Sex Hurts Now — Is It My Pelvic Floor or Perimenopause (or Both)?

Painful sex is a common but often misunderstood issue in midlife.

For many people, discomfort during or after intercourse begins or worsens during the perimenopausal years. This can happen for multiple reasons — and often, it’s a combination of factors.

Hormonal shifts can cause the vaginal tissue to become thinner, drier, and less elastic (a condition now often referred to as GSM: Genitourinary Syndrome of Menopause). This means that friction, pressure, or penetration may feel more irritating or even sharp.

At the same time, pelvic floor muscle tension can be playing a role. When the muscles around the vaginal canal are overactive or tight — which can happen after childbirth, with chronic stress, or even from sitting for long hours — the body has a harder time relaxing into sexual activity. That tightness can lead to:

• Burning or pinching sensations

• Difficulty with penetration

• Lingering pain or cramping after sex

In some cases, pelvic floor muscle tension develops as a response to pain — but in others, it’s part of the original issue. The tricky part is that hormone-related dryness and muscular tension often overlap, and it’s not always obvious which one came first.

Pain during sex may also show up in areas beyond the vagina: some people notice rectal pressure, lower abdominal pain, or tailbone soreness during or after intimacy. These symptoms are often tied to the deeper layers of the pelvic floor and surrounding muscle groups.

There’s no one-size-fits-all cause, which is why detailed assessment — both of the tissues and of muscle coordination — is often needed to understand what’s going on.