Vaginal dryness and painful sex: the side of menopause nobody talks about

Some menopause symptoms get talked about quite openly, such as hot flushes, while others stay unspoken. Vaginal dryness, itching, irritation or pain during sex usually belong to that second group. This is not a minor issue, nor something you simply have to put up with: there are effective, well-studied treatments. In this article we explain what happens in the body, what the evidence says and which options are available, always from an informative standpoint and never as a substitute for an individual medical assessment.

What is genitourinary syndrome of the menopause

Genitourinary syndrome of the menopause (GSM) is a term adopted by the Spanish Society of Gynaecology and Obstetrics (SEGO) to replace the older label 'vulvovaginal atrophy'. It covers the whole set of genitourinary signs and symptoms linked to the fall in oestrogen that comes with the menopause. The change of name is not merely cosmetic: it reflects the fact that the problem is not limited to the vagina, but can also affect the vulva and the urinary tract.

When oestrogen levels drop, the tissues in this area lose elasticity, thickness and natural lubrication. That is where dryness, irritation, itching and pain during sex come from, which in medical terms is called dyspareunia.

It is far more common than it seems

Although it is rarely discussed, this is a common condition. According to data published in Mayo Clinic Proceedings, in the postmenopausal phase the prevalence of vulvovaginal atrophy is close to 50%, and it is an under-reported condition. Other reviews suggest that, without oestrogen replacement, one third of women experience symptoms of atrophic vaginitis such as dryness, irritation, itching or pain during sex.

Other, more recent reviews give wider ranges, which vary a great deal depending on the study and the way the question is asked, and point out that a significant proportion of those affected receive no treatment. These figures should be taken with caution, as they come from reviews rather than a top-level primary source, but they point in the same direction: these symptoms are frequent and often left untreated.

Being common does not mean you have to resign yourself to it. Falling oestrogen levels explain why it happens, but treatment exists and it can greatly improve quality of life.

What the evidence says about treatment

SEGO proposes a stepped approach. First-line treatment for vaginal GSM consists of moisturisers, with level IA evidence, and lubricants, with level IIB. When these are not enough, or in moderate to severe cases, the treatment of choice is local oestrogens, also with level IA evidence. If there are also vasomotor symptoms such as hot flushes, systemic hormone treatment comes into play.

It is important to understand what each option does: lubricants and moisturisers relieve symptoms, but they do not reverse the changes in the tissue. Local oestrogens, on the other hand, act on the underlying cause.

A Cochrane systematic review of 30 randomised clinical trials concluded that there was no difference in efficacy between the various intravaginal oestrogen preparations, and that all of them improved the symptoms of vulvovaginal atrophy compared with placebo. Along the same lines, another review of 19 trials involving 4,162 women concluded that the available topical oestrogens are equally effective as one another for treating vaginal atrophy. The 2025 AUA, SUFU and AUGS guideline recommends offering low-dose local vaginal oestrogen to patients with GSM to improve vulvovaginal discomfort, dryness and pain during sex.

Dismantling the fear: the safety of local oestrogens

One of the biggest barriers to seeking help is fear of hormones. It is worth separating the data from the fear. The 2016 Cochrane review found no differences in adverse effects between the different forms of vaginal oestrogen, or compared with placebo. The 2025 AUA, SUFU and AUGS guideline states that there is no evidence linking low-dose local vaginal oestrogen with the development of breast cancer, and that this treatment does not increase the risk of atypical endometrial hyperplasia or endometrial cancer.

Even so, there are nuances that the product information (ficha técnica) sets out honestly. In the case of vaginal estriol, long-term endometrial safety beyond one year, or with repeated use, is uncertain, so if treatment is repeated it should be reviewed at least once a year. These nuances do not contradict the overall safety of low-dose local treatment, but they do explain why medical follow-up is part of the treatment.

The options authorised in Spain

For information only, and without this being a recommendation for your particular case, these are some of the options authorised in Spain according to their product information approved by the AEMPS:

• Vaginal estriol (Ovestinon): indicated for the symptoms of vaginal atrophy due to oestrogen deficiency in postmenopausal women. The product information describes a starting regimen of one pessary a day for a maximum of 4 weeks and a maintenance dose of one pessary twice a week. At that twice-weekly regimen, systemic exposure to estriol remains within the normal postmenopausal range and adding a progestogen is not recommended.
• Low-dose vaginal oestradiol tablets: available in Spain, with a starting regimen of one tablet a day for 2 weeks and a maintenance dose of one tablet twice a week.
• Prasterone (Intrarosa, 6.5 mg pessaries): it is metabolised into oestrogenic compounds; according to its product information, the risks of systemic hormone therapy apply to a lesser extent to vaginal oestrogens. It is contraindicated if there is a current diagnosis, history or suspicion of breast cancer, and it has not been studied in women with active or previous breast cancer.
• Ospemifene (Senshio, 60 mg oral tablets): a selective oestrogen receptor modulator, indicated for symptomatic vulvovaginal atrophy that affects quality of life. Its product information warns that the risk of cerebrovascular events cannot be ruled out.

On breast cancer, the 2025 AUA, SUFU and AUGS guideline states that neither vaginal prasterone nor ospemifene increases the risk of breast cancer. That said, it is worth being transparent: their product information is stricter. Prasterone's contraindicates it if there is a current diagnosis, history or suspicion of breast cancer; ospemifene has not been formally studied in women with a history of breast cancer and its product information says to use it only once cancer treatment, including adjuvant treatment, has been completed. In that situation, the decision requires specialist assessment.

Talking about it is the first step

Vaginal dryness and pain during sex do not have to be accepted as an inevitable part of getting older: they are symptoms with a name, an explanation and evidence-based treatment. The choice of regimen always rests on an individual medical assessment.

Putting it into words is the first step; the second can be taken today. What does exist in Spain today is menopause treatment with a prior assessment, a prescription where appropriate from a registered doctor and ongoing follow-up. If you want to know whether it fits your case, you can check whether you are eligible.