Dr. Rachel Rubin is a board-certified urologist and sexual medicine specialist. Let’s Talk Menopause spoke to her recently about painful sex, one of the most common symptoms of menopause. 

Why does sex become painful for so many women before and during menopause?

As estrogen levels decline during perimenopause (the lead up to menopause), your facial skin is not the only part of your body that loses elasticity. Your vulva and vagina do, too. Genitals are very hormone-sensitive and hormone-dependent structures. Without supple tissue, female sex organs become dry and thin. Arousal becomes physically difficult and intercourse can be agonizing.

Think of menopause as puberty in reverse. Just as we grow labia and develop genital sensitivity as hormone levels surge during adolescence, menopause is a time of hormonal withdrawal. In many cases, the tissues can become so desiccated during menopause that the labia minora actually reabsorb and disappear into the body.

How have we never heard about this? It was definitely not part of sex ed!

Unfortunately, the medical community doesn’t spend a lot of money or time on these topics. If a penis shriveled up at age 52, don’t you think we would have vaccines available for prevention? 

Pain with sex is a really important topic. No one should suffer through it. Not only does it jeopardize our ability to experience pleasure, which is reason enough to understand more about it, painful sex reflects our genital and urinary health, what is known as genitourinary symptoms of menopause or GSM. [link to glossary] Managing GSM is crucial to preventing morbidity and mortality in menopausal women. 

So painful sex is really a symptom of a larger issue?

Yes, it is your body’s way of signaling that your hormones have shifted and your tissues are being affected. The tissue becomes red and irritated. It becomes dry. It loses its acidity so it can't fight infections, leading to recurrent urinary tract infections. Women shouldn’t be waking up multiple times a night because they have to urinate. They shouldn’t be getting recurring infections. Depending on frequency and severity, these bacterial infections can range from nuisance to life threatening. 

Are there solutions for women who are suffering from painful sex?

There are many ways of treating painful sex and of preventing it. I believe that every woman should get three prescriptions when she turns 45: one for a mammogram, one for a colonoscopy, and one for vaginal estrogen that can keep genital organs plump, supple, and safe for sex.

These local hormonal therapies, which include twice-weekly vaginal suppositories and creams, are incredibly safe. But less than 10% of women use them. Just like dental floss, or seatbelts, hormone therapies are most effective for eliminating bladder atrophy and tissue damage when used consistently. Truly, it’s ALL about prevention. The good news is that even tissue that has already been severely depleted of elastin can often be restored. Of course, the sooner women get help for painful sex, the better. The key is to find a menopause-informed healthcare provider. 

Good to know that painful sex is not something we just have to suffer through. 

That’s right. But so many women are suffering. They are not going out because of their bladder leakage or because they have to find 12 bathrooms just on their commute to work. These are really significant quality of life issues and we need to talk more frequently and openly about them. I'm a urologist. I treat men about half the time. We talk about quality of life in men's health constantly, right? It’s time to do the same for women.

Both the International Society for the Study of Women’s Sexual Health (ISSWSH) and the North American Menopause Society (NAMS) have searchable databases for finding informed practitioners near you. 

Dr. Rachel Rubin, a medical advisor to Let’s Talk Menopause, is a board-certified urologist and sexual medicine specialist. She is an assistant clinical professor of Urology at Georgetown University and works in a private practice in Washington DC. She is one of only a handful of physicians fellowship trained in male and female sexual medicine. Dr. Rubin is a clinician, researcher, and vocal educator in the field of sexual medicine. She completed her medical and undergraduate training at Tufts University, her urology training at Georgetown University, and her fellowship training under Dr. Irwin Goldstein in San Diego. In addition to being education chair for the International Society for the Study of Women’s Sexual Health (ISSWSH), she also serves as Associate Editor for the Journal Sexual Medicine Reviews. She was named a Washingtonian Top Doctor for the past three years.