopause is natural, but it needn’t hinder your sexual experiences.