Pain with intercourse (dyspareunia) is not uncommon in older women. About 10% of all women want to discuss pain during sex at their annual gynecological examinations. Two-thirds of this group are women in their menopausal years.

The decline in hormone levels at menopause brings changes in vaginal tissues. The reduced circulation that occurs with aging affects the entire body. The vaginal tissues become thin and less moist. There is less vaginal wetness even when the woman is sexually aroused. What may be an occasional problem for the menopausal woman and her partner could become a more frequent and serious problem in later years if it is not addressed early and treated.

Causes of Pain with Sex

• Menopause:

  At menopause the levels of the hormones estrogen and progesterone drop, ovaries stop releasing eggs, and menstrual periods stop. As a result, a woman may notice changes, especially dryness, in her vaginal tissues. The lining of the vagina becomes thinner and less responsive to stretching, which can cause pain during sex.

• Other diseases and conditions:
  • endometriosis (growth of fragments of endometrium, the tissue that normally lines the uterus, in other places, such as the vagina or intestines)

  • tipped uterus, often due to relaxed ligament support

  • infections of the bladder or urethra (the tube from the bladder to the outside)

  • scarring from childbirth, episiotomy repair, or vaginal support surgery to correct urinary incontinence

  • pelvic inflammatory disease (PID), infection in the uterus, fallopian tubes, ovaries and surrounding tissues

  • sexually transmitted diseases (STDs) such as genital herpes or genital warts that can appear on or around the vagina

  • intercourse following prolonged periods of not having sex

  • spermicides or irritating douche solutions

  • adhesions or tumors of the uterus (fibroids), tubes, or ovaries (cysts).

Lack of Sexual Response

When a woman does not produce enough moisture or lubrication in her vagina as a response to sexual arousal or stimulation, the cause is due either to physical factors such as menopause, to psychological factors, or to a combination of both.

Many older couples and singles are faced with difficult circumstances that can contribute to lack of sexual response:

• illness or frailty, either of self or of partner, such that either sex is not considered a priority or is avoided out of a fear of hurting or being hurt

• loss of partner due to death or divorce

• lack of privacy and sexual freedom as a result of sharing a home with relatives or living in a retirement home that does not offer privacy

• psychological discomfort with sex outside of marriage

• dilemmas of widows and widowers, such as having to face financial hardships should they remarry because Social Security benefits would be reduced.

Options for Treatment

• Hormone replacement therapy:

  Hormone replacement therapy (HRT) refers to taking hormones to replace the natural hormones that dwindle as the ovaries stop functioning after menopause. HRT will reduce or get rid of many of the symptoms of menopause that cause painful sex, such as vaginal dryness.

  In addition, HRT helps to prevent osteoporosis (thinning and weakening of the bones due to lack of estrogen after menopause) as well as heart disease among women who are at risk for coronary disease. There are some risks associated with HRT, however, including some forms of cancer for a limited number of women. You will want to discuss the benefits and risks of HRT with your doctor.

• Vaginal lubricants:

  While in the past, any woman who had a problem with sex would automatically be thought of as frigid, we now know there is usually a medical or health-related reason. A woman might like and want to have sex, but avoid it because it hurts. Sex may be uncomfortable or painful because there is not enough moisture in the vagina.

  Therapists and doctors recommend use of a vaginal lubricant to women who cannot take HRT to prevent the discomfort caused by lack of moisture in the vagina during sex. Use of a vaginal lubricant should not suggest that either partner has a sexual problem. Benefits of vaginal lubricants include:

  • less irritation and fewer tears of vaginal tissue

  • less irritation and pain of the penis

  • greater ease of penetration

  • better climate for an exchange of affection without fear of pain or discomfort.

  A couple will want to use the lubricant in a fashion that will make it a routine part of foreplay or lovemaking.

  There are lubricants available that have no petroleum ingredients, chemicals or fragrances; are water soluble; and do not dry out quickly. Suppositories and some jellies need time to liquify after insertion. Suppositories are normally inserted well above the vaginal opening. They need time to melt at body temperature, which may require five minutes or longer. They can be inserted during the beginning of foreplay. Ask your physician what product would be best to use.

• Psychological counseling:

  If the reason for painful sex is psychological or social, you will want to ask your physician to arrange a referral to a psychologist, sex therapist, or psychiatrist for help.