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Sex after menopause doesn’t need to hurt

Between 13% and 84% of postmenopausal women experience dyspareunia—vaginal pain during sex—but the condition is rarely evaluated or treated despite the availability of safe and effective therapies.

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Between 13% and 84% of postmenopausal women experience dyspareunia—vaginal pain during sex—but the condition is rarely evaluated or treated despite the availability of safe and effective therapies. With life expectancy increasing and the functional health of older adults improving, the identification and treatment of painful penetrative sex represents a great unmet need.

A Northwestern University Feinberg School of Medicine comprehensive review of medical studies involving painful sex in post-menopausal women provides a roadmap for doctors to evaluate and treat the typically overlooked condition. 

It is the only comprehensive review of its kind because it examines multiple reasons for the condition beyond just vaginal dryness due to lack of estrogen, such as post-hysterectomy problems, arthritis, cancer treatments and more.

“Post-menopausal women shouldn’t accept painful sex as their new norm,” said Dr. Lauren Streicher, clinical professor of obstetrics and gynecology at Feinberg. “Many women try over-the-counter lubricants but continue to have pain. They, and sometimes their health care professionals, are unaware that there are other, more effective treatments. 

“In addition, women are increasingly treated by telemedicine and not examined. The cause of pain with penetration is assumed to be due to vaginal dryness when they may have another condition that has been undetected.” 

The review was published in Menopause: The Journal of The North American Menopause Society.

Aside from the obvious negative aspects of enduring pain and the inability to have penetrative sex, the consequences of dyspareunia include negatively impacting relationships and self-esteem and can contribute to depression and anxiety. In addition, other sexual dysfunctions such as hypoactive desire disorder and orgasmic dysfunction are often consequences of pain with penetrative sex.

Causes of vaginal pain during sex

Post-menopausal vaginal pain is often specifically due to lack of estrogen, but there are other, usually undetected and untreated causes for inability to have penetrative sex, Streicher said. These include post-hysterectomy problems; cancer treatments (chemotherapy, radiation, surgery); lichen sclerosus (patchy, discolored, thin skin) and other vulvar conditions; pelvic-floor tension; arthritis and other musculoskeletal problems; pelvic organ prolapse; and sexually transmitted infections.

More than 30% of women over the age of 50 are single and potentially will have a new sexual partner, Streicher added. 

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“Sexuality in women after the age of 50 years is marginalized, and gynecologic care is not prioritized, valued or even recommended,” Streicher said.

Why aren’t women being evaluated, treated for the condition?

Despite available treatments, dyspareunia often goes undetected for a variety of reasons. First, most American women no longer see a gynecologist after going through menopause, Streicher said. Secondly, women often don’t discuss painful sex with their primary health care clinicians, and, when they do, most clinicians are not equipped to treat these problems because they haven’t been trained to properly evaluate or treat dyspareunia in this population. Third, sexual function is often a low priority in women with other serious medical problems.

In a 2004 survey of more than 1,000 midlife women, 98% had at least one sexual concern, but only 18% of physicians broached the topic. This is particularly true in postmenopausal women who are unaware that solutions are available and rarely seek care for this complaint.

It’s also difficult to pinpoint the exact prevalence of dyspareunia in post-menopausal women because studies on dyspareunia require women to have at least one sexual encounter the month before enrollment, and women with dyspareunia avoid sexual activity because of pain. 

What can be done?

Doctors should broach the topic of dyspareunia with their patients using oral or written questionnaires, Streicher said. In addition to a thorough medical history and physical examination, various tools can be used as further assessments, including vaginal pH, vaginal dilators, imaging, vulvar biopsy, vulvoscopy and photography, the cotton swab test, sexually transmitted infection screening and vaginitis testing.

Some of the treatments discussed in the review include silicone lubricants, moisturizers, vaginal estrogen, ospemifene, dehydroepiandrosterone, local testosterone therapy, cannabidiol and fractional CO2 laser treatments. In some cases, dyspareunia may need to be specifically addressed by pelvic floor physical or sex therapists. 

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