From Ouch to Oh!

When Sex Hurts: From Ouch to Oh!

It’s a fact. Sex can hurt! Approximately 40% of post-menopausal women experience vaginal dryness and pain with intercourse— and only 20-30% of those discuss it with their physician! (1, 2)

Many peri-menopausal women also have the same complaint. Given the fact that the average age of menopause is 51 and the average lifespan for a woman in US is 82 years, wouldn’t you like to learn how to solve this problem so you can keep sex fun and pleasurable for 30-plus years?

So, what causes vaginal dryness?
In general it occurs with the onset of perimenopause where there are hormonal fluctuations in both estrogen and progesterone levels. Then at the time of menopause, defined as 12 months without a spontaneous menstrual cycle, there is a rapid decline in estrogen production, which leads to many symptoms, including vaginal dryness and pain with intercourse. Another medically used term for this is “vulvar vaginal atrophy” and although it is technically correct it doesn’t sound like a condition that many women would like to have. Right?

What are the symptoms?
Many of my patients describe it as “sharp knives cutting into the vagina” or a “rough sand-paper” sensation. Years ago, one of my patients exclaimed, “I think my vagina is broken. Broken!! It feels like the Sahara Desert!” Frequently, accompanying this pain is some vaginal bleeding due to tearing of the vaginal tissues during intercourse.

Not uncommon then for many women to avoid sexual relations all together, which can lead to strained relationships or worse.

Good News!! It doesn’t have to hurt!
That’s right, there are many ways to reduce these symptoms. Below are my top recommendations for relieving the pain and getting your sex life back on track:

1) Stay hydrated: Drinking six to eight glasses of water a day (and more if you exercise vigorously) will help keep your tissues moist, both above and below the belt.

2) Use water-based lubricants: You should look for natural, water-based lubricants to avoid developing sensitivities in your delicate areas. Make sure that they are also free of parabens and glycerin-free. One I highly recommend is JUST Love by Pure Essentials. 

3) Use a long-lasting vaginal moisturizer: The one I recommend most to my patients is Replens. It lasts for 48-72 hrs. and can be used 2-3 times a week, even without sex so you’ll be ready anytime. Usually, it will take at least 3 months before a significant difference is noticed and your vaginal tissues regain their elasticity and moisture.

4) Avoid personal hygiene sprays: These contain irritating chemicals, which will only further the pain and sensitivity to thin vaginal tissues.

5) Don’t douche!: Marketing companies were smart in trying to convince women that our bodies were dirty and smelly. Well, Mother Nature was smarter! She built a self-cleansing system which regulates and maintains a healthy vaginal environment. By douching, you’re washing away the healthy vaginal bacteria, lactobacilli, and acidic vaginal chemical balance (pH = 4.5) is disrupted leading to dryness and inflammation.

6) Use It or Lose It: Yes, this is true —- the more sexual activity you have, the more blood flow to all areas in your body, especially your vaginal tissues.

What if these don’t work?

For many patients, these remedies don’t completely knock out their pain and dryness. Fortunately, we have many options now. The next treatment I’d recommend would be intravaginal estrogen therapy, intravaginal DHEA therapy and oral therapy. If you are experiencing hot flashes, night sweats, mood swings, and any other common menopausal symptoms, then systemic (oral or transdermal) therapy might be needed.

Discuss these with your physician to see which one would work best for you, given your lifestyle and comfort level with applicators, etc.

7) Types of low-dose vaginal estrogen therapy:

  1. Vaginal creams:These include Estrace and Premarin vaginal creams and are used with a vaginal applicator with recommended dose ¼ – ½ applicator in the vagina twice a week at night on a regular basis.

I was fortunate to be one of the Primary Investigators with Premarin vaginal cream clinical trials. With the help of my study patients, as well as many others in the U.S. and Canada, the lowest effective dose of ¼ applicator twice per week was determined. (3)

  1. Vaginal tablets: Vagifem, 10 mcg of estradiol, tablets placed with applicator into vagina twice per week at bedtime. (4)
  2. Vaginal suppositories: These include Imvexxy at both 4 mcg and 10 mcg doses.
  3. Vaginal Ring: Estring, can be used for up to 3 months and is a very convenient way to deliver low dose estradiol to vaginal tissues.
  4. DHEA vaginal suppositories: Also known as Intra-rosa.
  5. Oral Therapy – Osphena, known as a selective-estrogen receptor agonist-antagonist, taken daily by mouth for treatment of vaginal dryness/pain with intercourse
  6. Bio-identical low dose estrogen therapy: Bio-identical means containing the same physiological hormone that your ovaries made before menopause, specifically estradiol. If you and your physician would rather have a Compounding Pharmacy formulate a vaginal treatment for your vaginal dryness, make sure that the Compounding Pharmacy is highly reputable and practices quality control.

Openly discussing this topic and addressing these concerns is incredibly satisfying for me and my patients! I know that I have helped them regain this important intimate part of their health and they are excited to have it back!

Remember – sexual health concerns are important, no matter what age!

Be honest with your physician.

Talking about sex and sexual issues should no longer be considered taboo. It is an astounding (and saddening) fact that 7 out of 10 women with this condition do not speak to their gynecologist or family physician about it. (3) In my practice, every woman is asked about physical intimacy and any sexual concerns, including vaginal dryness and pain. It is critical that you find a compassionate physician whom you trust, can confide in and be comfortable discussing this intimate issue with!

Talk with your doctor today – there is help ….and no need for the pain!

Also, for more information about women’s libido and challenges surrounding, pick up a copy of my book, Healthy Sex Drive, Healthy You: What Your Libido Reveals About Your Life.


  1. Bachmann, GA and Nevadunsky, NS. Diagnosis and treatment of atrophic vaginitis. American Family Physician, 2000; 61 (10): 3090-3096.
  2. Mac Bride, MB, Rhodes DJ, Shuster LT. Vulvovaginal Atrophy. Mayo Clin Proc. 2010; 85 (1): 87-94.
  3. Bachmann, G, Bouchard C, Hoppe D, Ranganath R, Altomare C, Vieweg A, Graepel J, Helzner, E. Efficacy and safety of low-dose regimens of conjugated estrogens cream administered vaginally. Menopause. 2009 Jul-Aug;16(4):719-27.
  4. Novo Nordisk Vagifem. October 2010.


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