Painful intercourse in women

Painful intercourse, also called painful sex, can happen for many reasons. They range from physical issues to emotional concerns. The medical term for painful sex is dyspareunia (dis-puh-ROO-nee-uh). It's pain that happens just before, during or after sex.

Painful sex can affect anyone of any gender. But research has shown that it tends to be much more common in women than in other people. In women, the pain may be felt in or around the opening of the vagina, within the vagina, or throughout the pelvis and nearby areas.

Painful sex can have a big impact on your quality of life, your relationships and the way you feel about yourself. If you often have pain during sex or if you are worried about the pain, talk with a healthcare professional. Treatment that focuses on the cause can often stop or ease this common concern.

Painful sex may include:

• Pain during sexual entry into the vagina, called penetration.
• Pain anytime something goes into the vagina, including a tampon.
• Deep pain within the vagina, pelvis or nearby areas.
• Burning, stabbing or aching pain just before, during or after sex.

The pain may happen every time you have sex. Or it may only happen in some situations but not in others.

When to see a doctor

Make an appointment with a healthcare professional if painful sex happens often, if the pain lasts over time, or if the pain is moderate to serious. Also make an appointment if you have other symptoms along with painful sex, such as bleeding or discharge from the vagina.

Physical causes of painful sex typically depend on when and where the pain happens. Emotional causes may be linked to many types of painful sex.

Entry pain

Pain at sexual entry into the vagina may be linked to a number of factors including:

• Vaginal dryness. Lower levels of estrogen in the body may make the vagina drier. That can lead to a lack of lubrication during sex. This often affects people who have gone through menopause and those who are breastfeeding.
• Medicines. Some medicines can lower sexual desire or arousal. That can decrease lubrication and make sex painful. Examples include antidepressants, high blood pressure medicines, sedatives, antihistamines and some birth control pills.
• Injury, trauma or irritation. This includes injury or irritation to the genitals, vagina or pelvis. For example, pain during sex may result from injury due to a car accident, pelvic surgery, female genital cutting, a tear during childbirth or an episiotomy. An episiotomy is a cut made during childbirth to help with delivery.
• Inflammation, infection or skin conditions. An infection in the genital area or urinary tract can cause sex to be painful. Eczema or other skin conditions in the genital area also may be the cause.
• Muscle spasms. Spasms of the muscles of the vaginal wall, called vaginismus, can make sex painful.
• Conditions 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 sex.

Deep pain

Pain felt deep within the vagina or pelvic area that happens during sex may be caused by:

• Some illnesses and conditions. Certain health concerns can cause pain during sex. Examples include endometriosis, pelvic inflammatory disease, pelvic organ prolapse and uterine fibroids. Other issues such as cystitis, irritable bowel syndrome, pelvic floor conditions, chronic pain syndromes, adenomyosis and ovarian cysts also may cause pain.
• Surgeries or medical treatments. Scarring from surgery in the pelvic area can cause painful sex. For example, scarring can happen after removal of the uterus, called a hysterectomy. Medical treatments for cancer, such as radiation and chemotherapy, also can cause changes that make sex painful.

Emotional factors

Emotions are often intertwined with sex, so they might play a role in sexual pain. Emotional factors may include:

• Psychological issues. Anxiety, depression, concerns about physical appearance, fear of intimacy or relationship issues can lower arousal and interest in sex and lead to painful sex.
• Stress. Pelvic floor muscles tend to tighten in response to stress. This can contribute to pain during sex.
• History of sexual abuse. Not everyone who has pain during sex has a history of sexual abuse. But if you have been abused, it can play a role.
• Fear of painful sex. When the pain first happens, that may lead to fear of it happening again. Then the fear can make it hard to relax during sex, which can lead to more pain.

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

To help find out why you might be experiencing painful sex, your healthcare professional may do:

• A thorough medical history. Your healthcare professional might ask when your pain started, where it hurts, how it feels and if it happens every time you have sex. Your healthcare professional also might ask about your sexual history, any past surgeries, medicines you take and if you have had children.

  Talking about sex might feel embarrassing. But being open and honest with your healthcare professional may help find the cause of the pain more quickly and easily.

• A pelvic exam. During a pelvic exam, your healthcare professional can check for symptoms of skin irritation, infection or other physical issues that could be causing pain. Your healthcare professional also might try to locate your pain by putting gentle pressure on your genitals and pelvic muscles.

  A visual exam of the vagina 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 sex also have pain during a pelvic exam. If the exam is too painful, tell your healthcare professional to stop.

  During a pelvic exam, your healthcare professional may take a sample of cells from within the vagina using a swab. The cells are then analyzed in a lab to see if an infection or other medical condition could be causing the pain.

• Ultrasound. An ultrasound is an imaging exam that uses sound waves to make pictures of structures inside the body. If your healthcare professional suspects certain causes of painful sex, you might need a pelvic ultrasound.

Treatment for painful sex depends on the cause of the pain. Treatment may include medicines, physical therapy, counseling or a combination of these.

Medicine

For many people who have gone through menopause, low estrogen levels can lead to less lubrication in the vagina. Replacing estrogen in the body can often help. Some forms of estrogen replacement that can help with painful sex are placed directly into the vagina. This is called vaginal estrogen.

The medicine ospemifene (Osphena) also can be used to treat a lack of lubrication. It's taken by mouth and acts like estrogen in the vaginal lining. Drawbacks are that it might cause hot flashes. It also may raise the risk of stroke, blood clots and cancer of the lining of the uterus.

Prasterone (Intrarosa) is another medicine that can ease painful sex. It's a capsule you place inside the vagina daily.

Changes to medicines

If too little lubrication could be a side effect of a medicine that you take, your healthcare professional may suggest lowering the dose or taking a different form of that medicine. Don't make any changes to your medicines before talking with your healthcare professional.

Pelvic floor physical therapy

This treatment involves learning pelvic floor muscle relaxation exercises that may help ease pain.

Treating an underlying condition

If a medical condition is leading to pain during sex, treating that condition may ease or stop the pain.

Counseling or sex therapy

If sex has been painful for some time, you might have a negative emotional response to sex even after treatment. If you and your partner have avoided intimacy because of painful sex, you also might need help improving communication and restoring sexual intimacy. Talking with a counselor or sex therapist may help you work through these issues.

Cognitive behavioral therapy also can be helpful in changing negative thoughts and behaviors around sex.

The following steps may help ease pain during sex:

• Use a lubricant. A sexual lubricant can make sex more comfortable. Vaginal moisturizers that you can buy without a prescription also may ease dryness.
• Don't rush. Spending more time on foreplay can help your body produce natural lubrication.
• Communicate. Talk with your partner about what feels good and what doesn't. If you need to go slow, be sure to say so.

Until sex 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, fulfilling and fun.

You're likely to start by seeing your primary healthcare professional. But when you call to make an appointment, you may be referred to a specialist in conditions that affect the female reproductive system, called a gynecologist, or to a sexual health specialist.

What you can do

When you make the appointment, ask if there's anything you need to do beforehand, such as not eat or drink before a test.

Before your appointment, make a list of:

• Your symptoms, including any that may not seem related to the reason for the appointment, and when they began.
• Key personal information, including major stresses, recent life changes and family medical history.
• All medicines, vitamins and other supplements you take, including the doses.
• Questions to ask your healthcare professional.

For painful sex, some basic questions to ask your healthcare professional include:

• What is the most likely cause of my symptoms?
• What kinds of tests might I need?
• What treatment do you recommend?
• Are there any home remedies I might try?

What to expect from your doctor

Your healthcare professional might ask you questions, including:

• How long has sex been painful?
• Was the start of the pain linked to an event such as childbirth, surgery, medical treatment or an injury?
• Where do you feel the pain?
• When do you feel the pain?
• Does the pain happen every time you have sex or only in certain situations?
• Do any activities other than sex cause you pain?
• Do you have irritation, itching or burning in your vagina?
• Have you gone through menopause?
• Have you ever been diagnosed with a gynecologic condition or had gynecologic surgery?
• Do you feel safe in your current sexual relationship? Have you ever been abused?
• Are you able to talk with your partner about the pain you're having?