Sex, pain and vaginal dryness: the symptom most people never mention

Of everything that changes around menopause, this is the cluster that women most often decide to live with. Not because it is minor, but because raising it feels like a bigger conversation than raising hot flushes, and because there is a widespread assumption that it is simply what happens now.

It is not, and the gap between how treatable these symptoms are and how often they go untreated is one of the clearer failures in midlife care.

What it is called and what it covers

The clinical term is genitourinary syndrome of menopause, or GSM. It groups together the signs and symptoms associated with menopause-related oestrogen deficiency involving the labia, vagina, urethra and bladder ⁴. Vulvovaginal atrophy is a component of it ¹.

The syndrome includes genital symptoms of dryness, burning and irritation; urinary symptoms of painful urination, urgency and recurrent urinary tract infections; and sexual symptoms of pain and dryness ¹.

The older term, vulvovaginal atrophy, was replaced partly because it described the appearance of tissue rather than the symptoms, partly because it left out the urinary tract, and partly because women disliked it ¹. That is a reasonable objection to a word that means wasting away.

NICE uses its own definition covering vulvovaginal dryness, pain with sex, vulvovaginal discomfort or irritation, and discomfort or pain when urinating ².

Importantly, for a diagnosis of the syndrome, symptoms must be bothersome, and other causes of similar signs and symptoms must be ruled out, including vulvovaginal skin conditions, infection, or cancer ¹. That last clause is why examination matters and why self-diagnosis has limits.

How common

GSM affects approximately 27% to 84% of postmenopausal women, and can significantly impair health, sexual function and quality of life. It is likely underdiagnosed and undertreated ¹.

That range is wide because studies define and ask about it differently. The direction of the finding is not in doubt.

The other reason to know the number: whatever the exact figure, this is not an unusual problem, and a clinician who has been in general practice for a decade has had this conversation many times.

Why it does not resolve on its own

Vasomotor symptoms typically decline eventually. Genitourinary symptoms behave differently, because they reflect a persistent change in tissue rather than an unstable transitional state.

NICE captures the practical consequence in the counselling it requires: when discussing vaginal oestrogen, clinicians should explain that symptoms often return when it is stopped, but that treatment can be restarted if necessary ².

The NHS lists vaginal dryness among the symptoms that can continue after menopause has ended ⁹.

That is why these symptoms tend not to resolve by waiting.

What guidelines say about options

Again, this is a description of guidance, not advice for you. The conversation belongs with a clinician who can examine you and knows your history, particularly if you have had breast cancer.

Non-hormonal first, for milder symptoms

The 2020 position statement describes first-line therapies for less severe symptoms as non-hormonal vulvar and vaginal lubricants used with sexual activity, and long-acting vaginal moisturisers used regularly ¹.

The NHS distinguishes the two clearly. Water-based lubricants are used before sex, applied in and around the vagina, on a partner or on a sex toy. Vaginal moisturisers are put inside the vagina to keep it moist ³. They are different products with different jobs.

The NHS also advises using unperfumed soaps and washes around the vagina, avoiding perfumed soaps, washes and douches, avoiding creams and moisturisers that are not intended for vaginal use because they can cause irritation or infection, and trying different types of foreplay to find what improves arousal ³.

NICE's version: consider non-hormonal vaginal moisturisers or lubricants where vaginal oestrogen is contraindicated or not wanted, and advise that vaginal oestrogen can be used on its own or in combination with them ².

Vaginal oestrogen

NICE recommends offering vaginal oestrogen to people with genitourinary symptoms associated with menopause, including those already using systemic HRT, with regular review ².

That inclusion is worth reading twice. Being on patches or tablets does not necessarily resolve genitourinary symptoms, and needing both is normal rather than a sign that something has gone wrong.

NICE requires clinicians to explain that vaginal oestrogen is absorbed locally, that a minimal amount reaches the bloodstream compared with systemic HRT, and that this is unlikely to have a significant effect throughout the body ². The choice between cream, gel, tablet, pessary or ring is a shared decision ².

The Menopause Society's 2022 statement says low-dose vaginal oestrogen preparations are effective and generally safe for GSM, with minimal systemic absorption, and are preferred over systemic therapies when oestrogen is used only for genitourinary symptoms ⁴. It also states that progestogen therapy is not required with low-dose vaginal oestrogen, while noting that randomised trial data are lacking beyond one year ⁴.

The NHS lists the available vaginal oestrogen products, and separately notes that oestrogen is sometimes used as a cream or pessary specifically to treat vaginal dryness and soreness, or urinary symptoms, after menopause ⁸⁷.

Other prescription options

The 2020 position statement lists low-dose vaginal oestrogens, vaginal DHEA inserts and oral ospemifene as prescription therapies, and notes that for women with moderate to severe painful sex associated with GSM who also have vasomotor symptoms, transdermal and oral hormone therapy are effective options ¹.

NICE includes vaginal prasterone, considered if vaginal oestrogen or non-hormonal moisturisers and lubricants have been ineffective or are not tolerated ².

Urinary symptoms

This is the part most often left out of the conversation.

Vaginal oestrogen increases the number of vessels around the periurethral and bladder neck region and has been shown to reduce the frequency and amplitude of bladder muscle contractions ⁴.

The direction of effect differs by route, which matters. Two large trials found that users of systemic hormone therapy had an increased incidence of stress incontinence, and increased incontinence was found with both oral oestrogen alone and combined therapy. Vaginal oestrogen use, by contrast, showed a decreased incidence of incontinence and of overactive bladder, with one to two fewer voids in 24 hours ⁴.

NICE cross-refers to its overactive bladder and recurrent urinary tract infection guidelines for the use of vaginal oestrogen in those situations, and points to a patient decision aid on reducing the chance of recurrent UTI in postmenopausal women ².

If recurrent UTIs are part of the picture and vaginal oestrogen has not come up, it is a reasonable thing to ask about.

Libido, which is a separate question

The Menopause Society's statement is direct: systemic hormone therapy generally does not improve sexual function, sexual interest, arousal or orgasmic response independently of its effect on GSM ⁴. Low-dose vaginal oestrogen does improve sexual function in postmenopausal women with GSM ⁴.

The statement also notes that where libido is a concern, transdermal oestrogen may be preferable to oral, because oral oestrogen increases sex hormone-binding globulin and reduces free testosterone ⁴.

The NHS notes that testosterone gel or cream can help improve low libido for some, that it may be available on prescription from a menopause specialist, and that there are many reasons for low libido around menopause including relationship difficulties, how you feel about yourself, and physical discomfort ⁷.

That last list deserves weight. Pain during sex can change desire, which is one reason the two are often discussed together.

If you have had breast cancer

This is a specialist conversation, and the guidelines treat it as one.

NICE says offer non-hormonal moisturisers or lubricants to people with a personal history of breast cancer and genitourinary symptoms ². Vaginal oestrogen may be considered where symptoms have continued despite non-hormonal treatment, and NICE notes that in November 2024 this was an off-label use ².

On risk, NICE is careful in a way that is genuinely informative. It states that it is unknown whether vaginal oestrogen affects the risk of breast cancer recurrence, and that vaginal oestrogen is absorbed locally with some systemic absorption, but minimal compared with systemic HRT ². For a history of oestrogen receptor-negative breast cancer, it says any systemically absorbed oestrogen is unlikely to increase recurrence risk and is likely to be safe. For oestrogen receptor-positive disease, it says whether it could increase recurrence risk is unknown ².

For anyone currently taking aromatase inhibitors as adjuvant treatment, NICE says work with a breast cancer specialist to identify options for symptoms that have continued despite non-hormonal treatment ².

The Menopause Society similarly says low-dose vaginal oestrogen should be prescribed in consultation with the patient's oncologist ⁴.

Laser and energy-based devices

Both guidelines say no, and for the same reason.

NICE says do not offer vaginal laser treatment for genitourinary symptoms associated with menopause unless as part of a randomised controlled trial ². The 2020 position statement says there are insufficient placebo-controlled trials of energy-based therapies, including laser, to draw conclusions on efficacy and safety or to make treatment recommendations ¹.

If you are being offered this privately, that is the evidence base you are buying into.

Two things about sexual health after menopause

The WHO makes a point that is rarely raised in menopause consultations. It is still possible to acquire sexually transmitted infections, including HIV, through unprotected sexual contact after menopause, and the thinning of the vaginal wall increases the chance of lesions and tears, which increases the risk of HIV transmission during vaginal sex ⁵. It also notes that older women may not consider themselves at risk or be counselled about it ⁵.

Second, on menopause and pelvic support: the WHO notes that menopause can result in weakening of the pelvic support structures, increasing the risk of pelvic organ prolapse ⁵. The Menopause Society notes that evidence for the effectiveness of oestrogen therapy for pelvic organ prolapse is lacking, though it may be used alongside pelvic floor training, pessaries or surgery ⁴.

Guidance in the US and Europe

In the US, The Menopause Society recommends low-dose vaginal estrogen, or other treatments such as vaginal DHEA or oral ospemifene, for bothersome genitourinary symptoms that over-the-counter products have not relieved ⁴. The FDA's 2026 label changes to hormone therapy products included vaginal estrogen ¹⁰.

In Europe, a European Menopause and Andropause Society (EMAS) clinical guide estimates that vaginal atrophy affects around half of postmenopausal women ¹¹. It says low-dose vaginal oestrogens are effective, also help urinary incontinence and prevent recurrent urinary infections, and that women should not be denied long-term use while it benefits them, because the safety data are reassuring ¹¹. For women taking hormone-blocking treatment after a hormone-dependent cancer, it recommends lubricants and moisturisers first ¹¹.

What is still uncertain

Long-term endometrial safety data for vaginal oestrogen, vaginal DHEA and ospemifene are lacking ¹.

Whether vaginal oestrogen affects breast cancer recurrence risk in oestrogen receptor-positive disease is unknown ².

Whether energy-based devices work is unestablished ¹².

When to see a clinician

The NHS advises seeing a GP if you have had vaginal dryness for a few weeks and self-care has not worked, if it is affecting your daily life, if you have unusual vaginal discharge, or if you have bleeding after sex, between periods, or after menopause ³.

The 2020 position statement recommends education about and screening for GSM in all perimenopausal and postmenopausal women ¹, which means it is entirely appropriate to raise unprompted.

Say the actual words. "Sex is painful." "I am getting UTIs every few weeks." "It burns when I pee and there is no infection." Vague phrasing gets vague care here more than anywhere else in menopause medicine.

Get checked: bleeding after menopause or after sex

Any vaginal bleeding after twelve months without a period needs to be checked by a GP, even if it happened once, even if it was spotting or pink or brown discharge, and even if you are not sure it was blood ⁶.

Bleeding after sex should also be seen ³. Thinning of the vaginal lining is one of the most common causes of postmenopausal bleeding, but it is not the only one, and the point of the appointment is to distinguish them ⁶.

Tracking, briefly

Genitourinary symptoms are easy to record and hard to remember, because they are constant enough to become background.

Three notes are enough: whether penetration hurt and how much, how many times you got up in the night to urinate, and whether you have had a course of antibiotics for a UTI in the last three months. Written down, that is a clear picture. Reconstructed in an appointment, it usually comes out as "sometimes".