Dealing with painful sex (dyspareunia)

A surprisingly large number of women experience painful sex at some stage. Although many cases are treatable, a lot of women are reluctant to seek help because they find it difficult to discuss. Apart from the physical impact on their bodies, painful sex can also affect mental and emotional health, and relationships.

Dyspareunia - what is it?

Dyspareunia means pain before, during or after vaginal intercourse. It affects over 14 per cent of premenopausal women, with the highest rate found in women aged 16-39. Postmenopausal women may also experience painful sex due to changes to their vaginal walls, increased vaginal dryness and narrowing of the vaginal opening.

Two main types of dyspareunia

1. Superficial Dyspareunia: pain on attempted penetration. This may be due to size disparity (the erect penis is too large for the vaginal entrance), an intact or thickened hymen, or vaginismus (spasm of the pelvic floor muscles that causes temporary narrowing of the vagina).
2. Deep Dyspareunia: pain at the top of the vagina related to thrusting, often associated with pelvic disease, e.g. endometriosis.

Pain can include burning, tearing or aching sensations. It can occur in any part of the pelvic region, but is commonly experienced near the vaginal opening, upon penetration. Other women report deep pain during thrusting, often described as ‘something being bumped’. 

Causes

The cause of the pain depends on its location.

Entry pain…

• Insufficient lubrication: when a woman is sufficiently aroused (‘turned on’), her vagina and glands around the vaginal entrance secrete fluids that reduce friction and allow penetration without pain. If you are not sufficiently aroused before attempting penetration, you may feel dry and experience a stinging, burning, tearing or throbbing sensation.
  Insufficient lubrication can also be caused by a drop in oestrogen levels, which occurs after menopause, after childbirth, and while breast-feeding. After menopause, the vaginal and vulval skin thins and looses elasticity. This can lead to narrowing of the vaginal entrance, causing pain with penetration.
  Emotional and psychological factors, as well as certain medications, can affect your libido (sex drive), which can also impact on arousal and lubrication.

• Inflammation, infection or skin disorder: infections of the genital area or urinary tract can cause painful intercourse. Skin problems include eczema, lichen sclerosis, psoriasis, vulvar vestibulitis and thrush. Skin irritations or allergies can be caused by fragrant soaps, scented toilet paper, laundry detergents or scented tampons/pads. A small number of women are allergic to latex in condoms and diaphragms. All these causes could lead to a skin irritation and dyspareunia.

• Vaginismus: involuntary spasms of vaginal wall muscles. This creates a feeling of tightness that makes penetration painful, difficult and at times impossible. Many women may even experience difficulties inserting a tampon, or find it impossible. Vaginismus can occur for many reasons, including fear, anxiety, stress, partner issues, inadequate sex education or abuse. Some of the triggers may be trauma during childbirth or surgery, endometriosis, recurrent urinary tract infections, or past history of traumatic events. It can also occur in women who are already experiencing dyspareunia. If you experience pain with penetration, for example, your vaginal muscles may try to protect you by tightening to prevent further attempts at penetration.

 Deep pain…

• Illnesses or conditions: including endometriosis, adenomyosis, pelvic inflammatory disease (PID), ovarian cysts, irritable bowel syndrome, uterine prolapse, uterine fibroids, cystitis and haemorrhoids.
• Infections of the cervix, fallopian tubes or uterus.
• Surgeries or medical treatments: scars from surgeries in your pelvic area such as hysterectomy, vaginal repair for prolapse or episiotomy for childbirth, or medical treatments such as chemotherapy. Radiation therapy for treating cancer within the pelvis can cause the vagina to narrow and the skin to become inflamed, leading to dyspareunia, 

Emotional factors

Feeling stressed, self-conscious, depressed or afraid of intimacy can affect your libido and make sex painful. Sometimes dyspareunia begins as a physical problem but subsequently affects your mental wellbeing and relationships, causing stress and anxiety. A cycle develops where past experiences of painful sex cause fear, creating stress and tension and making future sex painful. A small number of women with dyspareunia may have a history of trauma including sexual or emotional abuse. 

Seeking help

The first step is to make an appointment with your general practitioner (GP). Many people find discussing sex difficult or embarrassing so it may help to prepare for the appointment by writing down your symptoms and when/how often they occur. Other useful information to have with you is your medical history, including any other medical conditions and medications. 

Diagnosis

Medical history: Your doctor may ask questions such as when the pain began, what triggers it, how it feels and if it occurs with every sexual experience. Your sexual history, surgical history and childbirth experiences may also be relevant. It’s important to be open and honest, as your answers can help identify the cause of the dyspareunia.

Pelvic examination: This is a physical examination where your doctor will check for signs of infection, irritation or anatomical problems. This may involve gently touching the genital and pelvic area to locate the site of the pain and inserting a speculum into the vagina. Some women who experience dyspareunia also experience pain during a pelvic exam. You can ask your doctor to stop the exam at any time if it is too painful.

Further tests: You may need further tests such as pelvic ultrasound or laparoscopy if the cause is a condition inside the pelvis. A laparoscopy is a surgical procedure where a small incision is made in your pelvic wall and a thin viewing instrument (laparoscope) is inserted to view your pelvic organs. 

Treatment

The right treatment depends on the cause of the pain but almost all treatment options will include some sort of individual, couples or sexual counselling. If you are in a relationship, encourage your partner to be involved in your treatment, particularly the counselling sessions. Women, and their partners, often experience feelings of rejection, confusion, helplessness and frustration. For single women, dyspareunia can prevent them from approaching partners or entering new relationships because they feel ashamed, embarrassed, scared and afraid of rejection. 

If the dyspareunia has a physical cause, treating underlying medical conditions may alleviate the pain. In postmenopausal women, lack of lubrication can often be treated with oestrogen therapy, by using a cream, pessary or vaginal tablet. 

For some women, the solution may be a change in sexual techniques. Trying different sexual positions, engaging in longer or different types of foreplay and using a personal lubricant may help reduce pain. 

Pelvic floor physiotherapy can often help by using hands-on techniques such as trigger point therapy and gentle soft-tissue massage in the pelvic area and in the vagina. Most women have tried to ‘just relax’ without success. Physiotherapists can teach specific relaxation techniques and pelvic floor awareness exercises to help reduce over-activity of muscles and therefore decrease pain. Sometimes biofeedback therapy may be useful, and other techniques aimed at reducing skin or scar tissue sensitivity. 

Vaginal dilators are sometimes recommended. They are in graduated sizes and are used to help women relax their pelvic muscles to allow pain-free sexual penetration. 

General fitness is important but over-zealous training of abdominal muscles is also emerging as an issue for women, causing over-activity of pelvic floor muscles. (See Melanie’s story).

Expand your horizons

Treatment programs rarely deliver instant results, so it may take some time for you to notice any changes. Meanwhile, focus on fulfilling your needs (and those of your partner, if you have one) in other ways. You can show your affection and be intimate without intercourse; kissing, cuddling, massage, mutual masturbation and oral sex are all good alternatives and can expand your views on what constitutes a fulfilling sex life. 

Further resources

Fact sheet

Painful Sex – Dyspareunia254.56 KB

Websites

Australian and New Zealand Vulvovaginal Society

Gynaecological Awareness Information Network (GAIN)

Women’s Health Queensland Wide

www.vaginismus.com

The Foundation strongly urges women who are experiencing pain associated with sexual intercourse to see their GP. The Jean Hailes Medical Centre for Women is located in Clayton, Victoria. Call (03) 9562 7555 for an appointment.

Personal stories 

Judith, 56, hoped to reignite her sexual relationship with her husband but found that changes to her vagina after menopause were causing pain and dryness. She saw her GP who suggested she try a water-based lubricant, available at supermarkets and pharmacies. The doctor also suggested applying an oestrogen cream directly to her vagina. 

Judith admitted that although she wanted to want sex, her libido had dropped since menopause. Understandably, it’s hard to be in the mood for sex if sex is painful, and treating Judith’s vaginal dryness made a big difference. With the help of a counsellor, she realised that it was ok to have sex without initial desire, (as long as her partner wasn’t pressuring her) because she would almost always enjoy it once they got started. According to Judith, her doctor’s best advice was to “think outside the square when it comes to sex and explore other ways to be intimate with your partner”. 

Melanie, 31, commenced physiotherapy following referral from her GP. She described pain during sex that was so bad she had to stop. This had been a problem ever since she was sexually active with her previous partner. Melanie had a history of recurrent vaginal thrush up until a few years ago but this had now settled. She tried to ‘just relax’ during intercourse but this didn’t work. Her partner said it felt like there was a brick wall at the vaginal entrance, despite how gentle he was. 

The physiotherapist explained that Melanie’s pelvic floor muscles could be overactive and clenching involuntarily when she was trying to have sex. This may be due to past discomfort with thrush, causing her muscles to tighten involuntarily to protect her from further pain. Treatment included progressive ‘downtraining’ of these muscles, teaching Melanie to let them go voluntarily. The physiotherapist also performed gentle trigger point therapy to particular tight areas in the muscle and taught Melanie massage and stretches to do at home. 

She advised Melanie to have a break from penetrative sex while her muscles were learning their new role. The physiotherapist also modified Melanie’s gym program to avoid some of the core strengthening exercises and heavy weights work she was performing as this could exacerbate the problem. 

After this course of treatment, Melanie and her partner were eventually able to enjoy sex without pain.

Content updated April 6, 2010