Pain During Intercourse (Dyspareunia)

Pain at entry vs deep pain

Where the pain is felt is the most useful clue:

Causes of entry pain

• Vaginal dryness: not enough arousal, menopause, breastfeeding, hormonal birth control, antihistamines, some antidepressants and cancer treatments.
• Menopause: falling estrogen thins the vaginal lining. Atrophic vaginitis, now part of genitourinary syndrome of menopause, causes dryness, burning, urinary symptoms and pain with sex. It affects about half of postmenopausal women and does not improve without treatment.
• Infections: vaginitis from yeast or bacterial vaginosis, trichomoniasis and genital herpes.
• Vulvodynia: chronic vulvar pain lasting more than 3 months without another cause. Light touch at the vaginal opening, such as from a tampon or cotton swab, is painful.
• Vaginismus: involuntary tightening of pelvic floor muscles that makes penetration painful or impossible.
• Skin conditions: lichen sclerosus, lichen planus and eczema of the vulva.
• Scarring: from tears or episiotomy during childbirth, or from surgery.
• Allergic or irritant reactions to soaps, spermicides, lubricants or latex.

Causes of deep pain

• Endometriosis: tissue similar to the uterine lining grows outside the uterus. Deep pain with sex, painful periods and painful bowel movements are classic.
• Pelvic inflammatory disease: infection of the uterus and tubes, often from chlamydia or gonorrhea.
• Ovarian cysts and fibroids.
• Adhesions (scar tissue) after surgery or infection.
• Interstitial cystitis (bladder pain syndrome) and irritable bowel syndrome.
• Pelvic floor dysfunction: overactive, tight muscles.
• Pelvic organ prolapse or a retroverted (tilted) uterus.

Psychological and relationship factors

Anxiety, past painful experiences, sexual trauma, depression and relationship difficulties can cause or worsen sexual pain. Pain itself creates a cycle: expecting pain tightens the muscles, which causes more pain. Addressing both physical and emotional factors usually works best.

Pain during intercourse in men

• Infections: urethritis, prostatitis, epididymitis and sexually transmitted infections.
• Tight foreskin (phimosis) or a tight frenulum that tears.
• Peyronie's disease: scar tissue causing a curved, painful erection.
• Skin conditions such as balanitis and lichen sclerosus.
• Pain with ejaculation: often prostatitis or chronic pelvic pain syndrome.

How doctors find the cause

A doctor will ask where and when the pain occurs, how long it has been happening, about periods, childbirth, menopause, contraception, medicines and emotional factors. The examination is done gently and only with consent, and can be stopped at any time. It may include:

• inspection of the vulva and a cotton-swab touch test for vulvodynia
• a single-finger exam to check pelvic floor muscles
• a speculum exam and swabs for infection
• a bimanual exam to check the uterus and ovaries
• pelvic ultrasound, and sometimes laparoscopy for suspected endometriosis

Treatment

• Lubricants and moisturizers: water- or silicone-based lubricant during sex; regular vaginal moisturizers for ongoing dryness. Oil-based products can damage latex condoms.
• Low-dose vaginal estrogen or vaginal DHEA for menopausal dryness. These act locally with very low absorption.
• Treat infections with antifungals, antibiotics or antivirals.
• Pelvic floor physical therapy: relaxation, stretching, biofeedback and graded vaginal dilators. It is a mainstay for vaginismus and vulvodynia.
• Topical numbing gels before sex, and medicines for nerve pain in vulvodynia.
• Treat endometriosis and other causes with hormonal therapy or surgery.
• Sex therapy or cognitive behavioral therapy to address anxiety and the pain cycle.
• Practical changes: more time for arousal, different positions that allow control over depth, and non-penetrative intimacy while healing.

Frequently asked questions

Why does sex hurt?

Common reasons include not enough lubrication, infections, menopause-related dryness, tight pelvic floor muscles, vulvodynia and skin conditions at the entrance. Deep pain is often from endometriosis, pelvic infection, cysts or fibroids. Pain that keeps happening deserves a medical evaluation.

What causes deep pain during intercourse?

Deep pain with thrusting is commonly caused by endometriosis, pelvic inflammatory disease, ovarian cysts, fibroids, adhesions or pelvic floor muscle tension. Bladder and bowel conditions can also contribute. A pelvic exam and ultrasound are usually the first steps.

Is it normal for sex to hurt after menopause?

It is common but not something you have to accept. Lower estrogen thins and dries the vaginal tissues. Lubricants, vaginal moisturizers and low-dose vaginal estrogen are very effective, and pelvic floor therapy helps too. Symptoms usually worsen without treatment.

Can painful sex be cured?

Most causes of painful sex can be treated effectively. Infections clear with medicine, dryness responds to lubricants and estrogen, and pelvic floor physical therapy helps vaginismus and vulvodynia. Endometriosis may need ongoing treatment. Many people need a combination of approaches.

Can men have pain during intercourse?

Yes. In men, pain during sex can come from infections, a tight foreskin, Peyronie's disease, skin conditions or prostatitis. Pain on ejaculation is often linked to prostate inflammation. A urologist or primary care doctor can examine and treat these.