Painful Sex in Menopause & Perimenopause — Treatments That Work
December 9, 2025 2025-12-10 19:55Painful Sex in Menopause & Perimenopause — Treatments That Work
INTRODUCTION
You may feel embarrassed to talk about painful intercourse or difficulty reaching orgasm. But these changes are very common in perimenopause and post-menopause, and doctors speak about them every day — like any other symptom. Pain, reduced lubrication and changes in sensitivity are caused by low oestrogen levels and changes in the vaginal tissues and pelvic nerves. The most important message is simple: this is a medical condition, and there are treatments that work.
PART 1 — Why painful sex in menopause happens
1.1 How low oestrogen causes pain and orgasm changes
Pain during intercourse (dyspareunia) and difficulty reaching orgasm often appear together in perimenopause and post-menopause. When the vaginal tissues become thinner and drier — due to declining oestrogen — sexual activity can feel uncomfortable or painful. With time, the brain associates intimacy with discomfort, desire decreases and orgasm may become more difficult.
This has nothing to do with personal failure, attraction or the quality of the relationship. It is a biological change caused by low oestrogen and changes in blood flow, elasticity and pelvic nerve sensitivity.
1.2 How Painful Sex in Menopause Affects Pleasure
Oestrogen keeps the vaginal tissues healthy, elastic and well-lubricated. It also supports:
- blood flow to the genital area
- healthy pH and microbiome
- collagen and tissue elasticity
- normal nerve function and sensitivity
When oestrogen declines in perimenopause, especially after menopause, the vaginal walls become thinner, lubrication decreases and microscopic irritation increases. Pain during penetration can appear gradually, even in women who never had symptoms before.
Orgasm may also change if:
- blood flow to the clitoral and vaginal tissues is reduced
- sensitivity decreases
- pain interrupts arousal
- anxiety or anticipation of pain interferes
These changes are known collectively as Genitourinary Syndrome of Menopause (GSM), a chronic but treatable medical condition.
PART 2 — Treatments that work for painful sex and loss of orgasm
2.1 First-line, evidence-based options
The goal of treatment is to restore comfort, lubrication and tissue health, allowing intimacy to be enjoyable again. Treatment is individual, depending on symptoms, medical history and preferences.
Evidence-based options include:
Local oestrogen
(oestradiol, estriol, promestriene)
This is the first-line treatment for vaginal dryness and dyspareunia when there are no contraindications. It improves lubrication, elasticity and reduces pain.
Clinical studies show that low-dose vaginal oestrogen keeps blood hormone levels within the postmenopausal range and does not stimulate the endometrium at recommended doses.
DHEA (prasterone)
Approved for painful intercourse in postmenopausal women, DHEA is converted locally in vaginal tissues and improves sexual function without significant changes in serum hormone levels.
Ospemifene (SERM)
A selective oestrogen receptor modulator taken orally, shown to reduce vaginal dryness and pain, and in some women improve sexual comfort.
Non-hormonal support
Lubricants and vaginal moisturisers improve comfort and can be used alone or with hormonal therapy.
Pelvic floor physiotherapy
Especially helpful if pain has caused muscle tension or anxiety around penetration.
2.2 When the first treatment did not work
Some women do not respond fully to the first treatment they try. This can be frustrating, especially if they are told “there are no other options.” In clinical practice, it is common to adjust the dose, change the preparation (for example, from tablet to cream), or combine therapies safely.
Doctors see this often — it is not unusual to discuss second-line options when symptoms persist.
PART 3 — Emerging options when painful sex and orgasm issues persist
For women who cannot use standard treatments or do not respond fully, emerging therapies may help in selected cases. Evidence is still developing, and these options should be used under specialist medical supervision.
3.1 Topical testosterone
Some small clinical trials and one systematic review suggest that low-dose intravaginal testosterone may improve symptoms in postmenopausal women taking aromatase inhibitors for breast cancer, by acting locally on androgen receptors in the vaginal tissues. However, long-term safety data are limited, and this approach remains investigational. It should only be considered under specialist medical supervision.
3.2 Topical sildenafil (improving blood flow)
Topical sildenafil aims to increase genital blood flow, potentially improving arousal and sensitivity. Evidence is limited and mostly from small studies, but it may be considered in selected cases when other treatments have not been sufficient. More research is needed to confirm efficacy, optimal dosing and safety.
3.3 Pain-modulating creams
Some topical preparations can reduce local pain perception or help when pelvic floor hypertonicity causes burning or sharp discomfort. Evidence is still emerging, and use should be guided by a doctor experienced in pelvic pain and menopause medicine.
None of these treatments should be used without medical guidance, as safety, dosing and suitability depend on personal health history and goals.
PART 4 — When to seek help
4.1 There is nothing to be embarrassed about
Painful intercourse, reduced pleasure and changes in orgasm are extremely common in perimenopause and post-menopause. Doctors talk about these issues every day — like discussing hot flushes or bone health. There is no reason to feel ashamed or to suffer in silence.
If one treatment did not work for you, it does not mean there are no other options. This is a conversation we have regularly in clinical practice, including online consultations with women seeking a second opinion or asking why they are still uncomfortable.
4.2 Why a personalised plan matters
Sexual pain and orgasm difficulties can have many contributing factors:
- hormonal changes
- vaginal tissue health
- blood flow dynamics
- pelvic floor tension
- history of medications
- oncology treatment
- psychological impact
- relationship context
A personalised plan allows you to explore what is causing your symptoms and which evidence-based treatments are most likely to help you — safely.
If these symptoms sound familiar, you do not need to wait.
A private consultation can help you understand your options and choose the right treatment for your situation.
Book a private consultation to explore personalised, evidence-based options.
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References
- Bell R, et al. A systematic review of intravaginal testosterone for the treatment of vulvovaginal atrophy. Menopause 2018
- Gandhi J, et al. Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, aetiology, and management. American Journal of Obstetrics & Gynecology. December 2016.
- NICE (National Institute for Health and Care Excellence). Evidence summary: Prasterone for treating dyspareunia in menopause.
