Why sex hurts during menopause and what can help

Key takeaways

• Painful sex during menopause is caused by real, measurable changes to vaginal tissue driven by falling oestrogen levels, not something you should have to put up with.
• Unlike hot flushes, the underlying condition (genitourinary syndrome of menopause) tends to get worse over time without treatment, not better.
• Effective treatments exist, from vaginal oestrogen to CBT to testosterone, and the right combination depends on your individual symptoms and history.

Introduction

Painful sex during menopause is one of the most common symptoms women experience, and one of the least talked about. Research from the Natsal-3 study, a large British population survey of nearly 7,000 sexually active women, found that painful sex was most prevalent in women aged 55 to 64. Yet most women suffer in silence, either too embarrassed to raise it, or convinced they've already been told everything their GP has to offer.

If that sounds familiar, this article is for you.

Here, we explain what is actually happening in your body, why the condition tends to worsen over time if left untreated, and what the evidence says about every treatment option available to you, from lubricants to local oestrogen, pelvic floor physiotherapy to testosterone. Because painful sex during menopause is not something you should have to accept as your new normal.

You are not alone, and this is not something you have to accept

Sexual pain during menopause is far more common than most women realise, precisely because so few feel comfortable talking about it.

The Natsal-3 study found that painful sex (dyspareunia) was reported by around 1 in 10 women aged 55 to 64. But that figure almost certainly underestimates the true prevalence. As research published in the journal Menopause notes, many women stop having sex entirely because of the pain and are therefore excluded from prevalence studies altogether.

The British Journal of General Practice (2025) puts the prevalence of the underlying condition, genitourinary syndrome of menopause, at anywhere between 13% and 87% of women over 40, depending on how it is assessed. Despite this, only 4 to 35% of affected women are currently using any treatment. That is not because treatment does not work. It is because the condition is under-discussed, under-diagnosed, and under-treated.

You are not unusual for experiencing this. You are not unusual for not having raised it. And you deserve better than being told to manage with a tube of lubricant and no further conversation.

What is actually happening inside your body

To understand why sex becomes painful during menopause, it helps to understand what oestrogen does for vaginal tissue, and what happens when levels fall.

Oestrogen keeps the vaginal walls thick, elastic, and well-lubricated. It maintains the acidity of the vaginal environment, supports good blood flow to the pelvic region, and helps the tissue remain resilient and supple. During perimenopause and menopause, oestrogen levels decline, often significantly. The tissue that lines the vagina, vulva, bladder, and urethra begins to thin, dry out, and lose elasticity.

This is the condition now known as genitourinary syndrome of menopause (GSM): a clinical term that describes the full range of symptoms caused by this hormonal withdrawal, including vaginal dryness, irritation, burning, urinary symptoms, and pain during sex.

The 2025 BMS Consensus Statement on GSM from the British Menopause Society confirms that GSM is a chronic condition driven by oestrogen deficiency, affecting the vulva, vagina, bladder, and urethra. It is not an inevitable consequence of ageing that cannot be addressed. It is a physiological change with well-evidenced treatments.

GSM can begin during perimenopause, before your periods have stopped. If sex has started to feel uncomfortable or different in the years leading up to your final period, that is why.

What does the pain feel like: superficial vs deep

Not all sexual pain is the same, and knowing the difference can help you describe your experience clearly to a specialist.

Superficial pain is felt at the entrance to the vagina during penetration, or with touch to the vulva. It is the most common type associated with GSM and typically presents as burning, stinging, or tearing. It often occurs because the vaginal tissue has thinned and dried, making it fragile and easily irritated.

“Deep pain is felt further inside the pelvis during or after sex. It can be associated with other conditions alongside GSM, including endometriosis, pelvic floor dysfunction, or bladder issues. Deep pain that is new, severe, or accompanied by other symptoms (including unexplained vaginal bleeding) should always be assessed by a clinician promptly.”

Katy Jackson, Clinical Director - Women's Health

Many women experience both, and the picture can change over time. The international consensus review published in Sexual Medicine Reviews (2025) found that vaginal dryness is the most reported GSM symptom (affecting 47 to 100% of women with GSM), followed by dyspareunia affecting 20 to 77.6%. Both are on a spectrum. Both are treatable.

Why GSM tends to get worse without treatment

One of the most important things to understand about GSM is that it behaves differently from many other menopause symptoms.

Hot flushes and night sweats, for many women, ease over time. GSM does not follow this pattern. Without treatment, the tissue changes associated with oestrogen loss tend to be progressive: the vaginal walls continue to thin, lubrication decreases further, and symptoms typically worsen rather than resolve.

Research published in Climacteric (2025) confirms that vulvovaginal atrophy, the structural component of GSM, is progressive without intervention. The AGATA study, a large observational study, found that 84.2% of women at six years post-menopause showed signs of vaginal atrophy, with 77.6% reporting dyspareunia.

The BMS GSM Consensus Statement (2025) and the BJGP clinical overview (2025) both call for proactive clinical enquiry, noting that many women do not raise the issue themselves and that waiting for it to come up in a standard appointment means it often never does.

This is not about alarming you. It is about giving you accurate information: if you are experiencing symptoms now and wondering whether to seek help or wait and see, the evidence suggests that early treatment produces better outcomes.

The pain-and-anxiety cycle: why it can feel relentless

For many women, painful sex does not stay purely physical for long. There is a well-recognised psychological feedback loop that can develop, and understanding it can make the experience feel significantly less bewildering.

Pain during sex leads, understandably, to anticipatory anxiety before the next attempt. That anxiety activates the body's protective responses, including involuntary tightening of the pelvic floor muscles. When the muscles become tighter, they can create more friction and discomfort, which can increase pain. That pain can then lead to more worry or anxiety, causing the muscles to tighten even further. This can create a cycle where tension increases discomfort, discomfort increases anxiety, and anxiety increases muscle tension

Research in the journal Menopause acknowledges that many women withdraw from sexual activity entirely as a result of this cycle, and that the avoidance itself makes symptoms harder to address over time.

A 2025 study in Menopause examining GSM's impact on coupled relationships found that partner knowledge and open communication significantly influence how women experience and manage GSM. Women who felt their partner understood what was happening reported meaningfully better outcomes.

None of this is a character failing. It is a completely understandable physiological and psychological response to pain. And it is exactly why the most effective approaches to treating painful sex during menopause tend to address both the physical and the psychological dimensions together.

Treatment options: what is available and how it works

There is no single treatment for painful sex during menopause, and the right approach depends on your symptoms, your medical history, and your preferences. What follows is an overview of the main evidence-based options.

Lubricants and vaginal moisturisers

These are typically the first step and can provide meaningful relief for mild to moderate symptoms.

Lubricants are used during sex to reduce friction. Water-based or silicone-based lubricants are generally recommended; oil-based products can degrade latex condoms and may irritate sensitive tissue.

Vaginal moisturisers are used regularly (typically two to three times a week, not just during sex) to restore hydration to the vaginal tissue over time. They are available over the counter and do not contain hormones.

The BMS GSM Consensus Statement recommends these as first-line options alongside, not instead of, other treatments for women with more significant symptoms.

Vaginal oestrogen

Vaginal oestrogen is a topical treatment that helps restore vaginal tissue, making it thicker, more elastic, and more hydrated. It is applied locally (as a cream, pessary, or ring pessary) and works directly on the tissue without significant absorption into the bloodstream.

This distinction matters, because many women are concerned about the systemic effects of oestrogen. Vaginal oestrogen delivers a very low dose, locally. For most women, including many with a history of breast cancer (though individual assessment is always essential), it is considered safe for long-term use. Your specialist will assess what is appropriate for your specific situation.

The BJGP clinical overview (2025) notes that local oestrogen is underutilised relative to its evidence base, with only 4 to 35% of eligible women currently using it. The ICSM international consensus (2025) confirms strong evidence for its effectiveness in treating dyspareunia and vaginal dryness.

Systemic HRT

Hormone Replacement Therapy (HRT): a combination of hormones tailored to your symptoms and your body, taken systemically rather than locally, can address GSM symptoms as part of broader menopause management. It is often most appropriate for women who have other menopause symptoms alongside sexual pain (such as hot flushes, sleep disruption, and mood changes).

HRT is sometimes used alongside vaginal oestrogen, since systemic treatment does not always fully address local vaginal changes. Your menopause specialist will advise on the approach that fits your overall picture.

Pelvic floor physiotherapy

For women experiencing pelvic floor hypertonicity (where the muscles are involuntarily tightened, often as part of the pain-anxiety cycle described above), pelvic floor physiotherapy can be highly effective. A specialist physiotherapist can assess muscle tone and guide treatment, including internal work, relaxation techniques, and graduated desensitisation.

The ICSM consensus (2025) identifies pelvic floor dysfunction as a contributing factor to dyspareunia and supports physiotherapy as part of a multimodal treatment approach.

CBT and psychological support

Cognitive Behavioural Therapy (CBT): a structured talking therapy that can help manage menopause symptoms alongside or instead of medication, is particularly relevant for sexual pain because of the psychological feedback cycle described earlier.

CBT can help interrupt the anticipatory anxiety, reframe avoidance behaviours, and support gradual return to sexual activity. It is not a replacement for treating the physical cause, but for many women it is an essential part of a complete approach.

What about testosterone?

Testosterone is often associated with men, but it is equally important for women's energy, mood, and libido. During menopause, testosterone levels decline alongside oestrogen, and for some women this contributes significantly to reduced desire, arousal, and the capacity for pleasure.

When low libido is part of the picture, it can deepen the pain-anxiety cycle: if desire is low, the body is less likely to lubricate naturally, which increases friction and discomfort, which further reduces desire.

Testosterone replacement, available as Testogel, Androfeme, or Voy's own testosterone cream, is increasingly recognised as a legitimate part of comprehensive menopause care. In the UK it is prescribed off-label by specialists (meaning it is used outside its original licensed indication, but within an established and evidence-supported clinical framework). A testosterone blood test taken within the last three months is required before a prescription can be issued.

The BMS GSM Consensus Statement (2025) supports discussion of testosterone as part of holistic sexual health management in menopause. If you have never been offered this conversation, it is worth asking for.

What a Voy menopause consultation looks like

Many women arrive at Voy after years of raising this symptom and being met with a leaflet, a suggestion to try lubricant, and a five-minute slot that runs over time. That is not a reflection of what good menopause care looks like.

At Voy, menopause consultations are 45 minutes, with BMS-trained menopause specialists who have the time and expertise to understand your full symptom picture: not just the pain, but the sleep, the mood, the energy, the libido, and the relationship with your own body. From there, a personalised treatment plan is built around you, potentially combining vaginal oestrogen, HRT, testosterone, CBT, pelvic floor physiotherapy referral, nutrition support, and ongoing monitoring.

The results reflect this approach. 88% of Voy members felt more hormonally balanced at three months, compared to 62% receiving standard care (presented at The Menopause Society 2025; forthcoming in Climacteric). 93% reported improvement in overall quality of life (presented at The Menopause Society 2025; forthcoming in Climacteric).

When to seek help, and what to say

If painful sex is affecting your life, that is reason enough to seek specialist support. You do not need to wait until symptoms become unbearable, and you do not need to have tried everything available over the counter first.

There are some symptoms that should prompt a clinical assessment without delay:

• Unexplained vaginal bleeding, including bleeding during or after sex
• Sudden or severe pelvic pain, especially if new or different from your usual symptoms
• Pain accompanied by unusual discharge, odour, or urinary symptoms that are new

These may have straightforward explanations, but they need to be assessed to rule out other causes.

For symptoms that are less urgent but persistent and affecting your quality of life, the most important thing is to name them clearly. If you have been embarrassed to raise sexual pain with a healthcare professional before, you are in very good company. But the conversation is worth having. A specialist who understands menopause will not be surprised. They will not minimise it. And they will have something useful to offer.