Painful sex after menopause is often described as a relationship problem. It can be a genitourinary-syndrome problem that deserves medical evaluation.
Prasterone is one prescription option. DailyMed labels INTRAROSA as a vaginal insert for moderate to severe dyspareunia from vulvar and vaginal atrophy due to menopause. [1]
The important boundary is just as clear: this is not a general hormone replacement therapy page.
What prasterone is used for
Prasterone is dehydroepiandrosterone, used as a vaginal insert. The approved use is local: moderate to severe pain with sex from postmenopausal vulvar and vaginal atrophy. The INTRAROSA label gives a dose of one 6.5 mg vaginal insert once daily at bedtime using the provided applicator. [1]
That wording matters because the internet often collapses every menopause hormone topic into one decision. A woman searching "prasterone after menopause" may be trying to understand dryness, burning, pain, low desire, estrogen safety, or systemic hormone replacement therapy. Those are related questions, but they are not the same diagnosis.
The Menopause Society 2020 position statement on genitourinary syndrome of menopause lists vaginal dehydroepiandrosterone among prescription therapies for bothersome genitourinary syndrome of menopause when nonprescription measures are not enough. [2]
Who prasterone may fit
| Question | What the evidence supports | What still needs review |
|---|---|---|
| Moderate to severe pain with sex after menopause | INTRAROSA is labeled for dyspareunia from vulvar and vaginal atrophy due to menopause. [1] | A clinician still needs to confirm that the pain pattern fits genitourinary syndrome of menopause rather than infection, skin disease, pelvic-floor pain, or another cause. |
| Vaginal dryness with genitourinary syndrome of menopause signs | Trials measured dryness and tissue markers along with painful sex. [3] [4] | Dryness alone is not enough to rule out other causes of burning, discharge, odor, sores, or bleeding. |
| Desire, hot flashes, weight, mood, or sleep | These are outside the labeled painful-sex indication. [1] | A broader menopause or sexual-health review is a better fit than treating prasterone as a whole-body hormone plan. |
| Cancer history, unexplained bleeding, or complex medication history | The local route does not remove the need for prescribing judgment. [1] | These should be reviewed before a prescription decision. |
This is who-it-fits language, not a promise. Prasterone may fit a woman whose main problem is diagnosed genitourinary syndrome of menopause-related painful sex after nonprescription measures are not enough. It is not a fit as a shortcut for systemic hormone replacement therapy symptoms, low desire by itself, or unexplained pelvic or vulvar pain.
| Symptom pattern | Better first routing | Why |
|---|---|---|
| Dryness and friction discomfort only | Lubricants, moisturizers, exam, then prescription genitourinary syndrome of menopause options if persistent. [2] | Nonprescription care may be enough for milder symptoms. |
| Moderate to severe painful sex with VVA/genitourinary syndrome of menopause signs | Prasterone, vaginal estrogen, ospemifene, or other clinician-selected genitourinary syndrome of menopause care. [1] [2] | This matches the labeled prasterone category. |
| Low desire without penetration pain | Sexual-health and medication review before assuming prasterone fits. | Prasterone is not labeled as a libido drug. |
| Deep pelvic pain, discharge, odor, sores, fever, or bleeding | Diagnostic evaluation before genitourinary syndrome of menopause treatment. | Painful sex is not always genitourinary syndrome of menopause. |
| Breast cancer history or estrogen-sensitive cancer concern | Oncology-informed or specialist review. | The label notes estrogen is a metabolite of prasterone and INTRAROSA has not been studied in women with a history of breast cancer. [1] |
The evidence is symptom-specific
A trial report on intravaginal dehydroepiandrosterone found improvements in moderate to severe dyspareunia and vaginal dryness symptoms in women with vulvovaginal atrophy. [3]
Pooled prasterone data also evaluated tissue-level markers such as vaginal pH and cell maturation, along with dyspareunia. [4]
The 12-week phase III trial compared daily intravaginal 0.50% dehydroepiandrosterone, or 6.5 mg prasterone, with placebo in an intent-to-treat population of 325 women treated with dehydroepiandrosterone and 157 assigned to placebo. Pain with sexual activity improved by 1.42 severity-score units from baseline, or 0.36 units more than placebo. Vaginal dryness improved by 1.44 severity-score units from baseline, or 0.27 units more than placebo. The trial also found pH and vaginal-cell maturation changes, and vaginal discharge was the only side effect reasonably related to treatment, reported in about 6% of participants. [3]
A pooled analysis of three 12-week randomized trials included 436 women treated with 6.5 mg prasterone and 260 women assigned to placebo. It reported a 0.46-unit, or 49%, placebo-adjusted decrease in dyspareunia severity score, a 0.31-unit decrease in vaginal dryness severity score, lower vaginal pH, and improved cell-maturation markers. [4]
A 2026 systematic review and meta-analysis searched studies through July 2025 and included six randomized controlled trial reports representing five unique randomized trials with 1,611 postmenopausal women with vulvovaginal atrophy. Compared with placebo, intravaginal dehydroepiandrosterone improved vaginal dryness with mean difference -0.23 and dyspareunia with mean difference -0.40; reported adverse effects were mild and infrequent. [5]
Those are relevant outcomes. They are not evidence that prasterone improves hot flashes, weight, energy, mood, sleep, or global "anti-aging" symptoms.
That distinction is the safer answer. Evidence is limited outside diagnosed genitourinary syndrome of menopause-related painful sex and vulvovaginal atrophy outcomes. A careful answer helps a reader ask whether her pain fits genitourinary syndrome of menopause, whether another diagnosis has been ruled out, and whether a prescription vaginal treatment is appropriate.
Red flags before treating painful sex
Pain with sex can come from genitourinary syndrome of menopause, infection, pelvic-floor dysfunction, vulvar skin disease, trauma, medication effects, endometriosis history, bladder pain, neurologic pain, or lesions.
Unexplained bleeding after menopause is not a symptom to self-treat. New sores, discharge, odor, fever, deep pelvic pain, or pain that continues despite local therapy should trigger medical review before prasterone is considered.
The label lists undiagnosed abnormal genital bleeding as a contraindication and states that any postmenopausal woman with undiagnosed, persistent, or recurring genital bleeding should be evaluated before INTRAROSA is considered. It also warns about current or past breast cancer history because estrogen is a metabolite of prasterone, exogenous estrogen is contraindicated in women with known or suspected history of breast cancer, and INTRAROSA has not been studied in women with a history of breast cancer. [1]
One cancer-survivor study of vaginal dehydroepiandrosterone found dose-dependent increases in dehydroepiandrosterone sulfate and testosterone and an estradiol increase with 6.5 mg/day dehydroepiandrosterone in some participants, while estradiol did not change in women on aromatase inhibitors. The authors said further research was warranted in hormone-dependent cancers. [6] That is not a reason for panic, but it is a reason not to treat "local" as "irrelevant to cancer history."
Where prasterone fits beside vaginal estrogen
Prasterone belongs near local genitourinary syndrome of menopause care, not inside broad systemic hormone replacement therapy claims. Vaginal estrogen, prasterone, moisturizers, lubricants, ospemifene, pelvic-floor therapy, and infection evaluation can all be part of the broader care conversation. Menopause Society says choice of genitourinary syndrome of menopause therapy depends on symptom severity, treatment effectiveness and safety for the individual patient, and patient preference. It also notes that long-term studies on endometrial safety of vaginal estrogen, vaginal dehydroepiandrosterone, and ospemifene are lacking. [2]
The right order is:
- Name the symptom pattern.
- Rule out red flags and non-genitourinary syndrome of menopause causes.
- Match the treatment to the diagnosis.
- Monitor whether pain, dryness, tissue symptoms, and side effects improve.
What to ask a clinician
Ask whether your symptoms fit genitourinary syndrome of menopause, whether the exam suggests another cause, and whether nonprescription moisturizers or lubricants are enough before prescription treatment.
Ask how prasterone compares with vaginal estrogen, ospemifene, pelvic-floor therapy, infection testing, or dermatology evaluation for your symptom pattern. The comparison should be about diagnosis, contraindications, and preferences rather than about which option sounds more natural.
Ask what improvement would count as a response and how long to reassess. If pain, bleeding, burning, lesions, discharge, or pelvic symptoms persist, the next step should be re-evaluation rather than simply switching products.
Bottom line
Prasterone is a useful topic because midlife women search for painful sex treatments and often get a confusing hormone conversation instead.
The honest answer is that prasterone has evidence and labeling for a narrow postmenopausal genitourinary syndrome of menopause use: moderate to severe dyspareunia from vulvar and vaginal atrophy. It should be discussed as prescription, diagnosis-first care, not as systemic hormone replacement therapy or a broad menopause wellness claim.
How the assessment helps
A clinical intake can read this as a triage signal for prasterone (Intrarosa), not a self-diagnosis shortcut. The assessment helps organize symptoms, uterus status, bleeding pattern, contraindication clues, medications, preferences, and treatment fit so a clinician can decide what belongs in the plan.
Related reading:
- Progesterone vs Progestin in hormone replacement therapy.
- selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors for Hot Flashes After Menopause.
- Starting hormone replacement therapy After 60.
- Vaginal Estrogen After Menopause.
- Ospemifene After Menopause.
References
[1] DailyMed. INTRAROSA prasterone insert prescribing information. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=df731acd-7276-4fef-b037-bc7f30c112cb
[2] The NAMS 2020 GSM Position Statement Editorial Panel. The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause. 2020;27(9):976-992. doi:10.1097/gme.0000000000001609 https://pubmed.ncbi.nlm.nih.gov/32852449/
[3] Labrie F, Archer DF, Koltun W, et al. Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause. Menopause. 2018;25(11):1339-1353. doi:10.1097/gme.0000000000001238 https://pubmed.ncbi.nlm.nih.gov/30358731/
[4] Labrie F, Archer DF, Martel C, Vaillancourt M, Montesino M. Combined data of intravaginal prasterone against vulvovaginal atrophy of menopause. Menopause. 2017;24(11):1246-1256. doi:10.1097/gme.0000000000000910 https://pubmed.ncbi.nlm.nih.gov/28640161/
[5] Lemos MJ, Queiroz LF, Diniz AF, et al. Intravaginal dehydroepiandrosterone for the treatment of vulvovaginal atrophy: a systematic review and meta-analysis. Menopause. 2026;33(7):852-858. doi:10.1097/gme.0000000000002736 https://pubmed.ncbi.nlm.nih.gov/41589851/
[6] Barton DL, Shuster LT, Dockter T, et al. Systemic and local effects of vaginal dehydroepiandrosterone (DHEA): NCCTG N10C1 (Alliance). Support Care Cancer. 2018;26(4):1335-1343. doi:10.1007/s00520-017-3960-9 https://pubmed.ncbi.nlm.nih.gov/29164377/