Painful vaginal sex (dyspareunia)

What is painful sex (dyspareunia)?

You might experience pain during arousal, foreplay or orgasm. You may feel pain with external stimulation or during penetration. Some people experience pain after sex has finished. You might not feel pain every time you have sex.

Symptoms of painful sex

If you have painful sex, you might feel:

• entry pain
• deep pain
• burning, aching or throbbing pain.

What causes painful sex?

Painful sex can be caused by physical and emotional factors. You might feel entry pain (with penetration) or deep pain (with thrusting).

Physical factors may include one or more of the following:

• Vaginal dryness due to lower oestrogen levels, common when breastfeeding and after menopause (vaginal atrophy).
• Reduced thickness and elasticity of the vaginal walls – due to lower oestrogen levels (e.g. at menopause and when breast feeding).
• Reduced arousal and lubrication before sex.
• Lack of lubrication due to certain medicines (e.g. antidepressants).
• Overactive pelvic floor muscles or involuntary muscle spasms (vaginismus).
• Chronic pain or discomfort in the vulva (vulvodynia).
  
• Nerve damage in the pelvic area (pudendal neuralgia).
• Infections (e.g. thrush or sexually transmitted infections).
• Skin conditions (e.g. dermatitis or lichen sclerosis).
• Injury or trauma (e.g. an accident, surgery or tears during childbirth).
• Health conditions (e.g. endometriosis, adenomyosis, uterine fibroids, ovarian cysts, cystitis, irritable bowel syndrome, pelvic inflammatory disease).

Emotional causes may include relationship problems, stress, psychological issues, gender identity issues, past sexual abuse or not wanting to get pregnant.

Many people who experience painful sex also have lower sex drive (libido).

How is dyspareunia diagnosed?

Dyspareunia is usually diagnosed via a clinical examination. Your doctor will ask about your pain (e.g. where it hurts, how it feels, if it has happened with each partner and in different sexual positions). They may also ask about medical, sexual and family history, childbirth and past surgeries. These questions will help to find the cause of your pain.

Your doctor should also do a physical examination to check for signs of infection, irritation or physical problems. This usually involves gently touching your vulva and pelvic area to locate the pain. They might insert a plastic or metal instrument (speculum) into your vagina to check where the pain is coming from. If you find this too painful, you can ask your doctor to stop.

You may need other tests, such as a pelvic ultrasound, if your doctor thinks the condition is inside your pelvis.

If you have vaginal discharge or urinary symptoms, they may also take samples for testing.

Treatment and management

Treatment options depend on the cause of your pain. Your doctor may recommend:

• lubricant creams and gels
• vaginal moisturisers
• vaginal oestrogen cream or pessaries
• menopausal hormone therapy (MHT) to improve general wellbeing around the time of menopause
• changing medicines (e.g. contraception)
• seeing a psychologist or sex therapist to help reduce your fear of pain
• relationship counselling
• seeing a qualified pelvic floor physiotherapist to help with techniques such as pelvic floor muscle relaxation, trigger-point therapy, vaginal trainers or soft tissue and vaginal massage.

Watch this video on Vimeo featuring Jean Hailes physiotherapist, Janetta Webb, talking about pelvic floor physiotherapy for the management and treatment of dyspareunia.

What you can do

There are practical things you can do to improve your sexual experience.

• Tell your partner what you like or don’t like – and stop sex if you feel pain.
• Change sexual positions or techniques. If you experience pain during thrusting, sit on top of your partner so you can control the depth of penetration. You can also try different or longer foreplay to increase your arousal.
• Use lubricants to increase arousal and comfort during sex.
• Focus on yourself. Try to switch off any worries, tune in to your body and enjoy the moment.
• Be intimate in different ways. If you have a partner, try kissing, cuddling, massage, mutual masturbation and oral sex. This may enhance your sexual desire.
• Try a vaginal dilator (a tube-shaped device to stretch your vagina) or a small vibrator. These may help you to relax your pelvic floor muscles.

When to see your doctor

If you are experiencing painful sex, see your doctor. They will find and treat the cause or refer you to a specialist. It’s a good idea to seek help as soon as possible so you can resolve the issue and enjoy a healthy sex life.