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Sex isn’t always mind-blowing, but it shouldn’t be painful. All too often, sex can start becoming painful as you enter the stages of menopause. But this can lead some people to suffer through painful sex or avoid sex altogether.

However, you can reclaim your sexual pleasure and look forward to intimacy (e.g., no longer need to throw cold water on your partner’s attempts at foreplay). Keep reading to understand what happens in your body and brain when menopause hits and painful sex begins — and what you can do about it.

Why does menopause cause pain during sex?

Menopause causes a decrease in estrogen levels, which can lead to thinner and drier vulvar and vaginal tissues. This lack of moisture and lubrication, along with decreased blood flow to the pelvic floor, can result in pain during sex.

Along with hot flashes, night sweats, and other uncomfortable symptoms, the fluctuation of estrogen during the menopausal transition can directly impact sexual functioning, specifically:

• Weaker orgasms. Lower levels of estrogen are associated with decreased blood flow to tissues in the pelvic floor. The pelvic floor includes the muscles, nerves and connective tissue at the bottom of the pelvis that support bowel, bladder, and sexual functions. In addition, the clitoris may be less sensitive to stimulation, and orgasms may feel different, be less intense, or become absent altogether.
• Pain during intercourse. The vulvar and vaginal tissues (skin) often become thinner and drier when estrogen decreases. At the same time, less moisture and lubrication (also caused by lower levels of estrogen) can make the tissues more sensitive and less flexible. This all adds up to pain with any kind of vaginal penetration, a condition the medical field calls dyspareunia.

Experiencing painful sex even one time can lead to worries that the next time will be painful as well. The emotional distress that comes with anticipating pain can cause the muscles throughout the body to tense up, leading to even more pain during penetration. This cycle is called the vaginismus pain cycle, and we’ll dive into more detail below. In some people with genito-pelvic pain/penetration disorder (GPPD), even thinking about sex can result in reflexive pain and pelvic floor muscle tension.

What is the vaginismus pain cycle?

The vaginismus pain cycle is a loop of pain, fear, and increased pain that occurs during sexual activity. Here’s what’s going on in your body and brain. Talk to your healthcare provider if you have any questions about this pain cycle.

Phase 1

Pain during sex sends the signal to your brain to shift into fight-or-flight response. It may be difficult to stay calm, as your amygdala (the part of your brain that helps you process, interpret, and store emotions) takes over.

Phase 2

Since your brain now considers penetration a “threat”, your pelvic floor muscles tense up, especially those near the vaginal entrance.

Phase 3

Any attempts at penetration through those contracted muscles often causes more pain.

Phase 4

Your body was trying to protect you and “failed”. So, any pain during Phase 3 sparks future fear and anxiety about sex.

Phase 5

As this cycle repeats, your body has trouble letting go of the negative sexual experiences. The possibility of pain becomes imprinted on your nervous system.

Phase 6

You may dread, or even avoid, any sexual activity. This strengthens the fear and anxiety associated with vaginal penetration, allowing your amygdala to continue controlling your body’s response.

With time, this cycle can not only impact your romantic relationships but also your physical, emotional, and mental health.

What can I do about painful sex?

If you’ve experienced (or are currently experiencing) pain with sex, one step to consider is to see a pelvic floor physical therapist. Strengthening and rehabilitation exercises are effective treatments for the symptoms of menopause that can lead to painful sex.

How can a pelvic floor physical therapist help with painful sex?

A pelvic floor physical therapist can provide effective treatments for the symptoms of menopause that contribute to painful sex. They may use techniques such as vaginal dilators, core and pelvic floor strengthening exercises, breathing exercises, safe movement, and lifestyle recommendations. These interventions can improve blood flow, increase muscle strength and tone, and decrease sexual dysfunction when it bothers you that you have trouble having or enjoying sex.

What can I expect from pelvic floor physical therapy for painful sex?

In addition to the physical interventions, pelvic floor physical therapy can provide education on menopause and its effects on the body, information on alternative treatments, and support in building a network of healthcare professionals. The goal is to help you reclaim your sexual pleasure and improve your physical, emotional, and mental well-being.

Check out Origin to learn more.

How can a certified sex therapist help with painful sex?

You might also consider talking to a sex therapist about painful sex since pain and perception are often mental barriers. Sex therapy, along with pelvic floor physical therapy can be an integrated approach that incorporates mind-body functioning and helps with negative distortions or beliefs about painful sex.