Guest Expert Blog: "Understanding Pain During Sex in Perimenopause: Causes and Solutions"
As nutrition experts specializing in gut and hormone health, we know that perimenopause brings a wave of changes that can affect overall well-being—including intimate health.
To shed light on this important issue, I’m excited to feature a guest post from Dr. Maryssa Steffen, PT, DPT, Board-Certified Pelvic Health Specialist, who will be diving into the causes of pain during sex in perimenopause and what you can do to find relief. Whether you’re experiencing this yourself or supporting a loved one, this post offers valuable insights and solutions to help navigate this stage with confidence and comfort.
Let’s dive in!
Sexual pain can be a distressing symptom for those transitioning into menopause. The symptoms of painful sex are a complex dynamic between biological and psychological factors that will shape the experience of pain, as well as the effectiveness of treatment.
Nutrition also helps with the nutrients needed for perimenopause support. To learn more about pelvic health and perimenopausal support, check out Bodyful Physical Therapy and Wellness’s website here.
What can cause pain with sex during the menopause transition?
Vaginal dryness
Excessive friction
Tissue fragility
Tissue sensitivity
Decreased thickness of the vulvar tissues
Decreased elasticity of the vulvar tissues
Pelvic floor muscle abnormalities
What is the pelvic floor?
The pelvic floor musculature is a layered bowl of muscles at the bottom of the pelvis.
These muscles, fascia, and fat support your pelvic vasculature, nerves, pelvic organs and lymphatics.
Superficial pelvic floor muscles support your anal and urethral sphincters.
Deeper pelvic floor muscles support your rectum, cervix, and bladder.
The pelvic floor muscles blend together with your deep hip muscles, tailbone, and pubic bone for dynamic posture control.
Strong and relaxed pelvic floor muscles play an important role in orgasm and arousal.
People experiencing the menopause transition present with widely different severity of symptoms and quality of life changes.
Your medical and therapeutic care is most effective when it is tailored to you. An individualized approach works with your specific needs.
If you have pain with sex and you are in perimenopause, your vulva and vestibule may be sensitive due to hormonal changes, pelvic floor tension, and changes in blood flow to your tissues during sex.
What is the vestibule?
Vestibule tissue is highly innervated.
It is the transitional tissue between your labia minora and your vagina.
It provides mucosal lubrication and erectile function during arousal.
The nerves to the vestibule are autonomic and sensory.
The sensory nerve to your vestibule is called the pudendal nerve. This nerve also carries muscular function to your pelvic floor muscles. A pelvic floor therapist will assess more than “Kegels” when considering your complaints of sexual pain and your needs.
For example, your pelvic floor muscles tense during arousal. This muscular role enhances the capacities of your lymphatics, blood flow, lubrication, and sensations to work together for your arousal experience.
However, if your pelvic floor muscles are often very tense, not only will this decrease blood flow and limit the enjoyment of arousal, but it can also contribute to pain with penetrative sex.
Healthy muscles anywhere in your body, including the pelvic floor, need to:
tense
reverse the tension/relax
be flexible
be coordinated with your movement system (your “core” muscles, breath, and posture)
have power for sudden increases in load (sneezing and lifting)
have the necessary endurance
be able to rest fully
When your pelvic floor muscles are healthy, they help to pump lymphatic and blood flow and thus aid in optimal lubrication to decrease friction during sex.
Your pelvic floor muscles also help with pumping your blood flow to properly bathe the pudendal nerves and improve pleasurable sensation and reduce painful sensations.
Any relaxation practices will help with parasympathetic rest and thus improve the health of your vestibule because the vestibule also contains autonomic nervous system nerve fibers. This means that if you have any mindfulness practices or any opportunities to take a deep breath, then your pelvic health will benefit.
Frequent opportunities to breathe and rest shift your autonomic nervous system to parasympathetic. When you are resting, your body will automatically start to decrease inflammation, improve blood flow throughout your body, and allow your hormones to circulate freely throughout your body.
If you are experiencing pain with penetrative vaginal sex, and you are in perimenopause, the following may be recommended:
Vaginal lubricants
Vaginal moisturizers
Pelvic floor muscle training, ideally with a pelvic floor physical therapist, either virtually or in person
Other non-pharmaceutical treatments
Estradiol cream (consult with your gynecologist who specializes in menopause)
Painful sex during this natural time in your life is very common and can vary per person. Starting with breathing practices, specific exercises, and pelvic floor muscle awareness can be an empowering way to feel connected to your body and to experience pleasure again! And there are no adverse side effects to physical therapy!
Interested in speaking more with us about pelvic floor therapy?
We’d love to work with you! Schedule a complimentary Meet + Greet session. We look forward to finding individualized solutions to fit your needs.
Published: February 24th, 2025
Reference:
Cucinella L, Tiranini L, Cassani C, Martini E, Cumetti A, Memoli S, Tedeschi S, Nappi RE. Insights into the vulvar component of the genitourinary syndrome of menopause (GSM). Maturitas. 2024 Aug;186:108006. doi: 10.1016/j.maturitas.2024.108006. Epub 2024 Apr 25. PMID: 38704313.
