From the Guidelines
For severe painful intercourse after menopause, I recommend starting with low-dose vaginal estrogen therapy, such as Estrace cream (0.5-1g inserted vaginally 2-3 times weekly), Vagifem tablets (10mcg inserted twice weekly), or an Estring vaginal ring (replaced every 90 days), as it has been shown to be effective in treating vaginal dryness, itching, discomfort, and painful intercourse in postmenopausal women 1. This treatment approach addresses the underlying cause of painful intercourse after menopause, which is typically vaginal atrophy due to decreased estrogen levels. The thinning, drying, and inflammation of vaginal tissues lead to pain during sex. Vaginal estrogen works locally with minimal systemic absorption, making it safer than oral estrogen for most women. Some key points to consider when treating severe painful intercourse after menopause include:
- Vaginal estrogen is the most effective treatment for vaginal dryness leading to sexual dysfunction and has been shown to be effective in treating itching, discomfort, and painful intercourse in postmenopausal individuals 1.
- A large cohort study of almost 50,000 patients with breast cancer followed for up to 20 years showed no evidence that there was a higher risk of breast cancer–specific mortality in those using vaginal estrogen 1.
- For those who cannot use estrogen products, ospemifene (Osphena) 60mg daily by mouth or prasterone (Intrarosa) vaginal inserts nightly are non-estrogen options that may be considered 1.
- Pelvic floor physical therapy may also help if muscle tension contributes to the pain, as it has been shown to improve sexual pain, arousal, lubrication, orgasm, and satisfaction 1.
- Regular sexual activity or gentle vaginal dilation can help maintain vaginal health by increasing blood flow to the area. It is essential to note that the safety of vaginal hormones has not been firmly established in survivors of estrogen-dependent cancers, and therefore, caution should be exercised when prescribing these treatments to such patients 1.
From the FDA Drug Label
1.1 The Treatment of Moderate to Severe Dyspareunia, a Symptom of Vulvar and Vaginal Atrophy, Due to Menopause. Take one 60 mg tablet with food once daily.
Treatment for Severe Painful Intercourse Post-Menopause:
- Ospemifene (OSPHENA) is indicated for the treatment of moderate to severe dyspareunia, a symptom of vulvar and vaginal atrophy, due to menopause.
- The recommended dosage is one 60 mg tablet with food once daily 2.
From the Research
Treatment Options for Severe Painful Intercourse Post Menopause
- Ospemifene, a selective estrogen receptor modulator (SERM), has been shown to be effective in treating dyspareunia in postmenopausal women 3, 4, 5, 6.
- Vaginal estrogens, such as vaginal tablets, rings, and creams, are also effective in treating vaginal atrophy and dyspareunia 7.
- Ospemifene has been approved by the US Food and Drug Administration for the treatment of moderate to severe dyspareunia associated with vulvar and vaginal atrophy due to menopause 4, 6.
Mechanism of Action
- Ospemifene works by exerting a strong, nearly full estrogen agonist effect in the vaginal epithelium, making it well suited for the treatment of dyspareunia in postmenopausal women 6.
- Vaginal estrogens work by replacing the declining estrogen levels in the vagina, thereby reducing symptoms of vaginal atrophy and dyspareunia 7.
Safety and Efficacy
- Ospemifene has been shown to be safe and effective in clinical trials, with significant improvements in vaginal maturation index, vaginal pH, and severity of dyspareunia compared to placebo 5, 6.
- Long-term safety studies have revealed that ospemifene is well tolerated and not associated with any endometrium or breast-related safety concerns 6.
- Vaginal estrogens have also been shown to be safe and effective, with minimal absorption and no significant differences in endometrial safety among different preparations 7.