A significant number of women experience pain during sex. Not only is this uncomfortable, it is often distressing and leads to a sense of confusion, embarrassment, or other negative emotions. While pain during sex can happen for women of any age, it is more likely to occur during perimenopause and menopause, in part due to changes in estrogen levels. The relationship between menopause and sex can shift during this time.
If you're experiencing painful sex, it's important to get to the root cause, so you can experience relief and properly address the issues. In this article, we'll go over the causes and risk factors involved in painful intercourse, along with the best treatment and management options, which may include estrogen therapy, pelvic floor therapy, or an O-shot, among others. For many, painful sex and menopause happen together, so clarifying the cause can help you find targeted relief.
Understanding Pain During Intercourse
Persistent or recurring pain during sexual intercourse is known as dyspareunia. This condition can affect men and women, but it more often affects women. In women, dyspareunia can be either superficial (near the vaginal entrance and vulva) or deep (near the cervix, bladder, and/or lower pelvis).
Dyspareunia affects approximately 10 to 20% of women, although this number may be even higher due to issues of underreporting. Plus, many women have stopped having sex altogether due to pain, so these numbers may not take into account this significant percentage of women who would otherwise have pain, but don't currently due to abstinence.
How Prevalent is Painful Sex in Women with Menopause?
Rates of dyspareunia are higher in perimenopause and menopause compared to women not in these stages. In fact, between 40 to 84% of women report moderate to severe symptoms of dyspareunia or related issues, such as vaginal dryness. Unsurprisingly, these issues not only cause pain, they can also cause psychological distress, reduce sexual desire, and impact overall life satisfaction and well-being, making it a significant concern for many women in their 40s and 50s. These patterns reflect common perimenopause symptoms such as vaginal dryness and irritation, and changes in perimenopause and sex are widely reported.
Physical Causes of Painful Sex
There are many physical causes of painful sex, including:
- Hormonal changes
- Pelvic floor dysfunction
- Vaginal atrophy and dryness
- Other medical conditions
Hormonal Changes
Hormonal changes are a common cause of dyspareunia, especially for women in perimenopause or menopause. As women approach or reach menopause, estrogen levels fluctuate rapidly and eventually decline significantly over time.
This decline in estrogen may lead to thinning or atrophy of the vaginal wall and vulva, along with reduced elasticity, and decreased lubrication in these areas. In turn, this can lead to increased sensitivity and pain, negatively impacting overall sexual experiences. Such hormonal shifts are hallmark perimenopause symptoms that can influence comfort with intercourse.
Pelvic Floor Dysfunction
Another possible cause of painful sex is pelvic floor dysfunction. Individuals with pelvic floor dysfunction have a hard time controlling or relaxing the muscles of the pelvic floor, and many experience excessive tightness or weakness.
In women, pelvic floor dysfunction can lead to feelings of heaviness, tightness, or pressure in the vagina, especially if these muscles aren't able to relax. This constriction and pressure can make pain and discomfort during sex more likely.
Vaginal Atrophy and Dryness
Vaginal atrophy and dryness are often significant causes of pain during intercourse. As mentioned, declining estrogen levels during menopause and perimenopause can lead to thinning and weakening of the vaginal wall, along with decreased lubrication.
In turn, the vagina can become weaker, less flexible, and drier, which increases the likelihood of pain, heightened sensitivity, and irritation. Women may also experience burning, stinging, or sharp pain during sex. These symptoms are all part of a common condition that many menopausal women experience, known as genitourinary syndrome of menopause (GSM).
However, vaginal atrophy and dryness can sometimes stem from other causes too, such as breastfeeding, certain cancer treatments, birth control pills, or anti-estrogen medications.
What Medical Conditions May Cause Pain During Sex?
Many other medical conditions may lead to the development or exacerbation of painful sex for women. This includes (but isn't limited to):
- Vulvodynia: Chronic pain of the vulva, often accompanied by hypersensitivity to touch or stimulation. The pain can be provoked (e.g. during intercourse, inserting a tampon) or unprovoked, where it is basically there all the time.
- Postpartum dyspareunia: Painful sex that develops after childbirth. This could be due to structural/physical causes (e.g. vaginal tears) or related to emotional/psychological issues, such as trauma, anxiety, or fear.
- Dermatologic diseases: A variety of dermatologic diseases can cause inflammation and irritation of the vulva and vaginal skin. This can also cause irritation, burning, and other symptoms. Examples of such diseases include: Lichen sclerosus, Lichen planus, Psoriasis
- Vaginal and pelvic infections: Various infections can cause inflammation, irritation, and pain, which can worsen dyspareunia. Examples include: Gonorrhea, Chlamydia, Bacterial vaginosis
- Vaginismus: This involves involuntary tightening or contracting of the vaginal muscles when penetration is attempted, causing discomfort and pain.
- Endometriosis
Emotional and Psychological Factors
Several emotional and psychological factors are also involved in dyspareunia. This may occur in a vicious cycle, in that stress, anxiety, and other negative emotions lead to increased pain, which in turn makes women feel worse about their situation, thus affecting emotional well-being.
Impact of Anxiety and Depression
Stress, anxiety and depression can lead to tension and pelvic floor dysfunction, leading to pain and general discomfort during intercourse. Certain subtypes of anxiety, especially performance anxiety or fear of pain, may also lead to heightened pain sensitivity or hypervigilance, which can cause enhanced perception of pain.
Sometimes, anxiety, depression, or other mental health issues may be tied in with negative past experiences as well, such as sexual trauma or abuse. These can further complicate the issues and increase the chance of painful sex.
Body Image Issues
In addition, some women may have body image issues or negative self-esteem, which leads to increased stress and tension, often exacerbating pain sensations.
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Treatment Options
There are a variety of effective treatment options for painful sex during perimenopause and menopause. The exact treatments that are implemented depend on the specific cause, as well as other relevant factors, such as patient preferences. These approaches can also support concerns related to perimenopause and sex as hormones change.
Some of the leading treatments for pain during intercourse are:
- Hormone replacement therapy
- Pelvic floor therapy
- O-Shot (PRP injection)
- Vaginal rejuvenation (shockwave therapy)
Hormone Replacement Therapy
Hormone replacement therapy is not just for men!
In fact, women's hormone therapy, especially estrogen therapy, is one of the most effective and well-researched treatments for painful sex. This therapy helps increase estrogen levels, which in turn may improve vaginal thickness, lubrication, and elasticity. It is particularly beneficial for women whose pain and related symptoms are due to declined estrogen levels, such as in perimenopause and menopause.
Estrogen therapy usually is administered as a cream or gel, which is applied topically to the vaginal region. However, other forms exist, such as vaginal rings, tablets, or suppositories.
Besides estrogen therapy, some patients may also be treated with a hormone called DHEA. It can reduce vulvar and vaginal dryness, which may help with pain during intercourse.
At Genesis Lifestyle Medicine, we offer women's hormone therapy, which is tailored to your specific needs and goals.
Pelvic Floor Therapy
Pelvic floor therapy is particularly useful if you have pelvic floor dysfunction, which is also often associated with anxiety, depression, stress, or other mental health problems. This therapy helps restore pelvic muscle function and allows the pelvic floor muscles to relax when needed. Plus, it helps to desensitize pain receptors.
There are a variety of treatments that may occur in pelvic floor physical therapy and related physical treatments, such as:
- Relaxation
- Massage (e.g. Thiele massage)
- Myofascial release
- Muscle retraining
- Biofeedback
- Kegels
- Electrical stimulation
One of the newer options for restoring pelvic floor function is EMSELLA. This treatment, which is offered at Genesis Lifestyle Medicine, utilizes high-intensity focused electromagnetic (HIFEM) technology. This causes thousands of submaximal pelvic muscle contractions, which, over time, leads to retraining of the pelvic floor muscles, and improves muscle coordination.
O-Shot (PRP Injection)
The O-shot is a promising treatment for overall sexual wellness in women. In this treatment, the provider draws a small amount of your own blood, and processes it in a centrifuge to separate the platelet-rich plasma (PRP). The PRP solution is then injected into the genital area.
PRP contains growth factors and other beneficial compounds that improve blood flow, promote the growth of new tissues, stimulate collagen production, and stimulate stem cells. Together, these effects can improve vaginal tissue strength and rejuvenation, while also helping with dryness.
At Genesis Lifestyle Medicine, we've implemented the O-shot to help women with many issues, including not only pain during sex, but also:
- Enhanced sensation during sex
- More youthful and smoother vaginal skin
- Improved sex drive
- And more
And if you're worried about being too old for this treatment, rest assured that it can be done on women of any age. For further information, read this article on how the O-shot may benefit you.
Vaginal Rejuvenation (Shockwave Therapy)
Shockwave therapy uses a wand-like device that delivers high-frequency sound waves into the vaginal region. These shockwaves increase blood flow and stimulate growth factors and anti-inflammatory compounds, all of which aids in vaginal healing and rejuvenation. This treatment has been shown to reduce pain perceptions, decrease pain during intercourse, enhance lubrication, and improve overall sexual satisfaction.
At Genesis Lifestyle Medicine, shockwave therapy vaginal rejuvenation takes only 15 to 20 minutes, and you can leave the facility that same day right after. Plus, there's no downtime or recovery required.
Are There Other Possible Treatments?
There are several other possible treatments that may be useful for dyspareunia and related symptoms, such as:
- Laser therapy: Helps stimulate collagen production and promotes vaginal tissue rejuvenation
- Vaginal moisturizers and lubricants: These sexual wellness products don't solve the root causes of dryness or pain, but they help manage symptoms and can improve lubrication and function temporarily. These are usually combined with hormonal treatments for best results
- Topical anesthetics: For temporary pain relief
Seeking Help and Support
You may be reluctant to seek help from your doctors, whether that's due to embarrassment, privacy concerns, or other issues. However, seeking prompt help allows you to get treated sooner, so the issues can resolve and you can feel better.
How Should You Talk to Your Doctor?
It's best to be as open and honest with your doctor as possible, so they can figure out the best treatment that works for you. However, some doctors are certainly better than others at fostering a safe, supportive environment. So, if you ever feel uneasy, uncomfortable, or that you can't be open with your doctor, it's best to find a new one who totally supports you and listens fully.
At Genesis Lifestyle Medicine, we pride ourselves on delivering personalized, fully supportive care. All of our healthcare specialists are trained in customer service to make sure you get that comfortable, inclusive, and supportive experience you're looking for.
Importance of a Holistic Approach
For the best outcomes when dealing with pain during sex, a holistic approach is needed. Many women find it helpful to not only have a medical doctor, but also other health specialists involved in their treatment, such as:
- A sex therapist or other mental health professional
- Physical therapist
- Pelvic floor specialist
- Massage therapist
Experience Pain-Free Sex Once Again
If you've started to experience painful sex in perimenopause or menopause, you might feel that your days of enjoying sex are over. However, with the right personalized treatment, you can experience vaginal rejuvenation and comfort, along with improved sexual function overall. Hopefully, this will lead to more confidence and improved quality of life too! After all, you deserve to feel good and confident in your body, and to enjoy sexual experiences no matter your age. Remember that menopause and sex can still coexist comfortably with the right care.
If you're dealing with pain during sex or other related sexual concerns, reach out for a personalized consultation at Genesis Lifestyle Medicine. We'll address the root causes and find your optimal treatment plan.
FAQs
Listed below are answers to commonly asked questions about painful sex during perimenopause and menopause.
Why does painful sex start to happen in perimenopause and menopause?
One of the main reasons women may experience pain during sex as they reach menopause is due to changes in estrogen levels. The eventual decline in estrogen causes weakening and thinning of the vaginal wall and vulval tissues, as well as decreased lubrication and elasticity. These factors increase the likelihood of pain, discomfort, and sensitivity.
Can stress and anxiety make pain during sex worse?
Yes. Stress, anxiety, and other negative emotions can absolutely make pain during sex worse, or even cause it to come on on its own. These factors can cause hypervigilance and hypersensitivity to pain. Plus, stress and anxiety can cause tightness and tension in the pelvic floor muscles and vaginal region, making pain more likely.
Can painful sex due to menopause be treated?
Yes. One of the leading treatments for painful sex caused by menopause is estrogen therapy, which helps bring estrogen levels back up. Several other treatments may be beneficial too, such as:
- Pelvic floor therapy
- O-shot (PRP injections)
- Shockwave therapy
How common is painful sex, and does it really increase around menopause?
Pain during intercourse (dyspareunia) affects about 10–20% of women overall, and it’s likely underreported. Rates rise in perimenopause and menopause, when 40–84% of women report moderate to severe symptoms of dyspareunia or related issues like vaginal dryness. Beyond physical discomfort, this can reduce desire, cause psychological distress, and impact overall well-being.
What changes during perimenopause and menopause can make sex hurt?
Declining estrogen leads to thinning (atrophy) of the vaginal and vulvar tissues, less elasticity, and reduced natural lubrication,changes grouped under genitourinary syndrome of menopause (GSM). These shifts increase sensitivity and friction-related pain. Pelvic floor dysfunction (tight or uncoordinated muscles) can add pressure and pain. Other contributors include vulvodynia, postpartum changes, dermatologic conditions (e.g., lichen sclerosus/planus, psoriasis), infections (e.g., gonorrhea, chlamydia, bacterial vaginosis), vaginismus, and endometriosis. Emotional factors,stress, anxiety, depression, body image concerns,can heighten pain perception and pelvic tension, creating a cycle that worsens symptoms.
How do superficial and deep dyspareunia differ, and why does that matter?
Superficial pain is felt at the vaginal entrance and vulva; deep pain is felt higher up near the cervix, bladder, or lower pelvis. Noticing where pain occurs helps your clinician narrow likely causes,for example, superficial pain may point to vulvar skin conditions, dryness, or vaginismus, while deep pain may relate more to pelvic floor dysfunction or pelvic conditions. Share specifics about location, timing, and triggers with your healthcare provider to guide targeted evaluation and treatment.
What treatments actually help, and how are they chosen?
The best plan targets the root cause and your preferences, and often combines therapies. For estrogen-related pain, estrogen therapy is well researched and effective (available as creams/gels, rings, tablets, or suppositories); DHEA can also help with vulvar/vaginal dryness. Pelvic floor physical therapy addresses muscle tension and coordination with techniques like relaxation, myofascial release, retraining, biofeedback, Kegels, and may include EMSELLA (HIFEM technology) to retrain muscles. Regenerative and device options include the O‑shot (PRP injections to support tissue health, blood flow, and lubrication; can be used at any age) and vaginal shockwave therapy (brief, no-downtime sessions that may reduce pain and improve lubrication). Additional supports include laser therapy, vaginal moisturizers/lubricants (often combined with hormones), and topical anesthetics for temporary relief.
I feel embarrassed, how should I talk to my doctor, and who else can help?
Be open about your symptoms, what worsens or improves them, and how they affect your life; this helps tailor care. If you don’t feel heard or supported, seek a clinician who offers a comfortable, inclusive environment. A holistic team often works best,medical doctor, pelvic floor specialist or physical therapist, and a mental health professional or sex therapist. Genesis Lifestyle Medicine emphasizes personalized, supportive care and offers options like women’s hormone therapy, pelvic floor solutions (including EMSELLA), the O‑shot, and shockwave vaginal rejuvenation.
Medically reviewed by Dr. Alex Spinoso
References
- Hill, D. A., & Taylor, C. A. (2021). Dyspareunia in women. American Family Physician , 103 (10), 597-604. https://www.aafp.org/pubs/afp/issues/2021/0515/p597.html
- Carlson, K., & Mikes, B. A. (2026). Dyspareunia. In StatPearls [Internet] . StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK562159/
- Dąbrowska, J., Białogłowski, M., Mazurek, K., Gęborys, A., Wojcieszak, M., Matuszewska, J., ... & Miazga, D. (2026). When intimacy hurts: Dyspareunia in genitourinary syndrome of menopause-A review of treatment options. Quality in Sport , 49 , 67614. https://apcz.umk.pl/QS/article/view/67614
- El Husna, F., Putri, N. L. A. S. A., Dewangga, E. W., Wicaksono, G. P., & Andiani, A. (2023). Analysis of association of dyspareunia in menopausal women with the quality of sexual intercourse: Literature review. Jurnal Ilmiah Kedokteran Wijaya Kusuma , 12 (2), 167-181. https://www.academia.edu/127808692/Analysis_of_Association_of_Dyspareunia_in_Menopausal_Women_with_The_Quality_of_Sexual_Intercourse_Literature_Review
- Rastogi, M., Deka, K., Krishnan K, S., Narayan, A., Nayak, M. M., & Kumar K, V. (2024). Multifaceted therapeutic approaches for the management of dyspareunia: A narrative review. The Open Public Health Journal , 17 (1). https://openpublichealthjournal.com/VOLUME/17/ELOCATOR/e18749445358697/
