One of the most common gynecologic complaints among women during their reproductive years is pain during sex or dyspareunia. It accounts for 8-22% of visits to gynecologists and requires empathetic and complex evaluation, diagnosis, therapies, and counseling sessions. Pain during sex can begin with initial penetration, with thrusting, or a combination of the two. Pain during sex can be a result of anatomic variety such as size, shape, the orientation of reproductive organs, nerves, and muscle development. Hormonal changes, underlying infections or diseases, and emotional factors can all impact a woman's ability to enjoy sexual intercourse. Likewise, a partner's anatomy and technique can affect whether a woman can experience the pleasure of sexual intercourse.
Anatomy Affects Pain During Sex
The length of a woman's vagina and the direction that the uterus is tipped (forward or backward) can be one reason for pain during sex. Shorter vaginas and a uterus that is tilted towards the rectum are more common anatomic factors that can cause pain. One of the easiest ways to classify the different reasons for painful sexual intercourse is to divide the pain into 'initial penetration' pain and 'deeper penetration' pain. For instance, women who have pelvic organ prolapse such as a dropped bladder or uterus (which is uncommon unless the woman has had multiple pregnancies) can cause both initial and internal pain during sex. If a woman has a short vagina, the man needs to adjust his depth of thrusting or in the case of a backward tipped uterus; he would need to aim more towards the anterior part of the vagina towards the bladder and not towards the rectum. There are areas around the cervix that cause less pain and directly hitting the cervix can be very painful especially if the woman has had surgery to the cervix or a history of cervicitis. Cervicitis is an inflammation or infection due to vaginitis or sometimes sexually transmitted diseases such as pelvic inflammatory disease (PID).
Hormonal Causes of Painful Sex
During certain days of a woman's cycle like the time right before menstruation, the vaginal tissue may be drier due to the rise of the hormone known as progesterone. The blood vessels around the uterus can swell during this period and produce a throbbing sensation known as 'pelvic congestion syndrome' that can make sex painful. Certain medications such as birth control pills and nursing can change the lubrication levels in the vagina which can make sex painful or less enjoyable. The reason for this is that nursing lowers the estrogen levels, the hormone that causes the necessary arousal juices. An autoimmune condition known as Sjogren's Syndrome results in oral, vaginal, and eye dryness and sometimes the first symptom is vaginal dryness. Water-based lubricants are helpful but do not last very long. Silicone lubricants are longer lasting and have less risk of causing sensitivity. Sliquid brand has an organic line as well as silicone based versions.
An old favorite to help vaginal lubrication and improve pleasure with sex is extra virgin coconut oil. As a gynecologist, I do not recommend them. They can cause biofilms which are slick membranes that can cause bacterial vaginosis which is a vaginitis that results in a fishy discharge and irritation that is difficult to eradicate even with antibiotics. The link below is an easy-to-read article describing all sorts of facts about lubricants and lists some organic lubricants.
Diseases or Conditions That Can Cause Pain During Sex
There are diseases of the female reproductive tract that can cause pain such as:
Pelvic inflammatory disease (PID)- an STD that scars fallopian tubes
Ovarian cysts- benign growths on the ovaries
Endometriosis- lining of the uterus that spreads to other areas
Adenomyosis- lining of the uterus that buries into the muscle of the uterus
Skin rashes of the vulva- lichen sclerosis and others
Bladder diseases- Interstitual cystitis
Autoimmune diseases-Sjogren's Syndrome
Gastrointestinal conditions- Inflammatory bowel conditions
Diabetes- frequent yeast vaginitis
Endometriosis is one of the worst diseases of the female pelvis. It is penetrating disease where the lining of the uterus travels or grows on other structures in the pelvis, vagina, bladder, and elsewhere. It is stimulated by the ovarian hormone, estrogen, and there is only one positive thing to say about this awful disease; it can be treated with medications and surgery and usually disappears with menopause. That is why it is important to get a medical diagnosis so that early treatment can stop the pain before it becomes chronic or affects your sex life.
Vaginismus is a condition that describes painful spasms of the muscles that control the opening to the vagina, part of the kegel muscles. Kegel muscles support the vagina, bladder, and other organs of the pelvis. They are important for sexual enjoyment and orgasm strength, but when these muscles will not relax, they prevent penile penetration. It can be overcome by using vaginal dilators. They work by gradually enlarging and relaxing the vaginal opening. Biofeedback and physical therapy can be useful also.
Besides dilators and lubrication, topical steroids and oral medications can be useful for women with pain during sex. Estrogen therapy during the menopausal years both orally and topically can improve the vaginal elasticity and blood supply which is crucial for the production of natural lubrication. A recent FDA approval of a topical hormone (DHEA) treatment goes by the brand name of Intrarosa and is beneficial for those who cannot take estrogens due to cancer or history of blood clots. Sometimes, anti-anxiety and anti-depressant medications are used to reduce muscle spasms and fear of penetration. The role of cannabis has not been formally evaluated but has shown usefulness in other chronic pain syndromes or as a pre-sex behavior. Laser vaginal rejuvenation is becoming more popular for alleviating painful sex due to dryness found in menopause and postpartum/nursing women...and it also helps women who have mild incontinence. Lasers that stimulate collagen production have been used safely and effectively on other areas of the body such as the face for wrinkle reduction and skin tightening. Now, there's help for the vagina-- a few quick, painless FemTouch sessions for improving vaginal tone and sensation.
FemTouch effect on vagina under microscope
Pain During Sex: Emotional and Psychological Aspects
If you are experiencing pain with sex, it may related to emotional, psychological, or relationship issues Sometimes, changing the sexual positions can allow for a pain-free intimate session. One such position is the cross-wise position whereby the man is lying diagonally over the woman. While a history of sexual abuse has not been linked to future sexual pain syndromes, parental shaming of the sex act and labeling it as indecent has been linked to a variety of sexual conditions, including vaginismus. Talk to your sexologist or gynecologist. They will help you through therapy so that you can enjoy a lifetime of pain-free sex.
Concluding Remarks and Resources
The thing about sex, according gynecologists, is, “If you don't use it, you lose it” meaning that the more sex you have, the healthier your vagina remains, free of problems, with stronger and more intense orgasms. It is not always easy to discuss sexual issues, but it's time for women to open up the dialogue with their doctors and counselors. With the online community of support, help is out there. Below is a list of books for more in-depth reading while you are practicing your kegels, an essential component for a healthy vagina, bladder, and sex life.
When Sex Hurts: A Woman’s Guide to Banishing Sexual Pain by Andrew Goldstein, Caroline Pukall and Irwin Goldstein
Healing Painful Sex: A Woman’s Guide to Confronting, Diagnosing, and Treating Sexual Pain by Deborah Coady and Nancy Fish.