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Painful intercourse (dyspareunia)

Overview

Painful intercourse can occur for reasons that range from structural problems to psychological concerns. Many women have painful intercourse at some point in their lives.

The medical term for painful intercourse is dyspareunia (dis-puh-ROO-nee-uh), defined as persistent or recurrent genital pain that occurs just before, during or after intercourse. Talk to your doctor if you're having painful intercourse. Treatments focus on the cause, and can help eliminate or lessen this common problem.

Symptoms

If you have painful intercourse, you might feel:

  • Pain only at sexual entry (penetration)
  • Pain with every penetration, including putting in a tampon
  • Deep pain during thrusting
  • Burning pain or aching pain
  • Throbbing pain, lasting hours after intercourse

When to see a doctor

If you have recurrent pain during sex, talk to your doctor. Treating the problem can help your sex life, your emotional intimacy and your self-image.

Causes

Physical causes of painful intercourse differ, depending on whether the pain occurs at entry or with deep thrusting. Emotional factors might be associated with many types of painful intercourse.

Entry pain

Pain during penetration might be associated with a range of factors, including:

  • Not enough lubrication. This is often the result of not enough foreplay. A drop in estrogen levels after menopause or childbirth or during breast-feeding also can be a cause.

    Certain medications are known to affect sexual 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. These involuntary spasms of the muscles of the vaginal wall can make penetration 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 cause dyspareunia.

Deep pain

Deep pain usually occurs with deep penetration. It might be worse in 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 cause painful intercourse. Medical treatments for cancer, such as radiation and chemotherapy, can cause changes that make sex painful.

Emotional factors

Emotions are deeply intertwined with sexual activity, so they might play a role in sexual pain. Emotional factors include:

  • Psychological issues. 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. Not every woman with dyspareunia has a history of sexual abuse, but if you have been abused, it can play a role.

It can be difficult to tell whether emotional 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. You might start avoiding sexual intercourse if you associate it with the pain.

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.

Treatment

Treatment options vary depending on the cause of the pain.

Medications

If an infection or medical condition contributes to your pain, treating the cause might resolve your problem. Changing medications known to cause lubrication problems also might eliminate your symptoms.

For many postmenopausal women, dyspareunia is caused by inadequate lubrication resulting from low estrogen levels. Often, this can be treated with topical estrogen applied directly to the vagina.

The Food and Drug Administration approved the drug ospemifene (Osphena) 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.

Drawbacks are that the drug might cause hot flashes, and it carries a risk of stroke, blood clots and cancer of the lining of the uterus (endometrium).

Another drug to relieve painful intercourse is prasterone (Intrarosa). It's a capsule you place inside the vagina daily.

Other treatments

Certain nonmedication therapies also might help with dyspareunia:

  • Desensitization therapy. You learn vaginal relaxation exercises that can decrease pain.
  • Counseling or sex therapy. If sex has been painful for some time, you might have a negative emotional response to sexual stimulation even after treatment. If you and your partner have avoided intimacy because of painful intercourse, you might 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 can also be helpful in changing negative thought patterns and behaviors.

Lifestyle and home remedies

You and your partner might be able to minimize pain with a few changes to your sexual routine:

  • Change positions. If you have sharp pain during thrusting, try different positions, such as being on top. In this position, you might 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. You might 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, 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.

Preparing for an appointment

Talking to your doctor is the first step in resolving painful intercourse. Your regular doctor might diagnose and treat the problem or refer you to a specialist.

What you can do

To prepare for this discussion with your doctor, make a list of:

  • Your sexual problems, including when they began and how often and under what conditions they occur
  • Your key medical information, including conditions for which you're being treated
  • All medications, vitamins or other supplements you take, including doses
  • Questions to ask your doctor

Some questions 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? What websites do you recommend?

What to expect from your doctor

Your doctor might ask you questions, including:

  • How long have you had painful intercourse?
  • Where do you feel the pain?
  • Does the pain occur every time you have sex or only in certain situations?
  • How is your relationship with your partner?
  • Are you able to discuss your sexual concerns with your partner?
  • Do any nonsexual activities cause you pain?
  • How much distress do you feel about your sexual concerns?
  • Do you have vaginal irritation, itching or burning?
  • Have you ever been diagnosed with a gynecological condition or had gynecological surgery?

Last updated: January 12th, 2018

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