The Radical Sexologist

Up to 87% of women will experience pain with sex after menopause.

Let me say that again: Most women will have painful sex after menopause.

And yet, most women have never heard about this. They don’t know it’s coming. They don’t know why it’s happening. And they certainly don’t know that it’s treatable.

This is what frustrates me most in my practice: seeing women who’ve suffered for years with a completely treatable condition because no one told them this was normal, common, and fixable.

Here’s what you need to know: Menopause changes your vulva, vagina, and clitoris in ways that can make sex painful. But these changes don’t mean the end of your sex life. With the right treatment, most women can have comfortable, pleasurable sex after menopause.

Let me give you the five essential strategies for pain-free sex after menopause—the information you should have received years ago.

Why Menopause Causes Painful Sex

First, let’s understand what’s happening in your body.

The vulva, clitoris, and vagina are estrogen-dependent tissues. Estrogen causes them to develop during puberty and is necessary to maintain vulvovaginal health throughout your life.

Menopause means the end of estrogen production.

Without estrogen, these tissues change:

• The vaginal walls become thinner and less elastic
• Natural lubrication decreases dramatically
• The vaginal opening can become tighter
• Tissue becomes more fragile and prone to tearing
• Blood flow to the area decreases
• pH changes, increasing risk of infections

These changes have a name: Genitourinary Syndrome of Menopause (GSM).

GSM can cause:

• Pain with penetration
• Vaginal dryness
• Burning or irritation
• Urinary urgency or frequency
• Recurrent UTIs
• Decreased arousal and pleasure

The problem isn’t that these changes happen. The problem is that most women don’t know about them until they’re already experiencing painful sex—and many don’t realize it’s treatable.

Some women breeze through menopause with minimal symptoms. But if you’re reading this because sex has become uncomfortable or painful, you’re not alone. And you don’t have to accept this as your new normal.

Let’s talk about what actually helps.

Tip 1: Get an Exam

While hormonal changes are the most common cause of pain after menopause, they’re not the only cause.

You need someone to examine your vulva and vagina to rule out:

• Infections (yeast, bacterial vaginosis)
• Skin conditions (lichen sclerosus, lichen planus)
• Pelvic floor dysfunction
• Other sources of pain

I don’t recommend exams lightly. I know the medical establishment has a poor track record with pelvic exams. They’re a common source of trauma for many women.

What you deserve:

• A qualified, compassionate provider
• A trauma-informed exam (your experience guides the process, not provider convenience)
• Important conversations that don’t happen while you’re in a paper gown with your butt hanging out
• No stirrups unless absolutely necessary
• The ability to stop at any time

If you don’t feel comfortable during an exam, tell your provider. If that doesn’t feel possible, find someone else. Great providers exist, and you deserve to feel supported.

Where to find good providers:

• International Society for the Study of Women’s Sexual Health
• International Pelvic Pain Society
• Your gynecologist or primary care provider (if you feel comfortable with them)

If you’re near Ithaca, NY, I’d be happy to help.

Tip 2: Decide Whether Hormones Are Right for You

Since loss of estrogen causes GSM, replacing estrogen is the most effective treatment.

Fortunately, you have several options.

Hormonal Options:

Vaginal Estradiol (most commonly prescribed)

• Comes as creams, tablets, rings, or suppositories
• Estradiol is the most abundant and potent estrogen your body naturally makes
• Applied directly to vaginal tissue
• Very low dose—minimal systemic absorption
• Highly effective

DHEA Suppositories (Prasterone)

• DHEA is a hormone precursor your body converts to estrogen
• Vaginal tissue can also convert it to testosterone (may provide additional benefit)
• Applied directly to vaginal tissue
• Effective alternative to estradiol

Estriol

• A weaker estrogen, less commonly prescribed
• Only available from compounding pharmacies
• Some practitioners prefer it, believing it’s safer
• Fewer studies than estradiol, but appears safe and effective

Premarin (Conjugated Equine Estrogen)

• Older product, still available
• Made from pregnant horse urine (yes, really)
• Effective, with decades of safety data
• Contains other hormones that may not appeal to everyone

“But I heard hormones aren’t safe!”

I hear this constantly. And I understand why—there’s a lot of misinformation out there, including from the FDA itself (at least until November 2025, when they finally removed the misleading black box warning).

The truth: Low-dose vaginal estrogen is safe for most women—even many with a history of breast cancer.

The research that scared everyone about hormones was about systemic hormone therapy (pills and patches that raise estrogen throughout the body). It doesn’t apply to low-dose vaginal estrogen.

For the full story on vaginal estrogen safety, including the recent FDA announcement, read this post.

Non-Hormonal Option: Vaginal Moisturizers

If hormones aren’t right for you, moisturizers are an effective alternative.

Vaginal moisturizers work like facial moisturizers—they hydrate tissue and hold moisture in place. Recent research shows they can work just as well as estradiol for decreasing GSM symptoms.

How to use:

• Apply 3-5 times per week (not just before sex)
• Use regularly for ongoing tissue health
• Like the rest of your skincare routine

Good moisturizer brands:

• Hyalo Gyn (contains hyaluronic acid)
• Ah! Yes
• Good Clean Love Moisturizing Vaginal Gel

Cost considerations:

• Moisturizers: $20-40/month
• Hormonal treatments: Often cheaper with insurance (but coverage varies wildly)
• Without insurance, hormonal treatments can be expensive

Make It Part of Your Routine

GSM is chronic and progressive. Without treatment, symptoms don’t go away—they get worse over time.

Caring for your vulvovaginal tissue should become part of your regular self-care routine after menopause, just like:

• Brushing your teeth
• Using sunscreen
• Taking your vitamins

Choose a treatment that works for you and stick with it.

Tip 3: Use Lubricant Every Single Time

Hormonal treatments or moisturizers are the foundation. But lubricant is essential for comfortable, pleasurable sex.

The #1 reason for pain during penetration is friction. Dry fingers, toys, or penises dragging against delicate tissue hurts—especially after menopause when natural lubrication has decreased.

There is no shame in using lubricant. It’s the most basic and essential aid to sexual pleasure that exists.

Take time to find lubricants you love. For menopausal women, I recommend:

• Silicone-based (Uberlube) – stays slippery longest, great for sensitive skin
• Oil-based (coconut oil) – hydrating, natural, inexpensive

For a complete guide to choosing lubricants, read this post.

Use lubricant every time. Not just when you think you need it. Every. Single. Time.

Tip 4: Keep Your Vaginal Tissue Flexible

Loss of estrogen makes vaginal tissue tighter and stiffer. The vaginal opening can be especially problematic—even subtle loss of flexibility makes penetration painful.

Moisturizers and hormones help hydrate and loosen tissue. But these tissues also need to be mobilized, just like every other part of your body.

How to keep tissue flexible:

If it is in your sexual repetoire, Eengage in regular vaginal penetration—ideally of the pleasurable variety.

• Solo or partnered
• Approach it like physical therapy, but add pleasure (it’s more effective and, well, pleasurable)

If you have pain or restriction at the vaginal opening, you may benefit from vaginal dilators:

• Cylinder-shaped tools in varying sizes
• Used progressively to release the opening and increase flexibility
• Helpful when penetration is too painful to start with

How often? There’s no strict consensus. It depends on whether you currently have pain or are maintaining vaginal health.

If you have significant pain: See a pelvic floor physical therapist. I really, really strongly recommend this. Pelvic PTs are specialists in treating painful sex and can make an enormous difference.

For more on pelvic floor dysfunction and treatment, read this post.

Tip 5: Keep the Focus on Pleasure

When pain becomes a problem—actual or anticipated—it’s easy to lose sight of this truth:

Pleasure is always possible.

Your body is built for pleasure, even when there are changes that cause pain.

Pleasure as Medicine

Sexual pleasure literally heals vulvovaginal tissue.

Here’s how:

1. Pleasure creates arousal
2. Arousal increases blood flow (this is why the clitoris swells when you’re turned on)
3. Blood flow brings oxygen and nutrients to tissue, removes waste products
4. Increased blood flow heals tissue (just like wound healing requires good circulation)

Ways to increase blood flow:

• Sexual arousal (any kind)
• Vibration (yes, that kind) – increases arousal and further boosts blood flow
• Bonus: Use a vibrator for both pleasure AND vaginal mobilization

Pleasure Heals the Mind Too

Pleasure, joy, comfort, intimacy—these are basic life resources.

Your whole body, all your senses, can bring in pleasure if you take time to tune into it. Sexual pleasure connects you to your fundamental self and to your partner.

Leaning into sexual pleasure—even when there’s also pain—helps maintain this connection and provides essential refuge.

Sex is about pleasure. Even if penetration isn’t possible or comfortable right now, pleasure still is.

Lean into pleasure as much as possible, as often as possible.

I give you full permission.

The Bottom Line

All of this should be common knowledge. But women tell me constantly they’ve never heard any of it.

87% of women will experience painful sex after menopause.

Most have never been told:

• That it’s normal
• Why it happens
• That it’s completely treatable

The unnecessary suffering this causes is unacceptable.

If this is news to you, I’m glad you found it. Pass it on. Tell anyone who needs to know.

Here’s to women living long, happy sex lives without pain.

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Experiencing painful sex after menopause?

Sexual medicine consultations provide comprehensive evaluation and treatment planning for GSM and other causes of sexual pain. We’ll develop a personalized plan that works for your body and your goals. Learn more about sexual medicine here.

For questions about navigating sexual changes, sex counseling addresses both the physical and emotional aspects of pain and pleasure. Learn more about sex counseling here.

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Dr. Lori Davis is a Doctor of Nursing Practice, board-certified Family Nurse Practitioner, and AASECT Certified Sex Counselor specializing in menopausal sexual health and genitourinary syndrome of menopause (GSM). She teaches sexuality counseling at the University of Michigan.

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Note on language: In this article, terms like “woman/women” and “vagina/vulva” refer to anatomy rather than gender identity. This information applies to anyone with this anatomy, regardless of gender.