Between 25 percent and 45 percent of postmenopausal women find sex painful, a condition called dyspareunia.

While there are many causes, the most common reason for dyspareunia—painful sex—in women over 50 is vulvovaginal atrophy, a fancy name for a vulva and vagina that no longer have the beneficial effects from estrogen that they did prior to menopause.

Lower estrogen levels significantly affect your vagina, impacting its ability to secrete lubricant, to expand and contract and to grow new cells. Over time, blood flow diminishes, and the vagina and vulva can atrophy, or shrink, as cells die off and aren’t replaced.

The result? Soreness, burning after sex, pain during intercourse and, sometimes, post-sex bleeding.

The good news is that vuvlovaginal atrophy is very treatable. One of the best treatments doesn’t involve medicine! Turns out that the more often you have sex, the less likely you are to develop atrophy or, at the very least, a serious case of it. That’s because sex increases blood flow to the genitals, keeping them healthy.

Other treatments include:

Estrogen. As you might expect, if lack of estrogen is behind vulvovaginal atrophy, then giving back estrogen should help. Both systemic estrogens (oral pills and patches) and local estrogens (creams, rings and tablets applied to the vulva and/or vagina) work. However, most major medical organizations recommend starting with the local approach first because it keeps the estrogen right where it’s needed, limiting any effects on the rest of your body.

Studies on the estrogen ring, cream and tablets find extremely high rates of improvement in dyspareunia, with up to 93 percent of women reporting significant improvement and between 57 percent and 75 percent saying that their sexual comfort was restored, depending on the approach used.

Side effects vary. Most estrogen products applied locally are associated with minimal side effects. However, each woman’s response can differ. When using estrogen creams, pills or rings, it is important to talk to your health care provider about any symptoms, such as: headache, stomach upset, bloating, nausea, weight changes, changes in sexual interest, breast tenderness, abdominal pain, back pain, respiratory infection, vaginal itching or vaginal yeast infections.

If you have had breast cancer or a family history of breast cancer, be sure to discuss your history with your health care professional, if you’re considering using estrogen. Your health care professional likely has covered this topic with you already.

Non-medicated lubricants. If you’d rather not go the estrogen route, consider using some of the over-the-counter products designed to increase sexual comfort. Vaginal lubricants come in liquid or gel form and work by reducing friction. You can apply a water-based or silicone-based lubricant to your vagina and vulva (and, if desired, to a partner’s penis) just before sex. You may also try longer-lasting vaginal moisturizer, which is absorbed into the skin and can provide relief from vaginal dryness for up to four days.

Other Causes of Sexual Pain

Since many women over 50 do not experience vulvovaginal atrophy, women with sexual pain should be aware that there are other medical conditions that could be responsible for their symptoms. These include:

Vestibulodynia. Vestibulodynia is the most common cause of sexual pain in women under 50, but it can also affect older women. Women with this condition feel severe pain when any type of pressure or penetration is attempted at the entrance to the vagina (an area called the vestibule). It is treated with topical anesthetics, estrogen cream, antidepressants, antiepileptic drugs (often used for nerve-related pain) and physical therapy. Look for a physical therapist who is specially trained in pelvic therapy.

Vulvodynia. This condition involves stinging, burning, irritation, rawness or pain on the vulva, the tissue that surrounds the vagina. The pain and irritation can occur even when nothing touches the area and is likely related to abnormal nerve firing. Vulvodynia is treated similarly to vestibulodynia.

Vaginismus or Pelvic Floor Muscle Dysfunction. In this condition, the vaginal and perineal muscles involuntarily spasm with attempted sexual activity. This can make vaginal entry very difficult or even impossible. Vaginismus can occur after a trauma (such as nonconsensual sex), or it can be related to underlying physical conditions, including musculoskeletal injuries or vestibulodynia. Vaginismus is often treated with dilator therapy (in which women are taught relaxation techniques while using progressive-sized dilators in their vagina) and physical therapy.

Urinary tract conditions. Cystitis, which involves inflammation of the bladder, is a common cause for painful sex, because the bladder sits on top of the vagina and can be aggravated during sex. There are several kinds of cystitis. Chronic interstitial cystitis is a painful bladder syndrome that causes bladder pressure, bladder pain and sometimes pelvic pain. Acute cystitis is a bacterial infection of the bladder or lower urinary tract that occurs suddenly and causes pain—often referred to as a urinary tract infection (UTI). In postmenopausal women, lower estrogen levels change the pH and make bacterial infections more likely. Lack of estrogen also can make the vagina more vulnerable to vaginitis, including bacterial vaginosis and yeast infections. Both can cause pain and itching.

Other causes. A uterus that has “dropped” or prolapsed may cause pain during sex. Endometriosis, a condition in which the uterine tissue grows outside the uterus, usually ends after menopause but may continue in women taking estrogen and can cause pelvic pain. Sexual trauma and childbirth trauma, such as episiotomies or tears and repairs, may also cause painful sex.

Time to Speak Up

Unfortunately, most women do not talk to their health care providers about sexual pain or problems, nor do their health care providers bring up the topic. In an international survey of 391 women by the Women’s Sexual Health Foundation, fewer than 9 percent of women said their health care professionals had ever asked if they had sexual problems.

If you don’t bring up the topic of sex with your health care professional, it may not get addressed. Talk to a gynecologist or urogynecolosist about your sexual pain. They can offer the most options for treating this complex problem.