The clinical portraits on this blog are anonymised composites: they combine features of several patients to protect each person’s privacy while remaining faithful to the realities of clinical practice.

Sophie called me on a Wednesday, without an appointment. Her voice was composed and professional — she is a lawyer — but underneath was a tiredness I know well.

‘I would like to understand what is happening to me. I have been sexually active all my life without any problems. For the past eighteen months, I have not been able to do it. It is as though my body has become a different body.’

At 47, Sophie was facing something that none of the information she had read clearly named: late-onset secondary vaginismus, triggered by the hormonal changes of perimenopause.

What she had been told

She had seen three practitioners before me.

  • Her usual gynaecologist had told her ‘it is perimenopause, it is normal, use some lubricant’. Sophie left with a tube of Durex Play. It made no difference.
  • A pelvic health physiotherapist had told her ‘you do not have significant hypertonicity’ and recommended Kegels. The closure became worse.
  • A therapist specialising in female sexuality had told her ‘there may be an emotional element; would you like to explore your relationship with ageing?’. Sophie eventually stopped going.

Nobody had given her the right diagnosis, which combined two things:

  1. Genitourinary syndrome of menopause (GSM) — atrophy of the vaginal lining, loss of elasticity and reduced lubrication, a direct consequence of gradually falling oestrogen levels
  2. Secondary vaginismus — a pelvic floor contraction reflex that had developed in response to the repeated pain caused by GSM

The two had combined. Without identifying both, no treatment on its own could work.

How the sequence unfolded

Here is how it developed for Sophie over 18 months:

Months 1–3: intercourse with her husband, previously comfortable, began to cause some pain at the entrance. Dryness, irritation and a burning sensation afterwards. She put it down to stress.

Months 3–6: the pain increased. Sophie began avoiding intercourse. When they did have it, she tensed in anticipation without realising it.

Months 6–12: penetration became very difficult. Her body contracted before intercourse had even begun. The mechanism of vaginismus had developed on top of the GSM.

Months 12–18: it became completely impossible. No intercourse at all. Tension in the relationship. Sophie came to see me.

GSM had caused the wound. Vaginismus had formed the scar.

The difficult part was that treating only one of the two causes was not enough. If only the GSM had been treated with local hormone therapy, the established vaginismus would have remained. If only the vaginismus had been treated with dilators, the fragile, atrophied lining would have caused pain again with every attempt.

Both needed to be treated in parallel.

The protocol

The work lasted six months. Shorter than for some other profiles, because Sophie had a major advantage: a long, positive sexual history. Her body knew how. It simply needed the right conditions again.

Part 1 — Restoring the vaginal lining: the underlying tissue.

  • Mucogyne vaginal pessaries, 3 evenings a week
  • Intrarosa (vaginal DHEA, prescription-only), 1 pessary each evening for 3 months, then 3 times a week for maintenance
  • Yes WB lubricant with every episode of intercourse: water-based, glycerine-free and compatible with all tissues

Part 2 — Defusing the reflex.

  • Diaphragmatic breathing for 10 minutes a day
  • Velvi dilators, starting with size S, not to ‘widen’ the vagina — Sophie’s vagina had not anatomically narrowed — but to teach the nervous system again that penetration no longer means pain. A five-week protocol with 4 sessions a week.
  • No psychotherapy as the first approach: Sophie had no trauma, just a muscular reflex to retrain.

Part 3 — Resuming intimacy with her partner.

  • An explicit conversation with her husband about the new hormonal reality: he had not known about it, as many partners do not know what happens during menopause
  • Gradually resuming intimacy through external caresses, without penetration for 3 weeks
  • A first attempt at intercourse during the 4th month, with lubricant, Sophie in a position where she had control (on top), and keeping it brief
  • Intercourse was possible. There was some remaining discomfort, but no pain that prevented it.

What Sophie said when we reviewed the work

At our final session, Sophie said two things that stayed with me.

The first:

‘Nobody told me this could happen. I am 47, I have had three gynaecologists in my life, and none of them mentioned GSM before I found myself unable to make love. How is that possible?’

The second, later, as she was leaving:

‘My husband and I have grown closer. Not only because sex has returned, but because we had that conversation. It is sad that it took eighteen months and three practitioners to get there, but it was worth it.’

If you recognise yourself

Perhaps you are Sophie. You are 42, 45, 50 or 55. You had never experienced vaginismus. Now you have it, and nobody takes you seriously because ‘it is your age’ or ‘it is menopause’.

Four things to know:

  1. GSM is a condition that can be treated. It is not an inevitable part of menopause. Do not accept it being presented that way.
  2. Secondary vaginismus during perimenopause is very common and consistently underdiagnosed. Look for a gynaecologist who knows about GSM and takes an interest in sexuality after 45. They are not the majority; you need to search.
  3. Treatments exist: Mucogyne and Replens without a prescription; Intrarosa, Vagifem and Senshio on prescription; dilators; and a trained physiotherapist. The combination works in 80% of cases in less than 6 months.
  4. Your partner needs to understand. What is happening to you is not ‘I do not want to any more’; it is a change in your hormonal circumstances. This understanding saves relationships.

Taking it further

If you would like the complete chapter on vaginismus during perimenopause — distinguishing GSM, vaginismus and atrophy; detailed protocols; hormonal and non-hormonal treatments; and conversations as a couple — I have written Votre Vaginisme : fini l’errance, dénouer le plaisir selon votre profil.

Sophie is portrait no. 3 in Part I. The chapter in Part III covers the physiology of perimenopause in detail.

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📖 To explore further — Scarlett Kaplan’s book, Votre Vaginisme: the most comprehensive French-language reference on vaginismus.