Sometimes the most important health questions are the ones you’re too mortified to ask. You know your doctor’s a professional who’s heard it all before, but there’s just no way you’re bringing up that foul odor or that weird burning sensation after sex. We hear you. In our “Too Embarrassed to Ask” series, we’ll tackle your most uncomfortable questions. (And when you’re done reading, just clear your browser history. We’ll never tell.)

Sex after age 65 can be a great thing. With your kids grown and out of the house, you may find fewer distractions and more privacy. You’re often retired, or semi-retired, so you have more time to lounge around with your partner. Even better, after years of futzing with condoms or pills or IUDs, you don’t have to worry anymore about pregnancy!

But sometimes there’s a hitch. Almost half of all women who have gone through menopause find sex painful, at least some of the time. That number might surprise you, but it’s true.

The good news is it doesn’t have to be that way! If love making is uncomfortable, there are a number of options to help you find your groove again. Don’t let anyone tell you otherwise.

“I see women who’ve gone years being told that a normal part of aging is to have pain with sex,” Lisa M. Valle, DO, an ob-gyn and medical director of Oasis Women’s Sexual Function Center in Santa Monica, California, told Health this past January. “By the time they come to see me, that’s what I hear. The fact is, there’s a lot you can do.”

Why sex can hurt

Painful sex actually has a medical name: dyspareunia. There are a few reasons why it can happen:

Vaginal changes

Just like age affects your bones, skin, and joints, it affects your vagina, too. Over time, your vagina shortens and narrows, and its walls stiffen up. This can make sex more painful.

A drop in hormones

The loss of estrogen after menopause makes the once-stretchy tissues down there thinner, drier, and a lot less elastic. As a result, those tissues are more likely to bleed and tear during sex.

Certain medications

Some drugs, like those used to treat high blood pressure, can also dry out vaginal tissue. Antidepressants and allergy medications (even over-the-counter ones) can cause the same problems.

Underlying medical conditions

As they age, women are more likely to develop certain autoimmune conditions, such as Sjorgen’s syndrome. These diseases can also cause vaginal dryness.

Past pelvic surgery

If you’ve had a hysterectomy, you may have scarring from the operation that can make intercourse painful.

Pelvic floor disorder

More than a third of women over the age of 60 have a pelvic floor disorder, which is when the muscles and ligaments around your pelvis weaken. It occurs with age, especially if you’ve had kids. Sometimes, your pelvic organs – which include your uterus, bladder, and bowel – collapse onto your vagina, a condition known as pelvic prolapse. This can make sex very uncomfortable.

Stress

If sex is already painful for you, you may respond by automatically tightening up your vaginal muscles every time you have intercourse. It’s unconscious, so you don’t realize that you’re doing it. But this response can make sex even more uncomfortable.

How to make sex less painful

The first step is to talk to your doctor. It might feel awkward, but they need to examine you to figure out if there’s a physical cause for your pain, like a pelvic floor disorder or a past surgery. They may suggest one or more of the following approaches.

Over-the-counter moisturizers and lubricants

These add moisture around and inside your vagina. There are two types: internal ones that you insert, and others that you apply around your vaginal area. You can use these every day. You should also apply an OTC lubricant when you have sex. Look for water-based lubricants, since they’re less likely to cause irritation down there (which can make sex even more painful) than oil-based ones.

Estrogen creams and tablets

These are available only by prescription and are inserted into your vagina. Since very little estrogen goes into your bloodstream, they carry a very low risk of scary side effects like blood clots, breast cancer, and heart attack compared to birth control pills or menopause hormone therapy. They’re inserted every day for two weeks, then less frequently after that. If you have trouble remembering, there’s also a vaginal estrogen ring, Estring, that you replace every three months. You can keep it in even during sex or when taking a shower.

Pelvic floor physical therapy

This can help if your pain is due to tight, tender pelvic floor muscles. You actually see a physical therapist who specializes in this area. They will show you exercises to relax your pelvic floor muscles, to help relieve pain. They can also show you how to use a vaginal dilator, which are tube-shaped devices of different sizes. They stretch out your vagina. You start with the smallest one and then work your way up.

Osphena (ospemifene)

This is a prescription drug that’s similar to estrogen. It’s approved for post-menopausal women who have vaginal dryness that causes pain during sex. It may cause mild hot flashes as a side effect. It’s not recommended for long term use, since it may raise risk of blood clots or uterine cancer.

Staying sexually active

It might sound counterintuitive, but more sex could help. Regular sexual activity can help to reduce pain during sex, since it keeps vaginal tissue soft and elastic. But if it hurts too much, don’t push it. Stop and talk to your doctor.

Remember, there are lots of treatments out there, so if your doctor dismisses you or tells you it’s a normal part of aging, get a second opinion.

Getting past embarrassment

If you have pain during sex, you may feel embarrassed discussing it with your doctor. But a good doctor should be raising this question during your physical, the same way they ask about your quality of sleep and whether you exercise. As you now know, painful sex is a very common problem among women over age 65!

If your doctor doesn’t ask, take the initiative and bring it up yourself. Yes, it might feel awkward, so think about how you want to handle it ahead of time. If you have a joking relationship with your physician, a little humor can help put you at ease. (“So, doc, let me ask you: Is it normal for sex to feel like sandpaper?”) Or you could raise the general topic (“I have some questions about sexual health”) and let the conversation flow from there.

Or you could openly admit your embarrassment. (“I hate that I have to ask this, but lately having sex has just been so painful. Is there anything I can do about it?”) Rest assured, no matter how you approach it, your doctor will have heard this problem before.

You may also worry about discussing the problem with your partner. Perhaps you fear they’ll be less attracted to you or think you’re frigid. The truth is, they probably realize already that you’re uncomfortable during sex. They may think that you’re no longer attracted to them or that you’re upset or angry with them. That’s why an honest conversation is so important.

Let them know that you’re having pain during sex and what’s causing it (for example, vaginal dryness because you’re past menopause). Explain what you’re doing to help. Then focus on what feels good when the two of you are together. Even if you’re not up to actual intercourse right now, there are plenty of ways for you to enjoy each other’s company between the sheets!

Chances are, your partner has their own insecurities about how they perform in the bedroom. If you are open with them, it will strengthen your relationship and encourage them to open up to you as well.

It’s also important to remember that if sex has been painful for a while, you may have a negative response to it even after you’ve had treatment. Just the thought of being intimate could bring up bad memories and make you tense. That’s okay! You may need to talk to a counselor or even a sex therapist to help resolve these issues.

Medicare and pain during sex

Wondering whether you’re covered for treating painful sex? Original Medicare covers pelvic floor physical therapy, just like it would cover any other physical therapy. Most Medicare Part D plans cover prescription creams and tablets. Over-the-counter aids, like lubricants, aren’t covered under Original Medicare. Some Medicare Advantage plans offer discounts or quarterly stipends that can be applied to over-the-counter remedies. Curious how your plan compares to other Medicare plans in your area? Check out our easy-to-use Find a Plan tool.

Additional resources

Find a Medicare Plan

Health: “Tips to Enjoy Sex After Menopause

The North American Menopause Society: Pain with Penetration