Doc Talk: Why Does it Hurt When I Have Sex?

Experiencing pain during sex can seem like a normal occurrence, with nearly 3 out of 4 women saying they have had pain during sex at some point in their lives, according to The American Congress of Obstetricians and Gynecologists (ACOG). For some women, the pain may only be mild soreness, but for others, the pain can be deep and chronic. Recurring pain during sex is called dyspareunia, it is a medical condition where there is pain or discomfort in a woman's labial, vaginal, or pelvic areas during or immediately following sex.

While you may be reluctant to share your sexual experiences with your Women’s Health Connecticut provider, it is important to speak honestly and openly with your ObGyn if sex is more painful than pleasurable. We spoke with two providers at Women’s Health Connecticut;  Dr. Elisa Benzoni of Specialists in Women’s Healthcare and Dr. Gayle Harris of Connecticut Women OB/GYN, to discuss the main causes of painful sex and treatments that can help women experiencing dyspareunia.

What are the causes of painful sex?

Dr. Benzoni: There are many causes of painful intercourse. Vaginitis, which is an infection or irritation of the vagina, can cause discomfort during intercourse. Vaginitis can be cause by a yeast infection or atrophy, which is when the lining of the vagina has become thin due to low estrogen. Scarring can also cause painful intercourse, either from vaginal delivery or previous surgery. Endometriosis can be a very common cause of painful intercourse, as it can cause interstitial cystitis, which is an inflammatory condition of the bladder.

Dr. Harris: Common causes include menopause, infections, a history of sexual abuse or assault and musculoskeletal and neurologic conditions.

How can patients address sexual abuse with their doctors and how would you advise them to ease any symptoms they may have?

Dr. Benzoni: This is obviously a very sensitive issue for the patient, but I find if you ask the patient in a nonjudgmental way, then they usually find it a relief to talk about. I ask them how I can help them get through the exam and make sure I explain everything to them as I proceed through the exam. I always refer them to a counselor if they have not done so.

Dr. Harris: Previous sexual abuse is a cause of difficulty with sexual relations. This will usually involve a multi-pronged approach to treatment. Patients should feel comfortable speaking with their gynecologists about a previous history of abuse so that a treatment plan can be instituted.

What is vaginismus and can it cause painful sex?

Dr. Benzoni: Vaginismus is a painful and spasmodic contraction of the pelvic floor muscle. Vaginismus is usually related to physical contact of the vagina, such as a tampon insertion, or sexual activity. There are different types of vaginismus that can affect women at different ages. There is primary vaginismus, which is a lifetime condition in which the pain has always been present. It will be difficult to use a tampon or to have intercourse. Secondary vaginismus develops after a woman has already experienced normal sexual function. It can occur at any stage of life, and it may not have happened before. It usually stems from a specific event, such as an infection, menopause, sexual assault, surgery, or childbirth. Treatment involves psychological therapy and pelvic floor therapy. The use of lubricants, lidocaine jelly, and estrogen can help women during intercourse.

Painful Sex: Vaginitis and Vulvodynia

What is Vaginitis and how does it cause painful sex?

 Dr. Harris: Vaginitis is a inflammation in the vagina, but it is often referred to as a vaginal infection. Symptoms are discharge, itching, and burning of the vagina and vulva. Many different infections can cause painful intercourse including STIs, yeast, and bacteria. Patients may feel pain or burning with sex. Less often they may feel itching.

The mainstay of treatment is usually antibiotics and antifungals. In certain cases, other medications may be used as well.

What is vulvodynia and how can it cause painful sex?

Dr. Harris: Vulvodynia means painful vulva. The entire vulva may be painful, or pain may be centered in a specific area. Symptoms of vulvodynia can start and stop without warning, or they may occur only when the area is touched. There are multiple types of vulvodynia, some cause painful sex and some do not. It is generally thought to involve a dysfunction of nerves and muscles in the external genitalia, which then can cause painful sex.

Patients need to work with a skilled provider in developing a treatment plan. There are treatments available, but treatment is usually multipronged and needs close follow up.  If you have vulvodynia, gentle care of the vulva is best. Avoid products and other items that may be irritating.

Painful Sex: Menopause

Why does sex hurt during and after menopause?

Dr. Harris: Sex can often be uncomfortable after menopause, it can feel irritating and some women will describe burning or an inability to achieve penetration. This is caused by a lack of estrogen. During menopause, estrogen levels in the vulva and vagina decline. Without estrogen, the vaginal lining thins, shrinks, and dries out, this can be referred to as vulvovaginal atrophy.

What are some treatments for vaginal dryness?

Dr. Harris: Some women will respond to treatments that increase moisture in the vagina. Lubricants are a good first start.  Estrogen creams or suppositories attempt to provide additional moisture in the vagina, but must be prescribed by a medical provider and used regularly. A newer treatment is the laser treatment that can create moisture in the vagina without the use of medications or creams.

I think it is paramount for patients to discuss this with their providers as soon as symptoms begin. Studies have shown that longer standing symptoms are harder to treat and that patients will often get better results when treated early on.

Painful Sex: Endometriosis

What causes pain during sex with Endometriosis?

Dr. Benzoni: One of the most common places for endometriosis to occur is in an area in the women's pelvis called the posterior cul-de-sac. This is in the back of the uterus where the uteroscaral ligaments are. It is generally believed that endometriosis is caused by a retrograde flow of blood during menstruation. The tubes hang down and deposit the blood in the back of the uterus. There are small endometrial glands from the lining of the uterus in this retrograde blood. These implant in this area and are stimulated with estrogen and usually worsen or grow with each menstrual cycle. We know that the endometrial glands can migrate into the uterine wall, called adenomysosis, this is also painful if the uterus is moved with intercourse.

Endometriosis patients have described sex as feeling like a knife is in their pelvic stabbing them, sharp, and intolerable. Others describe it as burning pain that worsens and sometimes takes hours or days to subside. Endometriosis generally does not cause pain with entry but more with deep thrust. There are women who also have pain initially, but it worsens with thrusting due to the location of the uterosacral ligaments.

How is pain during sex treated for Endometriosis?

Dr. Benzoni: For Endometriosis patients that have pain during intercourse, there are several modalities that can help them. The goal is to try to decrease or stop their periods. By doing this, it decreases any further progression of endometriosis since we know endometriosis is a cumulative effect, meaning the more periods and the heavier the periods, the worse the endometriosis can get. We offer patients contraception and nonsteroidal anti-inflammatories, also called NSAIDS, which are ibuprofen, Naprosyn, and Advil. We now can offer them oral therapy, Orlissa. Orilissa can help by decreasing the amount of estrogen that is produced in your body. Endometriosis is stimulated and grows with estrogen so if you can decrease this amount the can effectively decrease endometriosis.

Experiencing pain during sex can affect multiple aspects of a woman’s life. Treatments are available for many of the causes of painful sex. If you are experiencing painful periods or pain during sex, it is important you speak to your Women’s Health Connecticut provider.