Dryness and thinning of the vagina is the most common cause of painful sex at midlife and beyond.
Menopause-related discomfort. As reviewed earlier, the dryness and thinning of the vagina (vaginal atrophy) that follows the drop in estrogen around menopause is the most common cause of painful sex at midlife and beyond. Less estrogen means less vaginal lubrication and a less stretchable vagina. The vagina also may shorten and become tighter at the opening. In some women this can lead to a feeling of vaginal tightness during sex along with pain, burning, or soreness. Inflammation and irritation can also develop (atrophic vaginitis), leading to greater discomfort and sometimes to tearing and bleeding of tissue with any penetration of the vagina.
Discomfort not directly related to menopause. Other types of vaginal discomfort are not directly related to menopause but can and do occur in peri- and postmenopausal women, making sex painful or difficult:
- Vaginitis. Although vaginitis, or inflammation of the vagina, can result from estrogen-related vaginal atrophy, it can also be caused by a yeast or bacterial infection or by irritation from soaps or hygiene products. Symptoms include vaginal discharge, itching, burning, and swelling of the vagina and vulva, sometimes accompanied by pain during urination. Once the cause is determined, vaginitis can be treated with medication or by stopping use of the irritating product.
- Vaginismus. Vaginismus involves involuntary spasms or contractions of the muscles at the vaginal opening or in the perineum (the area between the vagina and anus). In addition to making penetration of the vagina difficult or impossible, vaginismus can be painful, causing burning or stinging sensations. It may develop as a result of past sexual abuse, fear of sex, or lack of sexual experience. Vaginismus also may occur for the first time in midlife women as a response to painful intercourse caused by estrogen deficiency and vaginal atrophy. There are a number of treatment options, including cognitive-behavioral psychotherapy, physical therapy, relaxation exercises, vaginal dilators, biofeedback, and medications.
- Urinary tract conditions. These include recurrent bladder infections, bladder inflammation and irritation (sometimes called irritable bladder syndrome or interstitial cystitis), urethritis (irritation of the urethra, the short tube that passes urine from the bladder out of the body), sensitivity to latex condoms, and a prolapsed bladder (dropping down of the bladder into or even outside of the vagina).
Because vaginal discomfort can arise from so many different sources, persistent symptoms of dryness, irritation, burning, itchiness, or pain should be evaluated by a healthcare provider to determine their cause.