Sexual Health · Collection 07

Why does sex hurt now?

Pain after menopause can involve dryness, but dryness is only one possibility. Where it hurts matters, and care should begin by understanding what may be causing it.

The clinical education

Where it hurts matters. Painful sex has more than one possible cause.

“Painful sex is a symptom, not a diagnosis. And lubricant is not a diagnosis either.”

Pain at the vulva or vaginal opening, with initial penetration, during deeper penetration, or after intercourse can feel different and can point toward different possibilities. Burning, tearing, pressure, aching, pelvic pain, or muscle spasm are useful clues, but no one pattern establishes a diagnosis by itself. More than one cause can be present at the same time, and the answer is not always “use more lubricant.”

Pain at the opening or with initial penetration may feel like burning, rawness, scraping, tearing, or a sense that the body is closing. Dryness and friction can contribute. So can genitourinary syndrome of menopause (GSM), pelvic-floor muscles that tighten or are tender, vulvar skin conditions, infection, scars, or persistent vulvar pain such as vulvodynia or vestibulodynia.

Pain with deeper penetration may feel like pressure, aching, or sharp pain farther inside the pelvis. Depending on the history and examination, possibilities can include endometriosis, uterine or adnexal conditions, pelvic-floor pain, adhesions or other postoperative changes, bladder or bowel conditions, and other pelvic causes. Menopause can contribute to sexual pain, but it does not explain every kind of deep pelvic pain.

Other possible contributors include vulvar dermatologic disease, vulvodynia or vestibulodynia, infection when it is actually present, inadequate lubrication or arousal, medication effects, cancer treatment, childbirth or surgical scars, prolapse when relevant, and relationship or contextual factors. These are possibilities to consider, not diagnoses made from a symptom pattern. Painful sex, or dyspareunia, can have more than one cause at once.

Genitourinary syndrome of menopause (GSM) describes symptoms and tissue changes involving the vulva, vagina, and urinary tract that can occur with lower estrogen, including during menopause or after some cancer treatments. Dryness, burning, irritation, tissue fragility, urinary symptoms, and pain with penetration may be part of GSM. GSM is common after estrogen decline, but menopause does not make GSM the only explanation for painful sex.

“The treatment should match the reason sex hurts.”

Lubricant can reduce friction during sexual activity. A vaginal moisturizer used regularly may help with day-to-day dryness. Neither, by itself, diagnoses or treats every underlying tissue, skin, muscle, or pelvic condition.

The StrongHer truth

Pain is information. Not punishment. You are not broken or dramatic, and you do not have to keep going through an activity that hurts in order to prove that you are trying.

Sometimes the problem isn’t that the vagina is too dry. Sometimes the muscles are guarding.

Pelvic-floor muscles can become overactive, tender, poorly coordinated, or protective in response to pain. Pain can lead to anticipation and guarding; guarding can tighten the muscles and make the next experience hurt more. This is a body response, not a failure to “just relax.”

Things women are often told

“Painful sex is just part of getting older.” Pain is common, but it is not something a woman has to accept without evaluation or options.
“Just use more lubricant.” Lubricant may ease friction. Persistent pain can have other causes that need a different response.
“You need to relax” or “you must not be aroused enough.” Arousal, context, and time can matter, but these phrases do not identify a cause. Pain can also make the body guard.
“Do more Kegels.” Pain may involve overactive or poorly coordinated muscles. Strengthening is not right for every pelvic floor.
“If you’re menopausal, it must be low estrogen.” GSM is one possibility, not a complete explanation for every entry or deep pain pattern.
“After breast cancer, there is nothing you can do.” Nonhormonal care, physical therapy, and other options may help. Local hormonal treatment can sometimes be considered through individualized shared decision-making.
“The examination looks normal, so the pain isn’t real.” Pain is real even when its cause is not visible on a routine examination. A careful assessment may include muscle function, tenderness, pain mapping, and the whole history.

A composite experience

“I tried more lubricant. It still hurt.”

This composite vignette reflects experiences women commonly describe. It is not the story of one identifiable patient.

Sometimes she asks right away. Sometimes the words take half a visit to arrive. Quietly. Embarrassed. Irritated. Tearful. Sometimes ashamed that she still cares. Sometimes ashamed that she feels nothing at all.

She may buy another lubricant, change positions to find one that hurts less, or begin anticipating pain before penetration starts. She may avoid intimacy because she fears the pain and wonder whether her partner thinks she is rejecting them. She may feel embarrassed trying to name exactly where it hurts, or wonder whether she has “lost” her sexuality. The pain is physical. The loss of ease, closeness, comfort, or recognition can hurt too.

Understanding can be a mercy. But it is not the same thing as grief.

When penetration has hurt, her body may begin to expect pain. She may want affection and closeness while avoiding the activity that has become painful. Avoiding painful sex is not evidence that she does not love or desire her partner. Pain can suppress desire because the brain learns to anticipate pain. That change in desire does not automatically mean she has a primary desire disorder. Pain, fear of pain, and the body’s protective response deserve attention.

Low desire can also exist independently of pain, or alongside it. Health, medications, sleep, mood, relationship context, life stress, hormones, and what a woman wants for herself can all matter. Desire is not a test she has to pass for someone else.

She and a partner may choose kinds of intimacy that do not reproduce pain while she is being evaluated or treated. Penetrative intercourse is not the only measure of closeness or a healthy sexual life. The point is not to lower expectations for her comfort. It is to make room for pleasure, agency, and care that fits the people involved.

If this has been lonely, you do not have to make the story smaller before you tell it. You do not need to decide whether it is “just hormones,” “just your relationship,” or “just you.” Those are questions for a careful conversation, not reasons to stay silent.

For a fuller conversation about low desire and testosterone, read “She was told testosterone would fix everything.” You can also explore “I Love My Partner. So Why Don’t I Want Sex Anymore?”, a whole-person look at what can change desire and what may help. For burning, irritation, and vulvar pain, continue to “Why Does My Vulva Burn When Every Test Keeps Coming Back ‘Normal’?”

Dr. Rhaney’s perspective

Bodies usually make sense. I want to learn what this pain is telling us.

“When a woman tells me sex hurts, I don’t start by assuming she needs more lubricant. I want to know where it hurts, when it hurts, what the tissue looks like, what the pelvic floor is doing, and what changed.”

A thoughtful evaluation starts with your experience. You do not have to use perfect medical language or prepare a polished explanation.

I want to know whether the pain is superficial or deep, when it began, whether it is new or longstanding, what it feels like, and whether it happens with initial penetration, deeper penetration, after intercourse, with other sexual activities, or outside sexual activity. I will ask about dryness, burning, tearing, pressure, spasm, bleeding, discharge, vulvar symptoms, urinary symptoms, menopause status, medications, prior pelvic surgery or childbirth injury, cancer history or treatment, pelvic-floor symptoms, what you have already tried, and what you want your sexual life to look like.

An examination, when you are ready and agree to it, may include looking at the vulvar and vaginal skin, checking for tissue changes, scars or lesions, gently assessing areas of tenderness, or evaluating pelvic-floor muscle tone and coordination. Depending on symptoms, testing or imaging may be considered. The examination should be explained and paced with your consent. You can ask to pause, change position, or stop. You do not have to complete an examination to be believed.

Persistent burning, fissures, visible skin changes, focal tenderness, or pain that continues despite adequate lubrication deserves a closer look. Vulvar pain is not automatically a yeast infection. Repeated treatment for yeast without evidence can delay evaluation for a skin condition, vulvodynia, GSM, pelvic-floor pain, or another cause. Our Vulvar Burning and Vulvodynia collection explores these concerns in depth.

Sexual pain also deserves a different differential depending on whether it is at entry or deep in the pelvis. New deep pain should not simply be attributed to menopause; the clinical picture may call for assessment of pelvic organs, endometriosis, postoperative factors, pelvic-floor pain, or other causes.

When pain changes the way your body anticipates touch, desire may change too. That does not automatically make low desire the primary diagnosis.

Treatment depends on what the evaluation finds and on your health history and priorities. A confirmed or clinically well-supported infection deserves treatment directed to its cause; symptoms that recur deserve reassessment rather than automatic repeat antifungal or antibiotic treatment when evidence of infection is lacking. Sometimes the next step is addressing a skin condition, GSM, pelvic-floor function, a pelvic condition, or more than one of these together. If low desire remains distressing after pain and other contributors are considered, it deserves its own conversation.

For women with a history of estrogen-dependent breast cancer, nonhormonal options are generally considered first. If they do not provide enough relief, low-dose vaginal estrogen may be considered after a discussion of benefits, uncertainty, alternatives, and the woman’s cancer history. For a woman taking an aromatase inhibitor, ACOG recommends shared decision-making involving the patient, gynecologist, and oncologist. Vaginal prasterone has not been studied in women with a history of breast cancer, and ospemifene’s prescribing information notes that it has not been adequately studied in women with breast cancer. Neither should be assumed to be a simple, automatically safer substitute. Your cancer type, current treatment, symptoms, and preferences matter. See our Cancer Survivorship collection for the fuller discussion.

For GSM, treatments may include nonhormonal moisturizers, local low-dose vaginal estrogen, vaginal prasterone (DHEA), or oral ospemifene for appropriate patients. These options do not all work the same way, and not all fit every medical history. Local vaginal therapy is different from systemic menopausal hormone therapy.

GSM and menopause education can also be explored in “Your hormone levels can fluctuate. Your symptoms still deserve attention.”

You are allowed to stop bracing. You are allowed to want closeness without wincing. This is not hopeless.

Felicia L. Rhaney, MD, FACOG, MSCP
Double board-certified OB-GYN and urogynecologist

Your conversation guide

You deserve care that matches the reason sex hurts.

The goal is not to push through pain. It is to understand what may be contributing and choose a plan that fits your body, health history, and wishes.

“The treatment should match the reason sex hurts.”

When dryness or friction is part of the problem

A lubricant used during sexual activity can reduce friction. Vaginal moisturizers are used regularly, including when a woman is not planning sexual activity, to ease day-to-day dryness. Arousal, enough time, and the kinds of touch that feel good may also matter. A lubricant helps with friction; it does not rebuild tissue or treat every cause of pain. Persistent symptoms deserve an evaluation.

Products differ. A water- or silicone-based lubricant may be an option; follow product directions and check compatibility with condoms or devices. If a product irritates, stop using it and ask about alternatives.

When GSM is present

For appropriate patients, evidence-based choices can include local low-dose vaginal estrogen, vaginal prasterone (DHEA), or oral ospemifene for menopause-related painful sex. Moisturizers and lubricants can also be part of care. The best option depends on symptoms, exam findings, other health conditions, preferences, and treatment goals. These treatments are not interchangeable, and systemic menopause hormone therapy is a separate decision.

If you have a history of hormone-sensitive cancer, you do not have to assume every local treatment is forbidden, and no local hormonal option is automatically right for you. Nonhormonal options are often tried first. If symptoms continue, decisions about local vaginal estrogen should be individualized and shared with your cancer clinician when appropriate, especially during aromatase-inhibitor therapy. Our Cancer Survivorship collection explains that conversation in more depth.

When the pelvic floor is part of the problem

Specialized pelvic-floor physical therapy may help when muscles are tender, guarded, overactive, weak, or poorly coordinated. Depending on the assessment, therapy may focus on relaxation and down-training, muscle coordination, trigger points or myofascial pain, breathing and pressure strategies, and a gradual return to comfortable penetration. Some women need strengthening; others need a different approach. “Do more Kegels” is not universal pelvic-floor medicine.

For related pelvic-floor education, see our collection on bowel emptying, splinting, and pelvic-floor coordination.

When dilators are part of a plan

Vaginal dilators may help selected women with narrowing, guarding, treatment-related changes, or graded rehabilitation. A clinician or pelvic-floor therapist can help decide whether they fit and how to use them comfortably. Dilators are not a demand to force penetration. Pain is not the goal; stop and seek guidance if the approach is painful or distressing.

When vulvar pain or a skin condition may be involved

Persistent burning, itching, fissures, skin changes, focal tenderness, or pain despite apparently adequate lubrication calls for an examination. Treatment depends on the cause. Do not assume recurring symptoms are yeast without appropriate evidence. Continue to our Vulvar Burning and Vulvodynia collection for the fuller conversation.

When pain is deep

Deep pain deserves an assessment guided by its timing, location, and other symptoms. Depending on the clinical picture, evaluation may consider endometriosis, uterine or adnexal conditions, pelvic-floor pain, postoperative factors, or other pelvic causes. Menopause does not explain every new or persistent deep pelvic pain.

When pain and desire or arousal change together

A woman may stop wanting an activity her nervous system has learned to associate with pain. That does not automatically mean she has a primary desire disorder. Low desire can also coexist independently and deserves its own assessment if it causes distress. For a broader discussion, read “She was told testosterone would fix everything.” and “I Love My Partner. So Why Don’t I Want Sex Anymore?”

Intimacy does not have to mean penetration

While pain is being evaluated or treated, a woman and her partner may choose forms of touch and intimacy that do not reproduce it. There is no single activity that defines a healthy sexual life. Comfort, consent, connection, and what feels meaningful to the people involved matter.

When painful sex needs a closer look

Arrange an evaluation for persistent or worsening pain, bleeding with intercourse, visible vulvar or vaginal skin changes, sores, ulcers, fissures or other lesions, persistent burning, new deep pelvic pain, unexplained discharge or infection symptoms, pain after pelvic surgery or cancer treatment, significant pelvic-floor spasm or tenderness, pain that prevents sexual activity you want, or symptoms that do not improve with basic measures. Any new, unexplained, or concerning symptom is a valid reason to seek care. Heavy bleeding, severe sudden pain, fever, or feeling acutely unwell may need urgent assessment.

Questions you can bring to a visit

Does the location of my pain suggest different possible causes?
Could GSM, a vulvar skin condition, pelvic-floor muscle pain, or a pelvic condition be contributing?
What can we do to make an examination comfortable and consent-based?
Would a lubricant, moisturizer, pelvic-floor physical therapy, dilator plan, or a treatment for GSM fit my situation?
If I have a history of cancer, what options fit my cancer type and current treatment, and should my oncology team join the decision?
When should I return if the pain does not improve?

Do not ignore: New or persistent pain, bleeding after menopause or after sex, sores or skin changes, unusual discharge, or severe pelvic pain should be discussed with a healthcare professional. This education supports, but does not replace, individualized evaluation and care.

Clinical review

Educational content reviewed September 2026 by Felicia L. Rhaney, MD, FACOG, MSCP. This material supports, but does not replace, individualized evaluation and care.

Selected guidance

Continue exploring

One topic. A fuller conversation.

Return to The Knowledge Hub

I will not be surprised by a single word you say.