Pain During Intercourse (Dyspareunia) in Perimenopause: Regaining Comfort

Pain during intercourse (dyspareunia) is common during perimenopause, most often linked to a drop in estrogen levels, which weakens the genital tissues. It is neither inevitable nor “all in your head.” However, pain is also a symptom that warrants evaluation: depending on the situation, it may be a matter of comfort that you can improve on your own, or it may stem from a condition that requires evaluation by a healthcare professional. This article clearly distinguishes between the two.

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What do we mean when we say “pain during sex”?

Pain during sex, medically known as dyspareunia, refers to any pain, burning, pulling sensation, or irritation felt before, during, or after intercourse, or during genital stimulation.

During perimenopause, these symptoms are often part of a broader condition known as Genitourinary Menopausal Syndrome (GMPS), which encompasses changes in the vagina, vulva, and bladder associated with hormonal deficiency. The pain may be superficial (at the entrance to the vagina, often due to fragility of the mucous membrane or muscle spasms) or deep (at the back of the vagina or in the lower abdomen during deep contractions).

This pain results from specific biological changes that, if left untreated, perpetuate a vicious cycle: pain → anxiety → reduced arousal → increased dryness → more intense pain.

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💡 Note: Why is the pain sometimes worse after several months without sex?

A prolonged lack of genital stimulation can lead, in some women, to a gradual decrease in blood flow and tissue elasticity. Resuming sexual activity may then be less comfortable. A gradual return to sexual activity, accompanied if necessary by a lubricant or vaginal moisturizer, often helps improve the situation.

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Why does pain during sex occur during perimenopause?

Perimenopause is characterized by fluctuations in, and then a decline of, estrogen levels, which are essential for reproductive health. However, these changes are not solely related to estrogen: the gradual decline in androgens (particularly testosterone), as well as the loss of collagen, elastin, and hyaluronic acid naturally present in the tissues, also contribute to a decrease in the tissues’ suppleness, hydration, and ability to repair themselves.

This means you can still experience pain even if there is no visible dryness. The pain may result from a loss of deep elasticity, reduced blood flow to the tissues, or a reflex contraction of the perineal muscles.

Let's take a look at the main causes of this pain:

• ‍Trophic Changes in Vulvovaginal Tissues (SGUM)

The walls of the vagina become thinner, less elastic, and more fragile, and they stretch less easily without developing micro-tears.

• ‍ Decreased lubrication

Mucus production decreases and is triggered more slowly during arousal; the friction becomes irritating.

• ‍Changes in pH and the microbiome

The protective acidity decreases, and the decline in lactobacilli raises the pH, which can lead to irritation, bacterial vaginosis, yeast infections, or certain recurrent urinary tract infections.

• ‍Decreased blood supply

Reduced blood flow to the pelvis decreases tissue sensitivity and responsiveness.‍

• ‍Muscle impact

As a protective reflex, the pelvic floor muscles may become chronically tense (hypertonia), making penetration difficult. An evaluation by a specialized physical therapist can identify this muscle hypertonia. Your healthcare professional can then recommend an appropriate treatment plan.

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💡 Note: Is pain during intercourse always related to perimenopause or menopause?

No, and this is important: there are other possible causes (infections, vulvar conditions, deep-seated pain of gynecological origin, etc.). Any new, intense, or persistent pain warrants a medical evaluation to identify its cause, rather than assuming it is solely due to hormonal changes.

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What You Can Do

This approach combines immediate relief, skin care, and pelvic floor exercises. Important: Local hormone treatments, which are highly effective for SGUM, require a doctor’s prescription and are discussed further below in “When to Talk to a Professional.”

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Where to Start: How to Improve Your Immediate Comfort

• Lubricants (water-based or silicone-based): Use them consistently during intercourse to compensate for a lack of natural lubrication. Silicone-based lubricants generally provide longer-lasting lubrication, especially in cases of severe dryness, while water-based lubricants are often better tolerated but require more frequent reapplication. However, silicone-based lubricants are not compatible with certain silicone sex toys. Avoid using coconut oil with latex condoms (as it weakens them) and if you have recurrent yeast infections.
• Vaginal moisturizers (hormone-free): Unlike lubricants, they are used regularly (2 to 3 times a week), outside of sexual intercourse, to restore tissue suppleness over time.
• Extend foreplay: The body needs more time to trigger the blood flow necessary for comfort. Focus on caresses and non-penetrative arousal.
• Gentle intimate hygiene: Avoid harsh soaps; use only water or a pH-balanced syndet to avoid irritating the delicate mucous membrane.
• Hyaluronic acid-based gels: They can improve mucosal hydration and provide relief for some women, in addition to other measures.

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Pelvic Floor Rehabilitation

• Pelvic floor rehabilitation: with a specialized physical therapist or a midwife, to learn how to relax the pelvic floor muscles, which are often overly tense due to fear of pain. This is a key approach when the muscular component (hypertonia) is predominant.
• Vaginal dilators: When used gradually and gently, they help restore elasticity and desensitize the area in cases of muscle tension. Ideally, their use should be supervised by a specialized physical therapist, a midwife, or a sex therapist to tailor the progression and alleviate any apprehensions.
• Regular genital stimulation (with or without penetration): Maintaining regular stimulation promotes blood flow to the tissues, helps preserve their elasticity, and contributes to maintaining intimate comfort. Penetration is not necessary to achieve this effect.

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Establish a psychosexual counseling program

• Sexual Cognitive Behavioral Therapy (CBT): to alleviate anxiety about anticipated pain and explore new ways of approaching intimacy.
• Pelvic Floor Relaxation: Cardiac Coherence, Breathing, Relaxation: Nervous tension directly affects the perineum, causing it to tense up. Targeting this area helps alleviate the muscular component of the pain.

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Micronutrition and Sexual Pain During Perimenopause

A diet rich in high-quality protein, omega-3 fatty acids, vitamins A, C, and E, and zinc helps maintain normal tissue and mucous membranes. Although no single food directly treats dyspareunia, optimal nutritional status contributes to tissue health, repair, and long-term resilience.

In general, diet can be an important ally in managing perimenopausal symptoms.

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Take It Further with Ainoha

• Track and objectively assess symptoms using the Periscore: recording the frequency, intensity, and context of pain helps measure the effectiveness of the measures implemented and prepare for a medical consultation.
• Getting Guidance with Ainoha Pro: When pain persists or is a cause for concern, the app connects you with a gynecologist, midwife, or specialized physical therapist from the network.

💡 Please note: “natural” does not mean “without precautions.” Before incorporating a plant, essential oil, or supplement into your routine, consult your doctor or pharmacist, especially if you are taking medication, are pregnant or breastfeeding, or have a known medical condition.

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When to Talk to a Professional

Pain during sex is all the more reason to seek medical advice, as it is a clear warning sign. See a doctor, gynecologist, or midwife if:

• The pain persists despite the use of high-quality vaginal lubricants and moisturizers.
• You notice bleeding after intercourse.
• The pain is accompanied by unusual or foul-smelling discharge, or a burning sensation when urinating.
• The pain is new, intense, or deep-seated.
• Avoiding intimacy causes personal suffering or tension in the relationship.

An examination can rule out causes other than SGUM (infection, vulvar conditions, vestibulodynia, vulvar skin conditions, endometriosis, pelvic disorders, muscle pain, or other causes of deep pain) and allow us to discuss medical options based on your specific situation.

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Treatments That May Be Offered

• Local hormonal treatments: Vaginal estrogens (vaginal suppositories, vaginal tablets, creams, or rings, depending on the country and available formulations) are the standard of care for SGUM. They act primarily at the local level, with very low systemic absorption, and effectively improve tissue quality, lubrication, and pain associated with penetration.
• Prasterone (intravaginal DHEA): may also be recommended for certain women. It acts locally after being converted into sex hormones within cells and improves tissue quality as well as alleviating certain types of sexual pain.
• Nonhormonal options: Depending on the clinical context and the treatments available in the country, certain alternatives can be discussed with the doctor. For example, ospemifene, a selective estrogen receptor modulator (SERM), may be indicated for some women with dyspareunia related to SGUM.
• Systemic THM: It is helpful, but may not be sufficient for severe SGUM and is therefore often combined with local treatment.

The choice of treatment depends on your symptoms, medical history, risk factors, and preferences. These treatments require a medical evaluation to determine the strategy best suited to your situation.

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Key takeaways

Sexual pain during perimenopause is common but should never be considered inevitable. It results from hormonal, tissue, muscular, and sometimes psychological changes that may occur in combination. Early intervention—combining local measures, pelvic floor rehabilitation, lifestyle improvements, and, when indicated, medical treatments—can significantly improve intimate comfort and quality of life.

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FAQ

- Do the pains go away on their own after menopause?

No. Unlike hot flashes, symptoms of Menopausal Genitourinary Syndrome (MGUS) tend to worsen gradually if left untreated. Early treatment is recommended.

‍- What symptoms are often associated with pain during sexual intercourse in perimenopause?

• Vaginal dryness: the main cause of chafing pain.
• Intimate vaginal discomfort: irritation, burning, or tingling outside of sexual intercourse.
• Decreased libido: often a result of anticipating pain.
• Frequent urge to urinate or recurrent urinary tract infections: SGUM also affects the bladder.