Pain-free Sex After Menopause

As a women’s health physical therapist, I see many women devastated by painful sex after menopause. Please know that there is hope, there is help—in most cases, there is even a cure.

A reassuring news flash (versus a hot flash): Menopause signals the end of your childbearing years—not the end of your sex life.

Here’s a common scenario: As Eve goes through perimenopause and then menopause, intercourse becomes uncomfortable and then painful. (The medical term for painful intercourse is dyspareunia.) Thinking “I must be dry,” she tries vaginal lubricants and asks her doctor about topical estrogen. These products help—but only to a point.

That’s because there’s more to the story than Eve, and many women, realize. When sex hurts, the problem is usually more than skin-deep. A muscular cycle is also set in motion. To guard against more pain, Eve subconsciously tightens her vaginal and pelvic floor muscles; the tightness leads to more pain, which leads to less-frequent sex, which leads to more tightness; and so the cycle goes.

What’s the reassuring news? Pelvic floor physical therapy—a specialized type of physical therapy provided by specially trained physical therapists—can shift this sexual pain cycle into reverse. A range of gentle techniques has been proven to help many perimenopausal and menopausal women resume pain-free, pleasurable intercourse.

What happens during pelvic floor physical therapy?

Because each woman’s medical and sexual circumstances are different, treatment plans vary. Here are the cornerstones of pelvic floor physical therapy:

* The first phase is to relax, release, and stretch tightened pelvic and vaginal muscles. Your physical therapist will use manual (hands-on) therapy techniques on your pelvis, abdomen, back, hips, and thighs. For example, she may use soft-tissue massage, trigger-point release, and myofascial release to promote blood flow, increase elasticity, and reduce pain sensitivity. When you’re ready, she’ll gently introduce these techniques inside your vagina. She may teach you and your partner how to do them between appointments. This “homework” speeds and improves your progress.

* Your physical therapist will also teach you pelvic floor exercises such as “pelvic drops” to relax your pelvic muscles and open your vagina. Your therapist may enlist a biofeedback machine to train you to isolate and control your muscles, and to monitor your progress. You can easily do these “invisible” exercises anywhere, any time—for example, sitting at your desk or standing in line.

* After your pelvic and vaginal muscles are relaxed and stretched, your physical therapist may teach you pelvic floor toning exercises. These vaginal exercises help strengthen muscles that have weakened due to childbirth, hormonal changes, or aging. Again, your therapist may enlist biofeedback to improve your technique and to track your progress.

* After your muscles have begun to relax and stretch, your physical therapist may show you how to insert fingers, then tampons, and then progressively sized dilators to further stretch and desensitize your vagina.

* If your hips are tight—perhaps from sitting behind a desk every day—your therapist may show you hip stretches to relax your hips and open your pelvic floor.

* If you’ve had a C-section, hysterectomy, or other pelvic surgery, your physical therapist may add ultrasound or cold laser to heal and soften any vaginal tears or thick, sore scars. She may also give you abdominal strengthening exercises.

(Note: Biofeedback, ultrasound, and cold laser are not recommended for pregnant women.)

Partners in pain relief

Pelvic floor physical therapy works in concert with other treatments for perimenopause- and menopause-related sexual pain.

* As your hormone levels drop during perimenopause and menopause, your healthy, plump, pink vaginal tissue becomes thinner, less lubricated, and less elastic; your vaginal opening (vestibule) and vagina may narrow; and the contours of your lips (labia) and clitoris may change. All these changes can cause pain, burning, and irritation during and after sex. To replace lost estrogen, your doctor may prescribe topical or vaginal estrogen. (Caution: if you’ve had cancer, consult with your doctor about estrogen’s risks and benefits.)

* Vaginal skin conditions such as lichen planus and lichen sclerosis may develop during menopause. Lichen is usually painful or uncomfortable, and doctors often prescribe topical corticosteroids to treat or control it.

* Menopausal hormone dips can weaken your libido (sex drive or sexual desire). If you have sex less often, your vaginal muscles may tighten and sex may become uncomfortable. Your doctor may also evaluate you for non-menopausal causes of low libido. Some couples turn to sex therapy to address their concerns about aging, libido, and desirability, and to rekindle intimacy.

For more information, visit:

American Association of Sexuality Educators, Counselors and Therapists

American Physical Therapy Association Section on Women’s Health

International Pelvic Pain Society

The International Society for the Study of Vulvovaginal Disease

National Vulvodynia Association

The North American Menopause Society

The V Book: A Doctor’s Guide to Complete Vulvovaginal Health, by Elizabeth G. Stewart, M.D.

The Vulvar Pain Foundation

 

Raquel Perlis