Vaginal pain

Painful vaginal sex (dyspareunia)

Many women experience painful vaginal sex at some stage in their lives. Dyspareunia is the medical term used to describe pain before, during or after vaginal sex. The term ‘vaginal sex’ includes intercourse and any other sexual activities (e.g. sex toys) you may engage in – with or without a partner.

Symptoms

If you have painful vaginal sex, you might feel:

• entry pain
• deep pain
• burning or aching pain
• throbbing pain that can continue after penetration.

Causes

Entry pain

Pain with penetration may be caused by:

• the penis being too big for the vagina
• lack of lubrication due to lack of arousal or certain medicines (e.g. antidepressants)
• vaginal atrophy (common after menopause)
• pelvic floor muscle spasms (vaginismus)
• nerve damage in the pelvic area (pudendal neuralgia)
• infections (e.g. thrush and sexually transmitted infections)
• injury or trauma (e.g. an accident, surgery or tears during childbirth)
• a physical problem that is present from birth (e.g. a thick hymen).

Deep pain

Deep pain is usually associated with deep penetration (i.e. thrusting).

Causes may include:

• illnesses and conditions (e.g. endometriosis, cystitis, irritable bowel syndrome, pelvic inflammatory disease)
• adhesions or scarring due to surgery (e.g. a hysterectomy).

Emotions

Emotional factors may affect your sexual experiences and associated pain.

For example:

• psychological issues (e.g. anxiety, depression, relationship problems, feeling self-conscious, fear of intimacy)
• stress, which may cause your pelvic floor muscles to tighten or become ‘overactive’
• previous experience of painful sex
• previous experience of sexual abuse or trauma.

Diagnosis

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
• menopausal hormone therapy (MHT) to improve general wellbeing and symptoms, such as vaginal dryness, around the time of menopause
• changing medicines (e.g. contraception)
• seeing a psychologist or sex therapist to help reduce your fear of pain
• couples 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 featuring Jean Hailes physiotherapist, Janetta Webb, talking about pelvic floor physiotherapy for the management and treatment of dyspareunia.

What you can do

You can try different things to reduce pain during sex.

For example:

• 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 water-based lubricants. Personal lubricants can make sex more comfortable.
• Try a vaginal dilator (a tube-shaped device to stretch your vagina). This may help you to relax your pelvic floor muscles.
• Communicate with your partner. Tell them what you like and don’t like.
• 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.

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.

Vaginal episiotomy, tears and vulvovaginal splitting

Childbirth and episiotomy

Over 85% of women experience some form of tear during a vaginal delivery. The tears can happen in and around your vagina, including your labia. Your perineum (the area of skin between your vagina and anus) can also tear.

Tears caused by childbirth are classified as follows:

• First degree – small tears or grazes in and around your vagina, labia and clitoris.
• Second degree – perineal muscle and skin tears that usually require stitches.
• Third or fourth degree – tears that are deep enough to extend towards the anus and may go through the muscle layers of the anus. These tears happen in about 6% of first-time births. Surgery is needed to repair these injuries.

A procedure called an episiotomy may be performed during childbirth to prevent a tear. An episiotomy is a cut made in the perineum to widen the vaginal opening during childbirth. This procedure is only done when:

• a baby needs to be delivered quickly
• forceps or suction are used
• you are at risk of serious injuries to your perineum (e.g. if your baby’s shoulders are stuck behind your pelvic bone).

Episiotomies are performed by healthcare professionals, such as doctors or midwives, under local anaesthetic. After birth, the cut is stitched together using dissolvable stitches.

It’s normal to feel pain and discomfort for two to three weeks after an episiotomy. During this time, you can take over-the-counter painkillers and apply a cold pack (wrapped in a cloth) for 10 to 20 minutes at a time to help ease the pain.

Your healthcare provider will give you advice about how to manage daily activities, such as going to the toilet, sitting and walking.

For more information about episiotomy, visit the Pregnancy Birth and Baby website.

Vulvovaginal splitting

Vulvovaginal splits (or fissures) are injuries in and around the vagina. Splits can range from small cuts or grazes that heal on their own to more serious injuries that need medical attention.

If the splitting is on your vulva, it’s important to look at the area (using a mirror) when you first notice symptoms, so you can check to see if it improves with treatment.

Symptoms

Symptoms of vulvovaginal splitting vary depending on the severity of the injury. They may include:

• itching or burning sensations
• stinging pain when weeing
• discomfort with any type of penetration
• spotting or bleeding.

Causes

Vulvovaginal splitting may be caused by:

• sex (e.g. rough or strong thrusting into the vagina)
• drier, thinner and less elastic vaginal tissue (common after menopause and childbirth)
• skin conditions such as lichen sclerosus, lichen planus, psoriasis and eczema
• scarring or tissue damage after surgery
• hair removal (e.g. waxing or shaving pubic hair)
• childbirth.

Treatment and management

Minor splitting

Most minor splits heal by themselves, but there are ways to reduce discomfort. For example:

• use over-the-counter painkillers
• soak in a warm bath with salt or bicarb of soda (avoid scented soaps)
• gently wash and pat dry the area once or twice a day
• wipe from front to back after going to the toilet
• avoid having sex until the split has healed
• wear cotton underwear and loose-fitting clothes.

Severe splitting

See your doctor if:

• any minor splits don’t heal on their own
• the symptoms get worse
• you have a fever
• you notice a smelly or discoloured discharge.

What you can do

If you have sensitive skin that is prone to splits:

• use lubrication during sex
• try different sexual positions
• be careful with any vaginal penetration, including tampons and sex toys
• take extra care if you wax or shave your pubic hair.

When to see your doctor

Vulvovaginal splits can become infected if not properly looked after. They can also get worse and develop into larger or deeper splits. If your symptoms don’t get better, see your doctor.

Download our fact sheets or visit resources for more information.

This web page is designed to be informative and educational. It is not intended to provide specific medical advice or replace advice from your health practitioner. The information above is based on current medical knowledge, evidence and practice as at April 2023.