Sex Doesn’t Have to Hurt – Here’s How to Get Back to Pleasurable Intimacy

It’s easy to feel alone when sex hurts. What you may not realize is that about 30% of women at any age and up to 45% of postmenopausal women report pain with vaginal intercourse.

For some people, sex has always been painful. For others, discomfort began later in life. While the hormonal changes of menopause play a large role in creating vaginal discomfort, each person also brings with them a unique medical history and past experiences with sex. Treating painful sex starts with understanding the elements that may be contributing to your symptoms.

Start with Treating Symptoms of GSM

Genitourinary Syndrome of Menopause (GSM) is the term used to describe the genital, sexual and urinary symptoms women experience as a result of estrogen loss around menopause. Experts estimate that it affects 90% (but possibly more) of postmenopausal women.

Some of the most common symptoms include:

• Dryness, burning and irritation of the vagina
• Lack of vaginal lubrication leading to discomfort, pain and decreased sexual satisfaction during intercourse
• Increase in urinary urgency and recurrent urinary tract infections

If you are experiencing pain with sex for the first time around the menopause transition, it’s a safe bet that GSM is contributing to some degree. If you haven’t already, be sure to read the article about GSM linked below for more information about treatment options.

Studies have shown that GSM tends to worsen over time, so your management strategy may need to shift if you find it not as effective with passing years.

Other Important Contributors to Pain with Sex

Pain and sex are two of the most complex experiences for your mind and body. While GSM is a major single cause of painful sex for peri- and postmenopausal women, our experience with sex is influenced by a myriad of factors.

If you’ve been treating your GSM symptoms successfully for at least a few weeks and still having pain—or if you’ve ruled out GSM with your healthcare provider—consider these factors:

• Health status. How is your general health? Do you have any acute infections or chronic conditions?
• Medications. Are you taking any medications that influence your libido or change vaginal lubrication?
• Gynecologic history. Did your pain begin around the time of pregnancies, surgeries or pelvic procedures? Have you had any injuries to the vagina, anus or pelvis?
• Mental health. Are you living in “fight or flight” mode? High stress levels can exacerbate the body’s guarding response during sex and make it hard to achieve arousal and readiness for penetration.
• History of physical or emotional trauma and/or abuse. Traumatic experiences including—but not limited to—sexual trauma can deeply influence our nervous system. Those who have experienced sexual abuse may benefit from comprehensive support from mental health professionals, physicians and pelvic physical therapists. People who have histories of trauma can also experience heightened guarding responses, even when their trauma wasn’t around sex.
• Relationship dynamics. Are you facing challenges in your relationship with your sexual partner? Conflict or stress in your relationship is hard to compartmentalize and can affect you feeling aroused, engaged and safe in a sexual experience.

Your Body’s Guarding Response

Your nervous system is particularly sensitive to feelings of pain and “threat” in the genital area. Regardless of why you experience pain, the body deeply ingrains this experience and tries to guard against it the next time. Even if you feel aroused and enthusiastically consent to penetration, your nervous system may be working hard to “protect” you.

The guarding response of tightened muscles and hypersensitivity to touch usually make penetration painful again, which reinforces the guarding response the next time. It’s entirely logical, then, that repeated painful experiences can lower your sexual desire and have cyclical effects on subsequent sexual experiences.

This cycle of pain, guarding and low libido can sometimes end on its own, but many people need to take action to regain control and teach their body that sex is desirable and penetration is not a threat.

Moving Forward

Finding your way back to pleasurable sex looks different for each person and partnership.

Consider vaginal dilators, a widely used therapeutic tool that allows you to practice inserting increasing sizes into the vagina to regain comfort during your desired sexual activities. Learn more about dilators in the article linked below.

When it comes to partnered intimacy, consider the following temporary or ongoing strategies:

• Always have lubricant on hand. Invest in a high quality lubricant that agrees with your skin (this may require some trial and error). Even if you never needed lubricant in your younger years, it becomes an essential for many women after midlife. Check out the article about lubricants linked below.
• Use foreplay to help your body help you. When aroused, female anatomy changes to help make penetration more comfortable. In addition to creating lubrication inside the vagina, the vaginal canal actually lengthens and moves the cervix further away from the vaginal opening. Achieving arousal and readiness for penetration usually requires time and effort—but those non-penetrative activities are also often the most pleasurable! When you’re trying to reduce pain, lean into extended foreplay that helps your body get truly ready.
• Temporarily explore and enjoy only non-penetrative activities. Knowing that sexual intimacy will always end with vaginal intercourse can make it hard for you to relax and enjoy the other pleasurable parts of the experience. Talk to your partner about taking it out of your repertoire temporarily to see if it allows you to build excitement and desire around making each other feel good in other ways.
• Enjoy smaller levels of penetration during sex. If penetration with a penis is painful, penetration with fingers or smaller toys like vibrators may feel more tolerable or pleasurable. If you’re using dilators, consider bringing them into partnered intimacy. You may feel more comfortable in the beginning by controlling the penetration yourself, or guiding your partner with your hand on theirs.
• Buffer against deeper penetration. If deeper thrusting is a pain point for you, the Onut (linked at the end of the article) is a set of stretchy, stackable rings that allow you to set boundaries around depth of penetration. They are worn on a partner’s penis or dildo and allow you to relax knowing that the buffer will limit how far penetration can go.

The process of reclaiming pleasurable vaginal penetration isn’t always short or straightforward, but you don’t have to do it alone. If you’re looking for more support, consider:

• Individual or couples therapy. Whether they’re working with a sex therapist to talk through specific experiences around sex, or getting support in other areas of their lives or relationships, many people find talk therapy to be a game changer in treating pain with sex.
• Pelvic physical therapy. Pelvic PTs are experts in working with clients to treat painful sex once medical contributors have been addressed. In pelvic PT, you’ll learn about the pelvic floor, practice gaining control and confidence over the pelvic floor muscles and practical strategies to move you towards pleasurable sex.