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Sex hurts now. You are not broken, and it is fixable

It usually starts as friction. Then discomfort. Then a flinch you try to hide. Eventually you stop initiating, then you start going to bed early, and somewhere in there an entire part of your life closes quietly, without anyone naming what happened.

Up to 45 per cent of women in the menopause transition experience painful sex. Almost none of them raise it, and almost nobody asks.

This is not a relationship problem that showed up as a body problem. It is a tissue problem that became a relationship problem, because nobody treated it.

What is actually happening

Oestrogen maintains the tissue of the vulva, vagina and urinary tract: its thickness, elasticity, blood supply and natural lubrication. When oestrogen falls, that tissue becomes thinner, drier and more fragile. The clinical name for the cluster is genitourinary syndrome of menopause, and it covers dryness, burning, pain with sex, urgency, and recurrent urinary infections.

Here is the crucial difference from hot flushes. Flushes usually fade with time. This does not. Left alone, it progresses. That sounds like bad news. It is actually the argument for acting now, because it also responds well to treatment.

What helps

Three different things, routinely confused with one another.

Lubricant reduces friction in the moment. Useful, immediate, and not a treatment.

Vaginal moisturiser is used regularly, not only around sex, and improves the day-to-day comfort of the tissue. This is maintenance, and it is the one most women skip.

Local oestrogen, prescribed as a cream, pessary or ring, treats the tissue itself. It is not the same as systemic hormone therapy: the dose is very small and it acts where it is applied. Many women who cannot or do not wish to take systemic hormones may still be candidates. That is a conversation for your doctor, and it is worth having, because for most women it is the single most effective option and it is dramatically under-prescribed.

And then there is the part medicine stops at

Treat the tissue and the pain improves. That does not automatically restore desire, or undo months of bracing, or repair the silence that has grown between you and your partner. A body that has learned to expect pain does not simply forget. That relearning is real work, and it is not medical work.

Comfort first. Desire cannot return to a body that is braced.

What to do this week

Book the appointment, and use the word: pain. Not dryness. Not "things have changed." Pain. Ask specifically about local oestrogen. Start a daily moisturiser regardless. And stop treating this as the price of getting older, because it is not.

General education, not medical advice. Treatment decisions, including local oestrogen, should be made with your doctor.