Painful sex (dyspareunia)

What is dyspareunia?

Dyspareunia is the term used to describe pain before, during or after vaginal intercourse.

Pain with intercourse affects:

• women of all ages, with young women the most likely to be affected
• menopausal and postmenopausal women due to decreased elasticity of their vaginal walls, increased vaginal dryness and narrowing of the vaginal opening
• women who have surgical menopause (removal of the ovaries because of medical reasons)

If dyspareunia is not managed, it may result in a loss of sexual interest, mood changes and other psychological symptoms.

Types of dyspareunia

There are two main types of dyspareunia, which are classified according to where the pain is.

Superficial dyspareunia

This is pain on attempted penetration, which may be the result of:

• size disparity: the erect penis is too large for the vaginal entrance (as a result of menopausal changes or dermatological conditions)
• prolonged use of depot medroxyprogesterone acetate ('Depo') contraception (interferes with the body's naturally produced oestrogen)
• an intact or thickened hymen (the membrane that partially covers the vaginal entrance)
• vaginismus: spasm of the pelvic floor muscles that causes temporary narrowing of the vagina
• sexual arousal disorders
• infections (Candidia ablicans, Trichomonas vaginalis, genital herpes)

Deep dyspareunia

This is pain at the top of the vagina often experienced with thrusting. Pain can include burning, tearing or aching sensations. This pain may be the result of a pelvic disease, such as endometriosis, ovarian cysts or pelvic inflammatory disease from sexually transmissible infections such as chlamydia or gonorrhoea.

What causes dyspareunia?

There are many physical and psychological causes of dyspareunia.

Entry pain

Pain felt at the vaginal entry may be caused by:

• insufficient lubrication (sometimes the result of insufficient arousal)
• inflammation, infection or skin disorder
• vaginismus (spasms)
• pudendal neuralgia (nerve damage in the pelvis area)

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.

Main causes of lack of lubrication

1. Hormone changes such as after childbirth, while breastfeeding, during menopause or from an injectable contraception.
2. A narrowing of the vaginal entrance or thinning of the vaginal and vulva skin after menopause.
3. Lack of arousal because of emotional and psychological factors or certain medications.

What you can do about it

There are a number of options available including:

• hormone replacement therapy for hormone changes
• change in contraceptive method
• lubricant creams/gels
• talking with a psychologist or qualified sex therapist

Talk to your doctor to find the best option for you.

Inflammation, infection or skin disorder

The skin of the vulva (external parts of the female genitals) is extremely delicate, making it vulnerable to a wide range of conditions.

Sometimes part of the vulva, or sometimes the entire vulva, has some of the following:

• Redness
• Swelling
• Burning
• Itching
• Cracking
• Splitting (fissuring)
• Whitening of skin (leukoplakia)
• Discharge

Main causes of irritation

Infections of the genital area or urinary tract can cause painful intercourse.

Skin problems including:

• eczema (scaly, itchy rashes)
• lichen sclerosus (inflammation with white spots)
• lichen planus (redness and ulceration)
• psoriasis (silvery white, scaly patches)
• vestibulodynia
• thrush (white vaginal discharge and stinging)
• contact dermatitis (to perfumes or preservatives in soaps, sprays, creams, sanitary products) which can be made worse by wearing tight, synthetic fabric underwear

What you can do about it

There are a number of options available to help you including:

• oral medication
• corticosteroid based ointments
• vaginal tablets
• wearing clothes that allow airflow around the vulva
• avoiding skin irritants: washing with water or sorbolene cream only

It can also be helpful to see a psychologist or sex therapist to help you get over the fear of experiencing pain.

Talk to your doctor to find the best option for you.

Learn more about vulval irritation by downloading our booklet The vulva: irritation, diagnosis & treatment (PDF) or visiting the Vulva & vaginal irritation webpages.

Vaginismus (spasms)

Penetration may be painful for some women because the muscles in the vagina spasm. This creates a feeling of painful tightness that makes penetration painful, difficult and at times impossible.

Main causes of vaginismus

• Endometriosis
• Recurrent urinary tract infections, or recurrent genital infections
• Tight pelvic floor muscles
• Trauma during childbirth or surgery
• Emotions such as:
  • fear
  • anxiety
  • stress

These emotions may be caused by:

• partner issues
• inadequate sex education
• sexual abuse
• past traumatic events

What you can do about it

The underlying physical cause needs to be treated by a doctor or specialist.

Possible further action might include:

• pelvic floor physiotherapy
• bio-feedback
• massage
• relaxation skills
• counselling
• Botox injections.

Deep pain

Deep pain can be caused by:

• illnesses or conditions
• surgery or medical treatments

Illnesses

A number of illnesses or conditions can lead to painful sex.

Illnesses that can cause deep pain

• Endometriosis
• Cystitis
• Irritable bowel syndrome
• Pelvic inflammatory disease
• Ovarian cysts
• Adenomyosis
• Uterine prolapse
• Uterine fibroids
• Haemorrhoids
• Pelvic inflammatory disease

What you can do about it

The underlying physical cause needs to be treated by a doctor or specialist.

Possible further action might include:

• pelvic floor physiotherapy
• massage
• relaxation skills
• counselling
• medications to reduce pain signals
• antibiotics (tablets and injectable).

Surgery & medical treatments

Scars from surgery in the pelvic area can cause painful sex.

Surgery that can cause deep pain

• Hysterectomy
• Vaginal repair for prolapse
• Episiotomy for childbirth
• Chemotherapy
• Radiation therapy

What you can do about it

• Pelvic floor physiotherapy
• Soft tissue and vaginal massage
• Medications to reduce pain signals
• Relaxation skills
• Counselling

Emotional causes

• 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 also affects your mental wellbeing and relationships, causing stress and anxiety
• The stress and anxiety can then make the physical problem worse
• Some women with dyspareunia may have a history of trauma including sexual or emotional abuse.

How is dyspareunia diagnosed?

Medical history

Your doctor may ask questions such as:

• when do you feel pain?
• when did you first experience the pain?
• what sort of pain is it?
• how does it feel?
• does it occur with every sexual experience?
• what triggers it?

Your sexual history, surgical history and childbirth experiences may also be relevant.

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 (a plastic instrument that allows the doctor to see) into the vagina.

Further tests

You may need further tests such as a 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 the umbilicus (navel) and a thin viewing instrument (laparoscope) is inserted to view the pelvic organs.

Impact on libido

If you anticipate pain during sex, you will be anxious. Your potential to be become aroused will be reduced, you will have less lubrication, and this in turn can make sex even more painful. This all interferes with your desire to have sex.

Management & treatment

In the video below, Jean Hailes physiotherapist Janetta Webb, talks about pelvic floor physiotherapy for the management and treatment of dyspareunia. Janetta explains what you can expect from an initial consultation with a pelvic floor physiotherapist, to make you more comfortable and better prepared.

The right treatment for dyspareunia depends on the cause of the pain.

Physical treatment. If dyspareunia has a physical cause, treating the underlying medical conditions may alleviate the pain.

Psychological treatment. Treatment options for dyspareunia caused by psychological factors will often 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.

Change in techniques. 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 techniques such as trigger point therapy (identifying pain that is related to a discrete point) and gentle soft-tissue massage in the pelvic area and in the vagina. Physiotherapists can teach specific relaxation techniques and pelvic floor awareness exercises to help reduce over-activity of muscles and therefore decrease pain.

Vaginal dilators (these used to be called 'vaginal trainers') are sometimes recommended. They are available in graduated sizes (from small to larger) and are used to help women relax their pelvic muscles to allow pain-free sexual penetration

General fitness is important but too much training of abdominal muscles is also emerging as an issue for women, causing over-activity of pelvic floor muscles.

Enhance arousal

• Enhancing arousal is an important part of reducing discomfort and making sex more enjoyable – try to switch off the worry, and really tune into your body
• Focus on positive sensations during foreplay, and if you become aware that your mind has wandered, bring your attention back to the present
• You could also try using sexy fantasies to help you become aroused – using your imagination can't harm you and this is something a lot of women like to do
• You might like to read some erotic fiction to give you some ideas and to stimulate your sexual appetite.

How can you prevent dyspareunia occurring?

To prevent painful sex depends on the potential cause. There are things you can do to help prevent some causes of painful sex including:

• Increase foreplay to increase natural lubrication
• Use oestrogen preparations if you are postmenopausal and it is appropriate
• Use water-based lubricants, or olive oil
• Practise safe sex to prevent the STIs which may cause dyspareunia

Expand your horizons

Be aware that you may need to do things a little differently as you age. You may need more time or different techniques to become aroused or reach orgasm, so you will need to engage your partner in the process.

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 makes a fulfilling sex life.

Seeking help

If you are experiencing painful sex it is important to seek help from your doctor and receive appropriate treatment and/or management at the earliest time. Your doctor may refer you on to a psychologist or sex therapist. Seeking help early can also reduce the risk of further impact on your relationship.