Let’s be very clear: pain with sex is not just part of getting older. It’s not something you have to grit your teeth through, and it’s not something you should be told to “just relax” about. Painful sex—also known as dyspareunia—is common, but it’s absolutely treatable.
Why Does Sex Start to Hurt?
The most common culprit in perimenopause and menopause is genitourinary syndrome of menopause (GSM)—a fancy term for the vaginal and urinary changes that happen when estrogen declines.
As estrogen levels drop, the tissues of the vulva and vagina become:
- Thinner – we need estrogen for Collagen production
- Less elastic – we need estrogen for Elastin production
- Drier – out tissues are getting thinner, less elastic and that affects the blood supply to the vagina and vulva and also our microbiome and gland function
- More fragile – dry, thin skin can crack and tear
The result? Sex can feel irritating, burning, tight, or downright painful. And once that starts, it’s easy to get caught in a cycle of pain → tension → avoidance → disconnection—none of which supports your physical or emotional wellbeing.
Other Causes of Painful Sex
While GSM is the most common cause, other possible contributors include:
- Pelvic floor muscle tension or spasm
- Endometriosis or fibroids
- Vulvodynia or vestibulodynia
- Infections
- Scar tissue from childbirth or surgery
- Lack of arousal or lubrication
Bottom line: pain is not “just in your head.” It’s your body asking for support.
What You Can Do
- See a doctor trained in midlife sexual health. (Hi, I know someone!)
- Use vaginal estrogen. Low-dose estrogen therapy is safe, effective, and often underprescribed.
- Explore lubricants and moisturizers. Water-based, silicone, or oil—find what works best for you.
- Consider pelvic floor physical therapy. These pros can work magic for muscle-related pain.
- Address emotional and relational layers. Feeling safe and relaxed matters more than any checklist.
What You Should Never Be Told
“You’re just getting older.”
“Drink some wine.”
“Use more lube and push through.”
No, no, and absolutely not.
The Bottom Line
Sex should feel good. Or at the very least, not painful. If it hurts, speak up and seek care—you deserve support, not silence. There are real solutions out there, and suffering is not part of the plan.
👉 Painful sex is common, but it’s not normal. And it’s not something you have to just “deal with.” Let’s talk about real, effective solutions.
Need support or want to learn more about treatment options? Schedule a free 15-minute call to see how we can work together.
Dr. Aoife O’Sullivan is a family physician, board certified by the American Board of Family Physicians and a menopause specialist, certified by the North American Menopause Society, dedicated to empowering women through their midlife health journeys. She is the founder of Portland Menopause Doc, co-founder of the Portland Menopause Collective, podcaster on The Dusty Muffins, and an expert speaker, frequent podcast guest and active contributor to midlife women’s health research.
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