Painful sexual intercourse (commonly known as painful sex), can occur for reasons that range from structural problems to psychological concerns. Many women have painful intercourse at some point in their lives. If you experience pain before, during, or after sexual intercourse, then it is advisable to meet your gynaecologist at the earliest. Read on to understand more about this condition.

Intercourse is the physical sexual contact between individuals that involves the genitalia (male or female reproductive organs) of at least one person, either of the men or of females. 

The external female genitalia (vulva) includes the opening of the vagina (also called the birth canal). The vagina is part of your reproductive tract and extends from the womb (uterus) to the outside of your body. The fleshy lips (labia majora and labia minora) are present around your vagina. 

The medical term for painful intercourse is dyspareunia (dis-puh-ROO-nee-uh), defined as persistent or recurrent genital pain that occurs just before, during, or after intercourse. 

Dyspareunia is recurring and can be sharp or intense. Dyspareunia is more common in women than men. It has many possible causes, symptoms but can be diagnosed and treated. 

Causes of Dyspareunia

1. Physical causes of painful intercourse differ, depending on whether the pain occurs at entry or with deep thrusting. Entry pain is the pain experienced during penetration and might be associated with a range of factors like less lubrication, vaginal dryness, injury, vaginismus (involuntary or voluntary contraction of vaginal muscle during penetration), a decrease in estrogen levels after childbirth, breastfeeding, or menopause. Estrogen is the primary female sex hormone that regulates your reproductive system. 

2. Certain medications are known to affect sexual desire or arousal, which can decrease lubrication (a woman's vagina typically becomes lubricated, making it wetter and ready for sex) and make sexual intercourse painful. 

These include:

  • Antidepressants (medications to relieve depression, anxiety, and social disorders)

  • High blood pressure (hypertension) medications 

  • Sedatives (prescription medication that slows down your brain activity) 

  • Antihistamines (drugs that can relieve allergy symptoms)

  • Certain birth control pills (tablets are taken to prevent pregnancy).

3. Injury, trauma, or irritation. This includes injury or irritation from an accident, pelvic surgery (the procedure is designed to improve the support to the uterus or vaginal vault), female circumcision, or a cut made during childbirth to enlarge your birth canal (episiotomy).

4. Inflammation, infections, or skin disorders. An infection in your genital area or urinary tract can cause painful intercourse. Eczema (itchy inflammation of the skin) or other skin problems in your genital area also can be the problem.

5. Congenital abnormality.  A problem present at birth, such as the absence of a fully formed vagina (vaginal agenesis) or the development of a membrane that blocks your vaginal opening (imperforate hymen), could cause dyspareunia.

6. Certain illnesses and conditions. The list includes:

  • Endometriosis is a disorder in which tissue that normally lines the uterus grows outside the uterus.

  • Pelvic inflammatory disease is a bacterial infection of the female reproductive organs. 

  • Uterine prolapse is a condition in which your uterus descends toward or into the vagina. 

  • A retroverted uterus is when your uterus (womb) tilts backward rather than forward. 

  • Uterine fibroids are non-cancerous growths in your uterus. 

  • Cystitis is the inflammation of your bladder (a hollow muscular organ that stores urine from your kidneys).

  • Irritable bowel syndrome (IBS) is an intestinal disorder causing pain in the stomach, and diarrhoea, and constipation.

  • Hemorrhoids (piles) are swollen veins in your lower rectum (the chamber that begins at the end of the large intestine). 

  • Ovarian cysts are fluid-filled sacs or pockets (cyst) within or on the surface of your ovaries (the primary female reproductive organs).

7. Surgeries or medical treatments. Scarring from pelvic surgery, including hysterectomy, can cause painful intercourse. 

8. Medical treatments for cancer, such as radiation and chemotherapy, can cause changes that make sex painful.

9. History of sexual abuse. Not every woman with dyspareunia has a history of sexual abuse, but if you have been abused, it can play a role. 

10. Stress. Your pelvic floor muscles (a group of muscles found in the floor (the base) of your pelvis (the bottom of your torso)) tend to tighten in response to stress in your life. This can contribute to pain during intercourse.

11. Emotional factors might be associated with many types of painful intercourse. Emotions are deeply intertwined with sexual activity, so they might play a role in sexual pain. Emotional factors include psychological issues, anxiety, depression, concerns about your physical appearance, fear of intimacy or relationship problems, etc., that can contribute to a low level of arousal and resulting discomfort or pain.

Symptoms of Dyspareunia

If you have painful intercourse, you might feel: 

  • Pain only at sexual entry (penetration).

  • Pain with every penetration, including putting in a tampon.

  • Pain during thrusting (deep pain during penetration of penis, the primary male genitalia).

  • Burning pain or aching pain in your genitals.

  • Throbbing pain, lasting hours after intercourse.

Diagnosis of Dyspareunia

A medical evaluation for dyspareunia starts with collecting a thorough medical history.

Your doctor may ask questions to understand when your pain began, exactly where it hurts, how it feels, and if it happens with every sexual activity. Your doctor may also inquire about your sexual history, surgical history, and previous childbirth experiences.

Don't let embarrassment stop you from giving the correct answers. Make sure you are prepared to discuss these points with your doctor. Ensure you are calm and in a comfortable environment before starting the discussion with your doctor. The correct answers will help your doctor identify the right causes and proceed with further diagnosis and treatment. The common tests for dyspareunia include:

1. Pelvic Exam: During a pelvic exam, your doctor can check for signs of skin irritation, infection, or anatomical problems to identify the location of your pain.

A visual exam of your vagina, using an instrument called a speculum to separate the vaginal walls, may be performed as well. 

If your doctor suspects certain causes of painful intercourse you may be recommended to undergo a pelvic ultrasound (a test that uses sound waves to take pictures of the organs inside your pelvis).

Treatment of Dyspareunia

Treatment options vary depending on the cause of your pain.

1. Medications

If an infection or medical condition contributes to your pain, treating the cause might resolve your problem. Antibiotics, antifungal medications, topical or injectable steroids may be prescribed by your doctor depending upon the cause. 

For many postmenopausal women (women in the age group of the 40s or 50s), dyspareunia is caused by inadequate lubrication resulting from low estrogen levels. A tablet or cream may be applied to the vagina or a flexible ring may deliver a small regular dose at particular intervals of estrogen to the vagina. 

The drug ospemifene is used to treat dyspareunia. It is estrogen-free and acts like estrogen on the vaginal tissue making the tissue thick and less fragile, thereby reducing the pain during sexual intercourse. Ospemifene acts like estrogen on the vaginal lining, but doesn't seem to have estrogen's potentially harmful effects on your breasts.

2. Other Treatments

Certain non-medication therapies also might help with dyspareunia: 

  • Desensitization therapy: You learn vaginal relaxation exercises that can decrease pain.

  • Counseling or sex therapy: If sex has been painful for some time, you might have a negative emotional response to sexual stimulation even after treatment. If you and your partner have avoided intimacy because of painful intercourse, you might also need help improving communication with your partner and restoring sexual intimacy. Talking to a counselor or sex therapist can help resolve these issues. 

  • Cognitive-behavioral therapy can also be helpful in changing negative thought patterns and behaviors.

3. Lifestyle and home remedies: Your partner and you might be able to minimize pain with a few changes to your lifestyle and sexual routine:

  • Change positions. If you have sharp pain during thrusting, try different positions, such as being on top. In this position, you might be able to regulate penetration to a depth that feels good and less painful to you.
  • Communicate. Talk about what feels good and what doesn't. If you need your partner to go slow during sexual intercourse, say so.
  • Don't rush. Longer foreplay (a set of intimate acts) can help stimulate your natural lubrication. You might reduce pain by delaying penetration until you feel fully aroused. 
  • Use lubricants. A personal lubricant can make sex more comfortable. Try different brands until you find one you like.

Dyspareunia can be treated if you identify the causes of pain. Let your gynaecologist know when the pain starts occurring in the initial stages and notice if it occurs too frequently.

Disclaimer: This article is written by the Practitioner for informational and educational purposes only. The content presented on this page should not be considered as a substitute for medical expertise. Please "DO NOT SELF-MEDICATE" and seek professional help regarding any health conditions or concerns. Practo will not be responsible for any act or omission arising from the interpretation of the content present on this page.