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If sex hurts, it is called painful sex (Dyspareunia) and you can find out why, how to recognise the symptoms and what treatment options are available.
Many women may not realize that pain during sex is more common than they think, but many still don't mention it, even to their doctor. When sex has fallen out of favour or is painful, you're not alone, and there's almost always a medical reason why. This is known as dyspareunia and can be caused by a lack of lubrication or more serious problems like endometriosis, vaginismus or a decrease in oestrogen following menopause. For some women, the pain is only every now and then, for others it is at every single intimate encounter with their partner. In some instances there is a bit of light bleeding that is accompanied by pain, and this is obviously a source of concern. This article breaks down what painful sex really means medically, some of the most common causes of painful sex and what treatments have helped countless women return to a comfortable, pain-free sexual life.
Dyspareunia is a medical condition where sex is painful, and it's when genital pain happens during, before, or after sex and is both frequent or ongoing. It is said to be superficial if it is felt at the opening of the vagina, and deep if it is felt deeper within the pelvis, typically during more intense penetrations. The distinction is important because the causes are typically different for the two types. Superficial pain is more commonly associated with dryness, infection, or muscle tension close to the vagina, and deep pain is more commonly associated with conditions that affect the uterus, the ovaries and the pelvic organs. Your doctor will want to know exactly where the pain is, when you first felt it and if it happens every time you have intercourse or sometimes. This can narrow down the cause considerably quicker. Dyspareunia is not a diagnosis, it is a symptom and the primary aim of the consultation is to determine what is causing the symptom, not the symptom itself.
There are several possible causes of painful sex and sometimes more than one cause can be at play simultaneously. One of the most common causes is low arousal, some medications or hormonal changes that can cause sharp, burning pain at entry. Sexually transmitted infections, urinary tract infections or yeast infections may cause inflammation of vaginal tissues and make penetration painful. Even for people who are not experiencing any pain, some women find it impossible to penetrate if there is a tightening of the muscles in the pelvis or vagina, which is an involuntary reaction. In many cases, too, the causes are skin conditions of the vulva, scar tissue from childbirth or previous surgery, or tightness of the pelvic floor muscles from stress. There are a number of conditions (such as fibroids, ovarian cysts, pelvic inflammatory disease, or endometriosis) that are associated with deeper pain which can worsen during deeper penetration or specific positions. This is because reasons are so similar, a proper pelvic exam is usually necessary to determine which one, or combination of reasons, is relevant to you, rather than making an educated guess based on symptoms.
Sex is often painful after menopause and this occurs primarily because there is a sudden drop in oestrogen after the final period. When oestrogen levels drop, so does the thickness, elasticity and lubrication of the vagina, which can cause doctors to refer to the condition as vaginal atrophy or genitourinary syndrome of menopause. This may lead to painful, burning or raw sensations when you engage in sexual intercourse, and a slight bleeding after. Many women think that it is nothing unusual to endure after menopause, yet it is a disorder that is well recognised and treatable. Local vaginal oestrogen cream, moisturisers, and lubricants are all commonly used treatments, and can offer a vast improvement in a couple of weeks. Non-hormonal vaginal moisturisers and pelvic floor physio can be good alternatives for women who are not able to take hormonal treatments. This symptom should be mentioned in the normal gynae examination, before it becomes an accepted fact of life, as treatment is likely to be easier the sooner it is started, and there is no excuse for not talking about it.
One of the most troublesome reasons for deep pain during sex is because of endometriosis, and for many women, it's the first symptom that eventually results in a diagnosis. In the condition of endometriosis, the tissue that normally lines the uterus is found in other parts of the body, such as the lining of the pelvis, fallopian tubes, or on the inside of the ovary and responds to the monthly menstrual cycle. The displaced tissue may be stretched or pressed during deep penetration, causing an acute, shooting, or stabbing pain that could persist for several hours. Often the pain is worse just prior to or during a period, but may happen anytime in the cycle. In addition to painful periods, endometriosis often results in heavy or irregular periods, chronic pelvic pain and, in some cases, difficulty to conceive. Many women suffer with unexplained pain for years before a diagnosis is made because the condition does not present itself in any particular way and can only be diagnosed with imaging or laparoscopy in some cases. If the pain occurs while having sex, especially when accompanied by heavy periods, it's important to specifically ask your gynaecologist if it's related to endometriosis, because women often think sex and period pain are unrelated.
Sexual intercourse is normal but if there is any dryness or friction there may be occasional spotting after sex which is not a cause for worry, however there is nothing wrong with this if there is pain and regular bleeding, it needs proper evaluation. They usually occur because of vaginal dryness or small tears, irritated or infected cervix, or the presence of cervical polyps, or especially after menopause, thinning of the vagina walls. Rarely, bleeding during or after sex may be related to fibroids or cervical problems that must be eliminated by a screening test. So the pain and bleeding is significant as it generally indicates a physical, physical exam-able cause for the pain, as opposed to a purely muscular or psychological cause, and that's why a pelvic exam is especially useful in these situations. However, if the bleeding is excessive, with every act of sexual intercourse, or if a foul smell or fever is present, this should be investigated immediately, instead of at home. In most cases, the cause can be rapidly diagnosed by a simple pelvic examination and/or an ultrasound examination or a cervical screening test, and suitable treatment can be commenced.
Treatment of painful sex will depend entirely upon its underlying cause, so that treating the symptom without establishing its cause is less effective. Lubricants (water-based or silicone) or, in the post menopausal period vaginal oestrogen therapy are generally the first treatment options for dryness-induced pain. Pelvic floor physiotherapy and graduated dilator therapy for the vagina can be helpful, and sometimes counselling to discuss any anxiety about penetration. If infection is detected following testing, the appropriate antibiotic or antifungal drug is used for treatment. Treatment for endometriosis may vary from hormonal treatment to suppress the growth of the underlying tissue to surgery in severe cases, depending on the severity of the condition and the patient's desire for pregnancy. Specific physiotherapy and relaxation exercises may help to reduce pelvic floor tension. Of course, a combination approach is often helpful, such as in the case of treating an infection and dealing with the muscle tightness that occurred as a protective response to pain earlier in the day. Most importantly, it is important to have a discussion with a gynaecologist, as painful sex is a medical symptom and well recognised, and there are treatment courses available to follow – not one that you have to manage without medical help.
Sexual intercourse is a medical condition and can be made pain free, and you don't have to live with it. If you are experiencing pain, it is important to work out exactly what is causing it before you begin treatment. This will enable you to receive a better treatment, as the cause of your pain may be anything from vaginal dryness, to an infection, vaginismus, endometriosis or hormonal changes following menopause. If you have pain and bleeding, it is important to pay attention to this and not take it upon yourself to treat. A gynaecologist can usually make a diagnosis with a simple examination and, if necessary, some simple tests, and then work out what treatment is appropriate for you – it might be lubrication and hormone replacement therapy, physiotherapy or specific therapy for an underlying condition such as endometriosis. The more it is openly discussed, the sooner it will be resolved.
Others have pain around ovulation as a result of a small, temporary ovarian cyst that forms every cycle (mittelschmerz) or due to pain in the pelvis area caused by hormonal changes at this time in the cycle.
Why is it that sex hurts right after my period? If the vagina is somewhat dry and/or sensitive, or if there is some underlying inflammation of the pelvis or endometriosis which may flare up after a period, pain can occur just after a period.
It is normal to have some pain those weeks after giving birth as tissues heal, particularly if there was a tear or an episiotomy, but if pain persists for more than a few months then it should be explored as this might be a problem with the scar tissue, tension in the pelvic floor and/or hormonal changes associated with breastfeeding.
Most often it's due to vaginal dryness, infections, vaginismus, pelvic floor muscle tension, or conditions, such as endometriosis or ovarian cysts, that result in more painful deeper pelvic pain.
No. For many cases, the cause is easy to treat – it may be simply be due to dryness or a minor infection – but if this is the case, it's important to be seen to rule out conditions such as endometriosis from persistent or worsening pain.
A thorough history and pelvic exam are usually performed first and various tests may be ordered depending on the symptoms described, such as an ultrasound, swabs for infection, or a cervical screening test.
Yes, in most cases. Most women will be helped by the use of lubricants, a hormonal cream, pelvic floor physiotherapy and treating any underlying infection, and only rarely will surgery be required (for very large amounts of endometriosis).
Yes. Most women who use oestrogen for their vagina see results of effective moisturisers and lubricants within a few weeks of treatment and these can reduce any vaginal dryness or thinning that is likely to lead to painful sex after menopause.
If the pain is ongoing or worsening, if it is bleeding or if it affects your comfort with intimacy, you should see a doctor as the pain will not go away on its own.
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