Why Does Menopause Make Sex Hurt? Sex & Menopause Explained

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What is actually happening to the tissue?

GSM is defined as a collection of symptoms and signs tied to a drop in estrogen and other sex steroids, involving the labia majora and minora, clitoris, vestibule and introitus, vagina, urethra and bladder [2]. The consensus panel judged the term medically more accurate, all-encompassing and publicly acceptable than vulvovaginal atrophy, which is also known as atrophic vaginitis [2][4].

The consensus definition lists genital symptoms of dryness, burning and irritation; sexual symptoms of lack of lubrication, discomfort or pain, and impaired function; and urinary symptoms of urgency, painful urination and recurrent urinary tract infections [2]. Women may have some or all of them, the symptoms must be bothersome, and they must not be better explained by another diagnosis [2].

The FDA's consumer information puts it plainly: the vagina may become dry and thin, and sex may be painful [1]. MedlinePlus lists vaginal dryness, which may cause pain or discomfort during intercourse, among the changes of the menopausal transition [9].

How common is GSM, and does it settle down?

More than half of postmenopausal women are affected [4]. It is underdiagnosed and undertreated: women are often embarrassed to seek treatment, and clinicians do not always actively screen for it [4].

The symptoms do not reliably fade on their own. Some menopause symptoms improve over time while others stay the same or get worse, and without treatment the genital and urinary symptoms, including repeated urinary tract infections, may worsen over time [7]. In the STRAW+10 staging system, vaginal dryness becomes more common in the late postmenopause stage, stage +2 [10].

What treatments are recommended?

The Menopause Society's 2022 position statement calls hormone therapy the most effective treatment for vasomotor symptoms and for GSM. For bothersome GSM that over-the-counter products have not relieved, it recommends low-dose vaginal estrogen, vaginal DHEA (prasterone) or oral ospemifene [3].

Low-dose vaginal estrogen

Vaginal estrogen is used as creams, pessaries, tablets and an estradiol-releasing ring, and a Cochrane review compared those forms for vaginal atrophy in postmenopausal women [11]. A clinical review describes low-dose vaginal estrogen as the criterion standard for GSM: effective and safe for most patients, with caution suggested for survivors of hormone-sensitive cancers [4]. Vaginal estrogen products carry their own labeling.

Ospemifene (Osphena)

Ospemifene is an oral non-estrogen drug approved in 2013 for painful intercourse due to menopause [5]. It carries a boxed warning for endometrial cancer and cardiovascular disorders [5].

Prasterone (Intrarosa)

Prasterone is a vaginal insert of DHEA, approved in 2016 for painful intercourse due to menopause [6]. It is a non-estrogen product taken vaginally rather than by mouth.

Lubricants and moisturizers

Nonprescription options include vaginal lubricants, moisturizers and dilators [4]. The Menopause Society recommends the prescription options above when over-the-counter products do not relieve bothersome GSM [3].

Does systemic hormone therapy help?

Oral Premarin is indicated for moderate to severe vulvar and vaginal atrophy due to menopause [8], and the 2022 Menopause Society statement calls hormone therapy the most effective treatment for GSM as well as for hot flashes [3]. The Premarin label says that when prescribing solely for vulvar and vaginal atrophy, topical vaginal products should be considered [8]. For a woman with a uterus, the label says a progestin should be considered to reduce the risk of endometrial cancer [8].

The Premarin label's contraindications include undiagnosed abnormal genital bleeding, breast cancer or a history of it (except selected palliative use), estrogen-dependent neoplasia, active or past deep vein thrombosis or pulmonary embolism, active or past arterial thromboembolic disease, hepatic impairment or disease, and known protein C, protein S or antithrombin deficiency [8].

What do the estrogen labels warn about?

Estrogen labeling is in transition. In November 2025, the FDA asked manufacturers to remove the cardiovascular disease, breast cancer and probable dementia statements from boxed warnings, while retaining the endometrial cancer boxed warning for systemic estrogen-alone products [12][13]. The request covered local vaginal estrogen as well, with its safety information to be condensed [12]. On 2026-02-12 the FDA approved changes for a first batch of six products [14]. Many labels still carry the older box, including the Premarin oral label effective 2026-06-04, which still names endometrial cancer, cardiovascular disorders, breast cancer and probable dementia [8].

When the pain is not from GSM

Lichen sclerosus is a chronic inflammatory skin disease that mostly affects the anogenital area, causes itching and pain, and can lead to fissures and scarring; the diagnosis is confirmed with a skin biopsy and the first-line treatment is a high-potency topical corticosteroid applied early [15].

The Office on Women's Health states that vaginal bleeding after menopause is not normal [7].