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?

Each woman's experience with pain during intercourse, medically known as dyspareunia, is unique. Therefore, treatment plans for pelvic floor physical therapy are tailored to individual needs and circumstances. This article explores the cornerstones of pelvic floor physical therapy, helping women understand what to expect and how these techniques may lead to pain-free intimacy.

Phase 1: Relaxation, Release, and Stretching

• Manual Therapy: This involves hands-on techniques like soft-tissue massage, trigger-point release, and myofascial release applied to the pelvis, abdomen, back, hips, and thighs. These techniques promote blood flow, increase tissue elasticity, and reduce pain sensitivity.

• Internal Techniques: When ready, the therapist may introduce these techniques inside the vagina to address specific concerns. Patients and their partners may learn these techniques for home practice to accelerate progress.

• Pelvic Floor Exercises: "Pelvic drops" help relax pelvic muscles and open the vagina. Biofeedback machines can be used to train muscle control and monitor progress. These exercises are discreet and can be done anywhere, anytime.

Phase 2: Strengthening

• Toning Exercises: Once muscles are relaxed and stretched, a pelvic floor physical therapist may incorporate toning exercises to strengthen weakened pelvic floor muscles. Biofeedback can again be used for optimal technique and progress tracking.

• Dilators: For further stretching and desensitization of the vagina, the therapist may guide patients through inserting fingers, tampons, and progressively sized dilators.

Additional Techniques:

• Hip Stretches: For individuals with tight hips, these stretches can relax the hips and open the pelvic floor, potentially alleviating pain.

• Scar Management: Patients with C-sections, hysterectomies, or other pelvic surgeries may benefit from ultrasound or cold laser therapy to heal and soften scarred tissue. Abdominal strengthening exercises may also be included.

Important Note: Biofeedback, ultrasound, and cold laser therapy are not recommended during pregnancy.

By understanding the cornerstones of pelvic floor physical therapy, women experiencing dyspareunia can feel empowered to seek help and explore the path towards pain-free intimacy.

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