Vaginal Dryness, Painful Sex, and Genitourinary Syndrome of Menopause
Day 26 of the 30-day Perimenopause Series.
Sex should not hurt.
That sentence deserves a paragraph by itself, because so many midlife women have been quietly living the opposite for years. They cannot remember when it started. They just remember that at some point, intimacy went from a source of connection to a source of dread. They have not told their doctor. They have not told their partner. They may not even have told themselves.
Painful sex in midlife almost always has a physical cause. Most of those causes fall under one clinical umbrella: Genitourinary Syndrome of Menopause, or GSM. It is common. It is progressive. And — this is the part most women are not told — it is remarkably treatable.
What GSM Is
GSM is the name given to the constellation of changes that happen to the vulvar, vaginal, urethral, and bladder tissue when estrogen declines. It replaced the older term "vulvovaginal atrophy," which women (understandably) hated.
The physiology: estrogen supports thickness, elasticity, blood flow, moisture, pH balance, and the healthy microbiome of the pelvic tissue. As estrogen declines through perimenopause and menopause, that tissue thins, dries, loses collagen, and shifts pH — becoming more vulnerable to irritation, tearing, and recurrent infection.
GSM affects roughly half of postmenopausal women. Unlike hot flashes, GSM does not fade with time. It gets worse if untreated.
What It Actually Feels Like
Vaginal dryness, itching, or a subtle burning even when nothing is touching it.
Painful intercourse — sometimes described as sharp, sometimes as raw, sometimes as a tightness that will not relax.
Light bleeding or spotting after sex, from micro-tears in fragile tissue.
Reduced sensation and slower or less-intense arousal, because the tissue itself is less responsive.
Recurrent urinary tract infections — or the burning feeling of a UTI that does not culture positive.
Urinary urgency, frequency, or leaking with sneezing, exercise, or laughing.
Vulvar irritation or a "raw" feeling with everyday clothing.
Discomfort with bike seats, long car rides, or sitting for extended periods.
If any of this sounds familiar, please read the next section carefully.
What Actually Treats It
GSM is one of the most treatable conditions in perimenopause and menopause. The treatments are not exotic. They are well-studied, widely available, and — for most women — remarkably effective.
Vaginal estrogen (see Day 24). Low-dose, applied locally as a cream, tablet, suppository, or ring. Minimal systemic absorption. Standard of care for GSM. Most women see meaningful improvement within 4 to 12 weeks.
Vaginal DHEA (Intrarosa / prasterone). A daily insert that converts locally into small amounts of estrogen and testosterone. An alternative to vaginal estrogen for some women, including some with a breast cancer history following individualized discussion with their oncology team.
Ospemifene. An oral non-estrogen medication that acts on vaginal tissue. Useful when a woman prefers or requires a non-estrogen option.
Vaginal moisturizers — different from lubricants. Applied on a schedule (every 2 to 3 days), not just with intercourse. Look for glycerin-free, paraben-free products such as Good Clean Love, Revaree (hyaluronic acid), or K-Y Liquibeads. These improve tissue hydration but do not reverse tissue changes.
Lubricants for intimacy. Silicone-based lubricants tend to last longer and are less irritating than water-based products with lots of additives. Skip anything warming, tingling, or scented — the perimenopausal tissue does not need surprises.
Pelvic floor physical therapy. For women whose GSM has led to protective muscle guarding, painful spasm, or urinary dysfunction, this can be transformative. Often used alongside vaginal estrogen.
CO2 laser therapy (for example, MonaLisa Touch). Emerging evidence, still less regulated. Discuss with a menopause-trained provider before pursuing.
What To Do About Sex Right Now
Even while you are working on the underlying tissue, please stop having painful sex. Every episode of painful intercourse reinforces protective guarding and adds emotional weight to future encounters.
In the meantime:
Use a good silicone-based lubricant generously. "Enough" is more than most women think.
Slow the pace and expand the definition. Extended arousal, non-penetrative pleasure, and connection outside the bedroom all support what happens inside it.
Talk with your partner. "This is not about you. My tissue is treatable, and I am working on it. Right now, this hurts, and I need us to move at a different pace."
Get the vaginal estrogen prescription started. Do not wait until the next annual visit. Ask now.
If sex has become associated with dread, consider seeing a sex therapist or pelvic floor PT alongside the medical treatment. Retraining safety is real work.
Why This Conversation Rarely Happens
Providers often do not ask. Women often do not bring it up. A short appointment feels like the wrong container for a big vulnerability. And women were culturally taught that pelvic changes are private, embarrassing, and something to endure quietly.
None of that is true anymore. The clinical care has caught up. The stigma has not — and the only way it changes is if this conversation moves out of whispers and into ordinary medical visits.
You are allowed to say the words. You are allowed to ask. You are allowed to expect an informed answer.
Whole-Person Steps
Name it to yourself first. Then to your provider. You do not have to be dramatic. "Sex has become uncomfortable and I would like to try vaginal estrogen" is enough.
Start a schedule of vaginal moisturizer (every 2 to 3 days) while you pursue prescription treatment.
Stop painful intercourse until the tissue is healing. Guarding compounds.
Ask about vaginal estrogen, DHEA, or ospemifene at your next visit. If your provider declines to discuss any of them, get a second opinion.
If pelvic floor tension has developed, request a referral to a pelvic floor physical therapist. This is a specialty and it works.
If You Are in Utah
At Integrative Mind Body Psychiatry, I take pelvic symptoms seriously and treat them as part of the whole picture of midlife well-being. When vaginal estrogen or another GSM treatment is appropriate, I help you get it on board and coordinate with your OB/GYN or primary care. Telehealth for adults, adolescents, and women in hormonal transitions across Utah. Insurance accepted through Headway. Learn more at integrativemindbodypsychiatry.com.
This post is educational and is not a substitute for individualized medical advice. Please talk with your own clinician before starting, stopping, or changing any treatment.
Respectfully,
Beth Makar, RN, Dual-MSN, PMHNP-BC
Comments