Painful Sex (Dyspareunia): Causes and What Helps

Where it hurts gives clues

Causes of pain at entry

• Vaginal dryness: not enough arousal or lubrication, low estrogen after menopause, while breastfeeding, or from medicines such as some birth control pills, antihistamines and antidepressants. See vaginal dryness.
• Atrophic vaginitis (genitourinary syndrome of menopause): thin, dry, fragile tissue after menopause, causing burning, tearing and pain. It affects about half of postmenopausal women and does not improve without treatment.
• Infections: yeast infection, bacterial vaginosis, trichomoniasis, genital herpes.
• Vaginismus: involuntary tightening of the pelvic floor muscles around the vagina, making penetration painful or impossible. Often linked to fear of pain, past painful experiences or anxiety.
• Vulvodynia: persistent burning or rawness of the vulva without a visible cause, often provoked by touch at the vaginal opening.
• Skin conditions: lichen sclerosus, lichen planus, eczema and irritation from soaps, spermicides or condoms.
• Childbirth injury: a scar from an episiotomy or tear.

Causes of deep pain

• Endometriosis: tissue like the uterine lining grows outside the uterus, often behind it, causing deep pain with sex, painful periods and sometimes infertility.
• Pelvic inflammatory disease: infection of the uterus and tubes, often from chlamydia or gonorrhea, with deep pain, abnormal discharge and sometimes fever.
• Ovarian cysts and fibroids.
• Interstitial cystitis (bladder pain syndrome): bladder pain and urgency, worse with sex.
• Bowel conditions: irritable bowel syndrome and constipation.
• Pelvic adhesions after surgery or infection.
• Pelvic floor muscle tension.

Painful sex in men

• infections: urethritis from sexually transmitted infections, yeast infection of the penis (balanitis), prostatitis
• a tight foreskin (phimosis) or a tight band under the head of the penis
• Peyronie's disease: scar tissue causing a curved, painful erection
• skin conditions and allergies to latex or lubricants
• pain on ejaculation from prostatitis or pelvic floor tension

The role of the mind and relationship

Pain and anxiety feed each other. Expecting pain makes the pelvic muscles tense and reduces arousal and lubrication, which causes more pain. Past trauma, relationship stress and depression can contribute. This does not mean the pain is imagined: it is a real response that can be treated, often alongside physical causes.

How doctors find the cause

A doctor or gynecologist will ask where and when it hurts, how long it has been happening, your periods, contraception, childbirth, menopause, medicines and sexual history. They will examine the vulva and vagina, gently and only with your consent, sometimes using a cotton swab to map tender areas, and may do an internal exam. Tests may include:

• swabs for infections and sexually transmitted infections
• urine tests
• pelvic ultrasound for cysts, fibroids and other structural causes
• laparoscopy (keyhole surgery) to diagnose endometriosis in some cases

Treatment

• Lubricants and moisturizers: water- or silicone-based lubricants during sex, and vaginal moisturizers used regularly. Avoid oil-based products with latex condoms.
• Vaginal estrogen: low-dose creams, tablets or rings are very effective for menopausal dryness and atrophy, with minimal absorption into the body.
• Treating infections with antifungals, antibiotics or antivirals.
• Pelvic floor physical therapy: relaxation, stretching and graded dilator use for vaginismus, vulvodynia and pelvic floor tension.
• Vulvodynia treatments: topical numbing creams, nerve-pain medicines and physical therapy.
• Endometriosis treatment: hormonal therapy or surgery.
• Sex therapy or counseling to address anxiety, trauma and relationship factors.
• Practical changes: more time for foreplay and arousal, positions that allow you to control depth (such as being on top), emptying the bladder before sex, and a cold pack wrapped in a towel afterward for burning.

Frequently asked questions

Why does sex hurt for me?

The most common reasons are vaginal dryness, infections, muscle tightness (vaginismus), vulvodynia and, for deep pain, endometriosis or pelvic infection. After menopause, thinning vaginal tissue is a very common cause. A doctor can find the cause and recommend treatment.

What causes deep pain during sex?

Deep pain with thrusting is often caused by endometriosis, pelvic inflammatory disease, ovarian cysts, fibroids, bladder pain syndrome or bowel problems. Some positions press on a tilted uterus or ovary. Persistent deep pain should be examined.

How do I stop painful sex after menopause?

Use a lubricant during sex and a vaginal moisturizer regularly. If that is not enough, low-dose vaginal estrogen is highly effective at restoring the tissue. Regular sexual activity or dilator use helps keep the vagina elastic.

Can men have painful sex?

Yes. Causes include infections, prostatitis, a tight foreskin, Peyronie's disease, skin conditions and allergies to latex or lubricants. A doctor or urologist can identify and treat the cause.

Is painful sex normal the first time?

Some discomfort can happen, but sex should not be significantly painful. Anxiety, too little arousal and lubrication are common reasons. Persistent pain, or being unable to have penetration, may be vaginismus and is very treatable.