Painful intercourse (dyspareunia)

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

The medical term for painful intercourse is dyspareunia (dis-puh-ROO-nee-uh). It is lasting or recurrent genital pain that occurs just before, during or after sex. Talk with your healthcare professional if you're having painful intercourse. Treatments focus on the cause and can help stop or ease this common problem.

If you have painful intercourse, you might feel:

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

When to see a doctor

If you have recurrent pain during sex, talk with your healthcare professional. 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 happens at entry or with deep thrusting. Emotional factors can be linked to 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 breastfeeding also can be a cause.

  Certain medicines can affect sexual desire or arousal. That can decrease lubrication and make sex painful. Those medicines include antidepressants, high blood pressure medicines, 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, called episiotomy.
• Inflammation, infection or skin disorders. An infection in the genital area or urinary tract can cause painful intercourse. Eczema or other skin problems in the genital area also can be the cause.
• Vaginismus. These involuntary spasms of the muscles of the vaginal wall can make penetration painful.
• A problem present at birth. Not having a fully formed vagina, called vaginal agenesis, or having a membrane that blocks the vaginal opening, called imperforate hymen, could cause painful intercourse.

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, pelvic floor conditions, adenomyosis, 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 physical appearance, fear of intimacy or relationship problems can contribute to a low level of arousal and 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 everyone with dyspareunia has a history of sexual abuse. But if you have been abused, it can play a role.

It can be hard 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 sex if you associate it with the pain.

Many factors can raise the risk of painful intercourse. They include illnesses, surgeries and other medical treatments, and mental health issues.

A medical evaluation for dyspareunia usually consists of:

• A thorough medical history. Your healthcare professional might ask when your pain began, where it hurts, how it feels and if it happens with every sexual partner and every sexual position. Your healthcare professional also might ask about your sexual history, surgical history and history of childbirth.

  Don't let embarrassment stop you from answering truthfully. These questions provide clues to the cause of your pain.

• A pelvic exam. During a pelvic exam, your healthcare professional can check for symptoms of skin irritation, infection or anatomical problems. Your care professional also might try to locate your pain by applying gentle pressure to your genitals and pelvic muscles.

  A visual exam of your vagina also may be part of the evaluation. For this exam, an instrument called a speculum is used to separate the vaginal walls. Some people who have painful intercourse also have pain during a pelvic exam. You can ask to stop the exam if it's too painful.

• Other tests. If your healthcare professional suspects certain causes of painful intercourse, you might have a pelvic ultrasound.

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 medicines that can cause lubrication problems also might eliminate your symptoms.

For many postmenopausal women, painful intercourse is caused by too little lubrication resulting from low estrogen levels. Often, low estrogen levels can be treated with topical estrogen applied directly to the vagina.

The Food and Drug Administration approved the medicine ospemifene (Osphena) to treat moderate to severe dyspareunia in women who have problems with vaginal lubrication. Ospemifene acts like estrogen in the vaginal lining.

Drawbacks are that the medicine might cause hot flashes. It also carries a risk of stroke, blood clots and cancer of the lining of the uterus, called the endometrium.

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

Other treatments

Some therapies that don’t involve medicine also might help with painful intercourse:

• Desensitization therapy. For this therapy, you learn vaginal relaxation exercises that can ease 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 also might need help improving communication with your partner and restoring sexual intimacy. Talking to a counselor or sex therapist may help resolve these issues.

  Cognitive behavioral therapy also can be helpful in changing negative thought patterns and behaviors.

To help with pain during sex, you and your partner could try to:

• 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.

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.

Talking with your healthcare professional is the first step in resolving painful intercourse. Your primary healthcare professional might diagnose and treat the problem or refer you to a specialist.

What you can do

To get ready for the conversation with your healthcare professional, make a list of:

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

Some questions to ask 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 healthcare professional 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?