Sometimes menopause causes changes to the genitals and urinary system that causes symptoms, called GSM or Genitourinary Syndrome of Menopause and pain with sex is the most commonly described symptom. Vaginal pain may begin during the menopause transition or after menopause. It may be a burning pain, or itchy. Some women have a discharge coming from their vagina. The pain may be constant, or only during penetrative sexual activity. (If the pain is constant, read the section on vaginal pain not during sex.)

Pain during sex may be due to vaginal dryness. Just as our hair, skin, and eyes may become dry during perimenopause, so may our vaginas. If the vagina no longer has enough natural lubricants, sex with penetration can cause irritation, chaffing, itching, or burning.

Pain may also happen because the vaginal feels “too tight” and penetration is painful or impossible. We have specific recommendations for that.

Sometimes the pain and discomfort decrease a woman’s interest in sex. It is important to decrease the pain before trying ways to increase the desire for sex. When you are ready, you can read about low sex drives here.


The vagina and vulva change during perimenopause. The vulva is the area on the outside around the entrance to the vagina. There is less blood flow to the vagina and vulva, and the nerve signals take longer to work. The skin in the vagina and vulva gets thinner and smoother. There is often less natural lubrication to the vagina. Your health care provider may see these changes during an exam. The changes are called “genitourinary atrophy.”  But these changes do not strongly correlate with a woman’s symptoms. Meaning, you may or may not have these symptoms, even if your health care provider sees signs of atrophy.


These problems are more likely as women approach their final menstrual period. They are even more common after menopause when estrogen levels are low. Not all women with the visual signs of changes to the vagina and vulva have these problems.



  Treatments that are inappropriate or have not been studied for this symptom are not listed.


Treatment of the woman with symptomatic vulvo-vagina atrophy (VVA) related to sexual activity can be approached in a stepwise fashion based on the severity of symptoms. Options include nonhormonal vaginal lubricants to be used with intercourse/vaginal sexual activity, long-acting vaginal moisturizers used regularly (several times per week), and regular sexual activity. For symptomatic VVA that does not respond to these initial management approaches, low-dose vaginal ET is an option.

For women with moderate to severe dyspareunia associated with VVA who prefer a nonvaginal therapy, transdermal and oral hormone therapy (HT) as well as ospemifene are options. Some women may already have vaginal constriction or vaginismus limiting vaginal penetration.

Gentle stretching of the vagina with the use of lubricated vaginal dilators of graduated sizes can play an important role in restoring and then maintaining vaginal function. Reinitiating regular sexual activity once vaginal penetration is again comfortable will help to maintain vaginal health. Many women with this condition benefit from referral to pelvic floor physical therapy. Starting vaginal estrogen before initiating vaginal dilatation and/or pelvic floor therapy may facilitate progress.


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 Last reviewed: April, 2021


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