Painful intercourse (dyspareunia)
Painful intercourse can occur for a variety of reasons — ranging from structural problems to psychological concerns. Many women experience painful intercourse at some point in their lives.
The medical term for painful intercourse is dyspareunia (dis-puh-ROO-nee-uh) — which is defined as persistent or recurrent genital pain that occurs just before, during or after intercourse. Talk to your doctor if you're experiencing painful intercourse. Treatments focus on the underlying cause, and can help eliminate or reduce this common problem.
If you experience painful intercourse, you may feel:
- Pain only at sexual penetration (entry)
- Pain with every penetration, even while putting in a tampon
- New pain after previously pain-free intercourse
- Deep pain during thrusting
- Burning pain or aching pain
- Throbbing pain, lasting hours after intercourse
When to see a doctor
If you experience recurrent pain during sex, talk to your doctor. Treating the problem can help your sex life, your emotional intimacy and your self-image.
Physical causes of painful intercourse differ, depending on whether the pain occurs at entry or with deep thrusting. Emotional factors can be associated with many types of painful intercourse.
Pain during penetration may be associated with a range of factors, including:
Insufficient lubrication. This is often the result of not enough foreplay. Insufficient lubrication is also commonly caused by a drop in estrogen levels after menopause, after childbirth or during breast-feeding.
Certain medications are known to inhibit desire or arousal, which can decrease lubrication and make sex painful. These include antidepressants, high blood pressure medications, sedatives, antihistamines and certain birth control pills.
- Injury, trauma or irritation. This includes injury or irritation from an accident, pelvic surgery, female circumcision or a cut made during childbirth to enlarge the birth canal (episiotomy).
- Inflammation, infection or skin disorder. An infection in your genital area or urinary tract can cause painful intercourse. Eczema or other skin problems in your genital area also can be the problem.
- Vaginismus. Involuntary spasms of the muscles of the vaginal wall (vaginismus) can make attempts at penetration very painful.
- Congenital abnormality. A problem present at birth, such as the absence of a fully-formed vagina (vaginal agenesis) or development of a membrane that blocks the vaginal opening (imperforate hymen), could be the underlying cause of dyspareunia.
Deep pain usually occurs with deep penetration and may be more pronounced with certain positions. Causes include:
- Certain illnesses and conditions. The list includes endometriosis, pelvic inflammatory disease, uterine prolapse, retroverted uterus, uterine fibroids, cystitis, irritable bowel syndrome, hemorrhoids and ovarian cysts.
- Surgeries or medical treatments. Scarring from pelvic surgery, including hysterectomy, can sometimes cause painful intercourse. Medical treatments for cancer, such as radiation and chemotherapy, can cause changes that make sex painful.
Emotions are deeply intertwined with sexual activity and may play a role in any type of sexual pain. Emotional factors include:
- Psychological problems. Anxiety, depression, concerns about your physical appearance, fear of intimacy or relationship problems can contribute to a low level of arousal and a resulting discomfort or pain.
- Stress. Your pelvic floor muscles tend to tighten in response to stress in your life. This can contribute to pain during intercourse.
- History of sexual abuse. Most women with dyspareunia don't have a history of sexual abuse, but if you have been abused, it may play a role.
Sometimes, it can be difficult to tell whether psychological factors are associated with dyspareunia. Initial pain can lead to fear of recurring pain, making it difficult to relax, which can lead to more pain. As with any pain in your body, you might start avoiding the activities that you associate with the pain.
Preparing for your appointment
If you have recurrent pain during sex, talking to your doctor is the first step in resolving it. Primary care doctors and gynecologists often ask about sex and intimacy as part of a routine medical visit. Use the opportunity to discuss your concerns.
Your regular doctor may diagnose and treat the problem or refer you to a specialist who can.
What you can do
To prepare for this discussion with your doctor:
- Take note of any sexual problems you're experiencing, including when and how often you usually experience them.
- Make a list of your key medical information, including any conditions for which you're being treated, and the names of all medications, vitamins or supplements you're taking.
- Consider questions to ask your doctor and write them down. Bring along notepaper and a pen to jot down information as your doctor addresses your questions.
Examples of questions you may want to ask your doctor include:
- What could be causing my problem?
- What lifestyle changes can I make to improve my situation?
- What treatments are available?
- What books or other reading materials can you recommend? Do you recommend any websites?
Questions your doctor may ask
Your doctor will ask questions about the symptoms you're experiencing and assess your hormonal status. Questions your doctor may ask include:
- Do you have any sexual concerns?
- When did the pain begin?
- Where do you feel the pain?
- Does the pain happen each time you have sex or only in certain situations?
- Are you able to discuss your concerns with your partner?
- Do any other, nonsexual activities also cause you pain?
- How much distress do you feel about your sexual concerns?
- Do you also experience vaginal irritation, itching or burning?
- Have you ever been diagnosed with a gynecologic condition or had gynecologic surgery?
Tests and diagnosis
A medical evaluation for dyspareunia usually consists of:
A thorough medical history. Your doctor may ask when your pain began, exactly where it hurts, how it feels, and if it happens with every sexual partner and every sexual position. Your doctor may also inquire about your sexual history, surgical history and previous childbirth experiences.
Don't let embarrassment stop you from giving candid answers. These questions provide clues to the cause of your pain.
A pelvic exam. During a pelvic exam, your doctor can check for signs of skin irritation, infection or anatomical problems. He or she may also try to identify the location of your pain by applying gentle pressure to your genitals and pelvic muscles.
A visual exam of your vagina, using an instrument called a speculum to separate the vaginal walls, may be performed as well. Some women who experience painful intercourse are also uncomfortable during a pelvic exam, no matter how gentle the doctor is. You can ask to stop the exam at any time if it's too painful.
- Other tests. If your doctor suspects certain causes of painful intercourse, he or she might also recommend a pelvic ultrasound.
Treatments and drugs
Treatment options vary, depending on the underlying cause of the pain.
If an infection or medical condition contributes to your pain, treating the underlying cause may resolve your problem. Changing medications known to cause lubrication problems also may eliminate your symptoms.
For most postmenopausal women, dyspareunia is caused by inadequate lubrication resulting from low estrogen levels. Often, this can be treated with topical estrogen applied directly to your vagina.
The drug ospemifene (Osphena) was recently approved by the Food and Drug Administration to treat moderate to severe dyspareunia in women who have problems with vaginal lubrication. Ospemifene acts like estrogen on the vaginal lining, but doesn't seem to have estrogen's potentially harmful effects on the breasts or the lining of the uterus (endometrium). Drawbacks are that the drug is expensive, it may cause hot flashes, and it has a potential risk of stroke and blood clots.
Different types of therapy may be helpful, including:
- Desensitization therapy. During this therapy, you learn vaginal relaxation exercises that can decrease pain. Your therapist may recommend pelvic floor exercises (Kegel exercises) or other techniques to decrease pain with intercourse.
Counseling or sex therapy. If sex has been painful for a long time, you may experience a negative emotional response to sexual stimulation even after treatment. If you and your partner have avoided intimacy because of painful intercourse, you may also need help improving communication with your partner and restoring sexual intimacy. Talking to a counselor or sex therapist can help resolve these issues.
Cognitive behavioral therapy also can be helpful in changing negative thought patterns and behaviors.
Lifestyle and home remedies
You and your partner may be able to minimize pain with a few changes to your sexual routine:
- Switch positions. If you experience sharp pain during thrusting, the penis may be striking your cervix or stressing the pelvic floor muscles, causing aching or cramping pain. Changing positions may help. You can try being on top of your partner during sex. Women usually have more control in this position, so you may be able to regulate penetration to a depth that feels good to you.
- Communicate. Talk about what feels good and what doesn't. If you need your partner to go slow, say so.
- Don't rush. Longer foreplay can help stimulate your natural lubrication. And you may reduce pain by delaying penetration until you feel fully aroused.
- Use lubricants. A personal lubricant can make sex more comfortable. Try different brands until you find one you like.
Coping and support
Until vaginal penetration becomes less painful and bothersome, you and your partner might find other ways to be intimate. Sensual massage, kissing and mutual masturbation offer alternatives to intercourse that might be more comfortable, more fulfilling and more fun than your regular routine.
Last updated: January 24th, 2015