Pain-Free Sex After Menopause

Pain-Free Sex After Menopause
When intercourse hurts, physical therapy can help

by Raquel Perlis, P.T.

A reassuring news flash (versus a hot flash) for women: Menopause signals the end of your childbearing years—not the end of your sex life.

Here’s a common scenario: As Eve goes through perimenopause and then menopause, intercourse becomes uncomfortable and then painful. (The medical term for painful intercourse is dyspareunia.) Thinking “I must be dry,” she tries vaginal lubricants and asks her doctor about topical estrogen. These products help—but only to a point.

That’s because there’s more to the story than Eve, and most women, realize. When sex hurts, the problem is usually more than skin-deep. A muscular cycle is also set in motion. To guard against more pain, Eve subconsciously tightens her vaginal and pelvic-floor muscles; the tightness leads to more pain, which leads to less-frequent sex, which leads to more tightness; and so the cycle goes.

What’s the reassuring news? Pelvic floor physical therapy—a specialized type of physical therapy provided by specially trained physical therapists—can shift this sexual pain cycle into reverse. A range of gentle techniques have been clinically proven to help many perimenopausal and menopausal women return to pain-free, pleasurable intercourse.

What is pelvic floor physical therapy?

Because each woman’s medical and sexual circumstances are different, each woman’s pelvic floor therapy plan may be different. Here are some treatment guidelines:

* The first phase is to relax, release, and stretch tightened vaginal and pelvic muscles. Your physical therapist will use manual (hands-on) therapy techniques on your pelvis, abdomen, hips, and thighs. For example, she may use soft-tissue massage, trigger-point release, and myofascial release, which promote healthy blood flow, increase elasticity, and reduce pain sensitivity. When you’re ready, she’ll gently introduce these techniques inside your vagina. She may teach you and your partner to do them at home, between appointments. Doing “homework” can speed and improve your progress.

* Your physical therapist will also teach you pelvic floor exercises, such as “pelvic drops,” to relax your pelvic muscles and open your vagina. You can easily do these exercises between appointments. Your therapist may use a biofeedback machine to guide your exercises and monitor your progress.

* After your pelvic and vaginal muscles are relaxed and stretched, your physical therapist may teach you Kegel exercises to do on your own. These vaginal contract-and-release exercises help strengthen muscles that have weakened due to childbirth, hormonal changes, and aging. Again, your therapist may use biofeedback to improve your technique and track your progress.

* After your muscles have begun to relax and stretch, your physical therapist may show you how to insert fingers, and then progressively sized dilators, to further stretch and desensitize your vagina.

* If your hips are tight—perhaps from sitting behind a desk every day—your therapist may show you hip stretches to relax your hips and open your pelvic floor.

* If you’ve had a hysterectomy, C-section, or other pelvic surgery, your physical therapist may add manual therapy techniques to release adhesions (scar tissue). She may also give you abdominal strengthening exercises.

After 12 weekly sessions of pelvic floor physical therapy, most women can resume pain-free intercourse. Some women may need additional weeks or months of treatment, depending on the severity of their condition. In general, the sooner women begin treatment, the faster it progresses.

Partners in pain relief

Pelvic floor physical therapy works in concert with other treatments for perimenopause-related and menopause-related sexual pain.

* As your hormone levels drop during perimenopause and menopause, your healthy, plump, pink vaginal tissue becomes thinner, less lubricated, and less elastic; your vaginal opening (vestibule) and vagina may narrow; and the contours of your lips (labia) and clitoris may change. All these changes can cause pain, burning, and irritation during and after sex. To replace lost estrogen, your doctor may prescribe topical or vaginal estrogen. (Caution: if you’ve had cancer, consult with your doctor about the risks and benefits of using estrogen.)

* Vaginal skin conditions such as lichen planus and lichen sclerosis may develop during menopause. Lichen is usually painful or uncomfortable, and doctors often prescribe topical corticosteroids to treat or control it.

* Menopausal hormone dips can weaken your libido (sex drive or sexual desire). If you have sex less often, your vaginal muscles may tighten and sex may become uncomfortable. Your doctor may evaluate you for non-menopausal causes of low libido. Some couples turn to sex therapy to address their concerns about aging, libido, and desirability; to rekindle intimacy; and to reinvent their sex life.

Resources: > Find a PT > Find a PT: Start Your Search > Expertise: Women’s Health

Raquel Perlis, P.T., is a registered physical therapist specializing in women’s health physical therapy and pelvic pain physical therapy. Based in Wellesley, MA, she has lectured in hospitals, universities, and other facilities to increase awareness of physical therapy’s role in sexual health. Visit