Pain during sex

Pain or discomfort during or after sex. The medical word is dyspareunia.

At this stage of life it is most often part of the changes doctors group as genitourinary syndrome of menopause, or GSM. NICE NG23 lists pain with sex alongside vaginal dryness, irritation and discomfort when passing urine as the genitourinary symptoms of menopause.

A burning or stinging feeling at the start. Soreness, rawness or itching afterwards. Sometimes a little spotting. Women's Health Concern describes how thinner skin is more easily damaged, so even gentle friction can hurt when there is not enough lubrication.

And then the part no leaflet lists: dreading it. Bracing before your husband comes to bed. Wondering whether something is wrong with you.

Women's Health Concern explains that as estrogen falls after menopause, the skin of the vulva and vagina becomes thinner, drier and less elastic, and there is less natural lubrication during sex. The NHS website links the same symptoms, dryness, burning and irritation, to sex feeling painful.

It is not always the menopause. That is why the Pakistan Menopause Society asks doctors to investigate pain that persists rather than assume (Table 4).

The NHS website suggests water-based lubricants before sex, vaginal moisturisers to keep the vagina moist, unperfumed washes, and trying different kinds of foreplay so you feel more aroused. Women's Health Concern adds taking more time, so the body has longer to make its own lubrication.

The Pakistan Menopause Society suggests moisturisers be used regularly rather than only at the time of sex (section 6.2).

NICE NG23 recommends offering vaginal estrogen for genitourinary symptoms, on its own or with moisturisers or lubricants, and lists moisturisers or lubricants for women who cannot use vaginal estrogen or prefer not to (1.5.5, 1.5.8 and 1.5.9). The British Menopause Society's statement on GSM lists the same two routes. Both are worth asking about; vaginal dryness sets out the options in more detail.

Some women find the vagina has narrowed, or the pelvic floor muscles tighten up against the pain. For them, The Menopause Society says gentle stretching with lubricated vaginal dilators, which come in graduated sizes, can play an important part in making sex comfortable again, and that many benefit from a referral to a pelvic floor physiotherapist.

Women's Health Concern notes that relief from the pain often brings desire back. If desire itself is the bigger problem, see low libido.

If sex keeps hurting, see a doctor. The Pakistan Menopause Society asks doctors to refer persistent pain during sex (Table 4).

Go sooner if you bleed after sex. The Pakistan Menopause Society lists bleeding after sex among its red flags (section 2.3), and the NHS website's vaginal dryness page lists it among the reasons to see a GP.

If you itch as well as hurt, say so. The European Menopause and Andropause Society (EMAS) describes lichen sclerosus, a long-term skin condition of the vulva that mainly itches and can make sex painful, and says hormone creams, estrogen included, are not recommended for it.

If you would feel easier with a woman, it is a fair question to ask whether a female doctor is available. The Pakistan Menopause Society also says many Pakistani women may not bring up sexual symptoms unless asked respectfully and in private (section 2.2), so if nobody asks, it is fine to be the one who says it first.

Intimacy is part of marriage, and pain changes it. Some women carry quiet questions about intimacy in marriage when sex hurts. Those questions belong with a qualified scholar, not a website, and Roshara does not rule on it. What we can say is that pain during sex is a medical symptom with medical options.

The Pakistan Menopause Society names a husband's support as important, including honest talk about hormonal changes and respect for sexual health (section 4.2.6). Partner and family support has ideas for starting that conversation.