Why can sex be painful?
Too many women are having painful sex and not realising how much of a problem that is. Painful sex, which affects women of all ages, can affect self-confidence and have adverse effects on relationships. Painful sex or dyspareunia may have different causes in different age groups, but conditions can often overlap.
There are two kinds of painful sex: superficial dyspareunia— pain on initial penetration; and deep dyspareunia which is pain on deep penetration. It’s important to separate these as the causes and management are often different.
Many women find sex painful. However, they rarely bring it up during a medical consultation, unless they are specifically asked. Women may be shy, think they are the only ones suffering and often put up with it, thinking they won’t be taken seriously by their doctor or that it’s not a real condition.
Unfortunately, it is sometimes the case that doctors are poorly equipped and uncomfortable in discussions about painful sex, also known as dyspareunia. They might also lack the time needed to take a detailed history. Usually after a cursory examination to rule out obvious causes, women are often falsely reassured or referred to a counsellor, with no real recommendations on how to help them address this real issue.
Moreover, partners are usually missing from this discussion and many women find it difficult to explain why they are avoiding sex.
Let’s look at some of the common causes of painful sex and how to address them.
Vaginal dryness
This can be a real issue for many women at all ages. It can get worse in the perimenopause and menopause as women get older. Some women also experience vaginal dryness while breastfeeding.
In these situations, a lack of oestrogen can make the vaginal skin dry and bruised, especially after sex, with many women complaining of a sensation of paper cuts that can leave them sore for many days. Some menopausal women and women who are breastfeeding sometimes need local vaginal oestrogen for a while, if the methods described below make no difference.
What else can I do?
Management of vaginal dryness includes following good vaginal hygiene measures such as avoidance of perfumed toiletries, feminine wipes, synthetic perfumes and soaps in the genital area, all of which can lead to increased dryness by removing natural body oils and beneficial bacteria.
The use of natural oils can be helpful and the daily application of natural oils such as coconut, Vitamin E or almond oil after a shower to lock the moisture in around the vulval area helps many of my patients. Just massage the vulval area and DON’T WORRY if some of the oil enters the vagina. It’s safe. We eat oils!
The regular use of water-based vaginal moisturisers can also help keep the area supple and make sexual intercourse less uncomfortable.
Using non-biological laundry detergents which are low in harsh chemicals and appropriate organic sanitary ware (period pants/ menstrual cup/ material pads) can all help in relieving symptoms.
For some young women, being on the combined contraceptive pill may cause vaginal dryness, which if distressing enough, I would suggest trying another form of contraception.
Vaginismus
This is the term used to usually describe pain at the entrance of the vagina. This may be because of a physical cause as described above, vaginal spasms or tight vaginal muscles.
A detailed history to check that there is no previous sexual trauma is a key part of successful management. In my experience, patiently explaining the underlying cause and the use of graduated vaginal dilators (easily available online) allows for successful intercourse in many women, while a small number may need referral for further counselling. However, patience is the key for both the woman and the doctor as some women need more than just a couple of consultations. I find that partner involvement really helps.
Cysts and swellings in the vagina such as a Bartholin’s cyst or abscess can sometimes cause pain on sex but is usually short-lived and easily managed medically.
Vulvodynia
Women may suffer from chronic vulval or vaginal pain, burning or soreness, a condition better known as Vulvodynia. This vulvo-vaginal pain may be generalised or localised and is often made worse with sex.
Many women have put up with these symptoms with a poor quality of life for years without a diagnosis. Often, they are repeatedly diagnosed incorrectly as thrush or vaginal infections. These women may in fact, be suffering from a variety of conditions such as lichen sclerosus, eczema, lichen planus or psoriasis or inflammation of the vestibular glands (vestibulitis) or from Vulvodynia. Thorough history, examination and individualised treatment by an experienced and empathetic vulval specialist is recommended. Cognitive behaviour therapy is helpful in some women.
Vaginitis
Inflammation of the vagina can also cause painful sex. This could be because of a simple yeast infection (thrush) or bacterial vaginosis and is managed with a combination of medication (oral or vaginal), dietary advice of eating a whole food plant based diet and perineal hygiene measures as appropriate.
Vestibulitis
Inflammation of the vestibular glands located just inside the entrance of the vagina is known as vestibulitis and usually responds well to treatment with local antibiotics, a numbing or soothing agent and steroid ointments to reduce the inflammation. If treated early, long term vulval/vaginal pain may be averted.
A sexually transmitted infection or a bacterial vaginal infection can sometimes lead to vaginitis by causing an irritating vaginal discharge. Both need appropriate management combining antibiotics, sexual education and perineal hygiene.
What else could cause this kind of pain?
Physical issues may sometimes cause pain on sexual intercourse. A very thick hymen or a vaginal band or septum (thick wall) may make it either impossible to achieve penetrative intercourse or result in significant bleeding or vaginal injury.
Women who have been subjected to female genital mutilation may also find intercourse very painful or impossible and will often need corrective surgery.
In these situations, surgery is usually needed to make the vaginal opening bigger. In some situations, using graded vaginal dilators by the woman can be helpful in avoiding surgery or is needed after surgery to keep the vagina open. The advantage with dilators is that the woman can do this in her own time and in private.
Allergies
Allergies and hypersensitivity to chemicals used in and around the female genital area can cause significant discomfort during sexual intercourse.
Allergies to semen, a question I get asked on a regular basis is very rare.
Developing sensitivity to laundry detergents and sanitary ware is not uncommon at all. Avoiding soaps, harsh chemicals, feminine wipes which deprive the vagina of healthy bacteria can help provide symptom relief.
Eating plenty of fruit and vegetables will provide the natural prebiotics that the good bacteria need to thrive.
Psychological concerns
A bad experience for a child in the doctor’s room can leave long lasting issues, right into adulthood. I always teach my trainees that when a child or a young girl needs examination because of vaginal discharge or soreness in the anogenital area, it may need more than one consultation to gain the confidence of the child. It is also usually recommended that she is accompanied by a parent or a chaperone she feels comfortable with and who can help her undress. The psychological impact and possible negative effects of these childhood encounters should not be underestimated.
Sexual abuse also may have a lasting impact, buried deep only to manifest many years later as painful sex or a fear of vaginal childbirth (tokophobia).
A stressful lifestyle can also have a significant impact on the quality of sexual health and an effort should be made to identify and manage these factors.
Helping women access evidence-based information, partner involvement and self-help all go a long way in addressing the distressingly rather common issue of painful sex.
Dr Nitu Bajekal FRCOG Dip IBLM
Consultant Gynaecologist and Women’s Health Expert
Lifestyle Medicine Physician
Updated January 2020
