Painful Intercourse

• Not enough vaginal lubrication – This can be the result of not enough foreplay or because of vaginal atrophy caused by decreased estrogen levels during menopause (see section on vaginitis: atrophic vaginitis). Inadequate lubrication can also be caused by certain medications that are known to decrease sexual desire and arousal, such as anti-depressants, high blood pressure medicines, sedatives, antihistamines, and certain birth control pills.
• Injury, trauma, or irritation – This includes injury or irritation from pelvic surgery, or a cut made during childbirth to enlarge the birth canal (episiotomy).
• Inflammation, infection, or a skin disorder – An infection in the genital area or urinary tract can cause entry pain. Eczema or other skin problems in the genital area can also be the problem.
• Vaginismus – This is involuntary spasms of the muscles of the vaginal wall that can make penetration painful.
• Congenital abnormality – This is an anatomic problem present at birth, such as a membrane that blocks the vaginal opening (imperforate hymen) or an incompletely formed vagina (vaginal agenesis).

• Certain illnesses and conditions – These include endometriosis, pelvic inflammatory disease, a sagging uterus (uterine prolapse), a back-tilted uterus (retroverted uterus), uterine fibroids, irritable bowel syndrome, pelvic floor muscular dysfunction, and ovarian cysts.
• Surgeries or medical treatments – Scarring from pelvic surgery, including hysterectomy, can cause painful intercourse. Medical treatments for cancer, such as radiation and chemotherapy, can cause changes that make deep penetration painful.

A thorough medical history that also explores possible emotional and psychological factors is very important. When painful intercourse began, where in the vagina sex hurts, how it feels, and if it happens with every sex partner and position are key points for the gynecologist to know, as are the woman’s sexual, surgical, and childbirth histories.   Embarrassment shouldn’t prevent a woman from providing the important information that could provide vital clues to the cause of dyspareunia.

Physical examination with use of a speculum allows assessment of the vagina to check for signs of vaginal irritation, infection, or anatomical problems. Pain may be located by applying gentle pressure to the vagina and pelvic muscles. If certain causes of painful intercourse are suspected, a pelvic sonogram or MRI may be ordered.

Treatment of painful intercourse depends on the cause of the pain.

If it’s due to an infection or a medical condition, treating that cause might resolve the problem. If a medication side effect decreases vaginal lubrication, changing medications can also help eliminate the symptoms of dyspareunia. For menopausal women, as mentioned above, dyspareunia is caused by inadequate lubrication secondary to low estrogen levels. This can be initially managed with vaginal lubricants and moisturizers, but if ineffective, topical estrogen creams or tablets can be tried. Certain non-medication therapies also might help with dyspareunia. Desensitization therapy is a series of vaginal relaxation exercises that can decrease pain. Counseling or sex therapy can help resolve a negative emotional response to sexual stimulation. Finally, dyspareunia might be minimized with a few changes to a woman’s sex routine: changing positions, better communication during sex, better foreplay, and use of vaginal lubricants.