Is painful intimacy ‘all in my head’?

Lubricants aren’t doing enough to make it pleasurable—or even comfortable. The anticipation of pain is keeping me from even trying.

You’re not at all alone, for whatever comfort that gives you.

Once a woman transitions through menopause, defined as the one-year mark after her last period, she will be postmenopausal for the rest of her life. That means there is no source of estrogen, which results in what we call chronic and progressive vaginal atrophy. The effects of this are increasing vaginal dryness and thinning and narrowing of the vagina. This is not something that will reverse itself over time; without treatment, it only progresses.

The majority of postmenopausal women who want to continue to have intercourse need to compensate for the loss of estrogen. Localized estrogen is one option for treatment; it’s a long-term treatment, not a “cure.” It replaces the estrogen your body used to produce, directly in the area where it can have positive effect. This localized hormone treatment is preferred for women whose only issue is painful intercourse. There are fewer risks associated with it than with systemic hormone therapy (called HT or HRT, for hormone replacement therapy), which introduces hormones to more systems in your body.

There may be a secondary cause of pain, like vaginismus or vulvodynia. It is important to give feedback to your health care provider to be sure that the sources of pain are properly identified and treated. (And if your provider used the phrase “all in your head,” you may want to seek out a new one with a deeper understanding of menopause; the North American Menopause Society’s website is a good place to start.)

It may be that your tissues are now healthy, but because you’ve avoided intercourse you’ve lost “patency” and your vagina is narrower or shorter than before. Regular use of dilators will gradually stretch your vaginal tissues so that intercourse is comfortable again.

Alas, the sexual enjoyment that came so easily, with so little effort, is now a different story. But I hope you find the efforts of regaining sexual comfort worth the time and energy! I’m privileged to hear from patients about their successes, so I know it can happen!