Dyspareunia (Painful Intercourse)

Where does it hurt? Entry vs deep pain

Some people have both, and pain can also persist after sex as aching or burning.

Causes of entry pain

• Vaginal dryness: from not enough arousal, breastfeeding, some birth control pills, antihistamines, antidepressants and cancer treatments.
• Genitourinary syndrome of menopause: low estrogen thins and dries the vaginal tissue. See atrophic vaginitis.
• Infections: yeast infections, bacterial vaginosis, trichomoniasis, herpes and urinary tract infections.
• Vulvodynia and vestibulodynia: chronic burning pain at the vulva or vaginal entrance without a visible cause; touch causes pain.
• Vaginismus: involuntary tightening of the pelvic floor muscles around the vagina, making penetration painful or impossible.
• Skin conditions: lichen sclerosus, lichen planus and contact dermatitis from soaps, condoms or lubricants.
• Childbirth: tears or episiotomy scars.
• Congenital differences: such as a thick hymen or vaginal septum.

Causes of deep pain

• Endometriosis: a leading cause of deep dyspareunia, often with painful periods and bowel symptoms.
• Pelvic inflammatory disease: infection of the uterus and tubes.
• Ovarian cysts, fibroids and adenomyosis.
• Retroverted (tilted) uterus in some people.
• Interstitial cystitis: bladder pain worsened by sex.
• Pelvic floor muscle dysfunction: tight, tender muscles.
• Irritable bowel syndrome and constipation.
• After pelvic surgery or radiation.

Psychological and relationship factors

Anxiety, past trauma, relationship stress, depression and fear of pain can all contribute, and pain itself leads to anticipation and muscle tension that worsens the next experience. This does not mean the pain is "in your head"; physical and psychological factors usually interact.

Diagnosis

A gynecologist or primary care doctor will ask where and when it hurts, how long it has been happening, about periods, childbirth, menopause, contraception, medicines and emotional factors. The examination may include:

• looking at the vulva and gently touching specific spots with a cotton swab (for vestibulodynia)
• checking pelvic floor muscle tone
• a gentle speculum and bimanual exam, as tolerated
• swabs for infection
• pelvic ultrasound for cysts, fibroids or signs of endometriosis
• sometimes laparoscopy to confirm endometriosis

You can ask for the exam to be stopped at any time.

Treatment

For dryness and atrophy

• Lubricants during sex: water-based or silicone-based. Avoid oil-based products with latex condoms.
• Vaginal moisturizers used regularly, not just during sex.
• Low-dose vaginal estrogen (cream, tablet or ring), very effective for menopause-related dryness and safe for most people.
• Vaginal DHEA (prasterone) or oral ospemifene are alternatives.

For muscle-related pain

• Pelvic floor physical therapy: relaxation techniques, manual therapy and biofeedback.
• Graduated vaginal dilators for vaginismus.
• Cognitive behavioral therapy and sex therapy to reduce fear and anxiety.

For specific causes

• treating infections with antifungals, antibiotics or antivirals
• topical steroids for lichen sclerosus
• topical anesthetics, nerve-pain medicines and physical therapy for vulvodynia
• hormonal treatments or surgery for endometriosis
• treating cysts, fibroids or bladder pain

Things you can try

• more time for arousal and foreplay
• positions that allow you to control depth, such as being on top
• emptying your bladder before sex
• non-penetrative intimacy while you are being treated
• communicating openly with your partner

Frequently asked questions

What causes painful intercourse?

Common causes of pain at entry include vaginal dryness, menopause, infections, vulvodynia and vaginismus. Deep pain is often caused by endometriosis, pelvic infection, ovarian cysts, fibroids or tight pelvic floor muscles. Psychological factors and past trauma can contribute.

Why does sex suddenly hurt?

New pain often comes from an infection such as a yeast infection, vaginal dryness from breastfeeding, a new medicine or menopause, or a new pelvic problem such as an ovarian cyst. See a doctor if it persists or comes with fever, discharge or bleeding.

How is dyspareunia treated?

Treatment depends on the cause: lubricants and vaginal estrogen for dryness, pelvic floor physical therapy and dilators for muscle tension, medicines for infections and skin conditions, and treatment of endometriosis or other pelvic conditions. Therapy can help with anxiety and fear of pain.

Is painful sex after menopause normal?

It is common but not something you have to accept. Falling estrogen thins and dries vaginal tissue. Regular moisturizers, lubricants and low-dose vaginal estrogen are highly effective, and most people get significant relief.