Painful Sex: Common Causes And Treatment Approaches

Painful intercourse (dyspareunia) is common and very rarely random. As many as 28% of people with vulvas will experience painful sex at some point in their reproductive years and many have no idea why.

There are many possible causes; it’s important to understand some of the most common ones, and then you can begin to seek proper treatment and implement a healthcare plan that works for you.

Common causes of pain: “the 3 V’s”

While there are many potential causes of painful intercourse, 3 common medical conditions faced by patients can lower quality of life if not properly identified. The good news is that by understanding the symptoms, you are better prepared to talk to a women’s health specialist about your concerns so we can help you find a treatment plan that works for you!

Vulvodynia: 

Can be provoked or unprovoked pain anywhere in the vulva. The vulva is the female genital area, which includes the skin surrounding the opening of the vagina.

Vulvodynia can arise from particular stimuli or may be present all the time – without a physical stimulus.

Can be primary (symptoms presented at the first attempt at penetration) or secondary (symptoms appear after periods of pain free insertion).

Often described as burning, stinging, itching, irritation or a feeling of “rawness”

Vaginismus:

An involuntary pelvic floor contraction that interferes with penetration

Associated with pelvic floor tightness and myalgia

Normal vulvar sensation

Can be primary (symptoms presented at the first attempt at penetration) or secondary (symptoms appear after periods of pain free insertion).

Inability to have penetrative sex, or use tampons

May result in fear regarding sex or loss of sexual desire

Vestibulodynia:

Can be provoked or unprovoked pain which is isolated to the vestibule (area between the two labia minora)

Often characterized by redness and tissue atrophy in this area

May be described as painful burning, stinging or soreness during sexual intercourse, with tampon use, during a pelvic exam, during physical activities, or while wearing tight clothing

Summary of the 3 V’s

All three of these conditions can occur in combination or independent of each other. It is important to have a thorough assessment by your obstetrician or pelvic floor physiotherapist to determine which umbrella you may fall under – this is because the treatment for each of these conditions differ and are not a one size fit all.

Endometriosis

Endometriosis is a disorder in which tissue similar to the uterine lining (endometrium) grows into other areas, such as the ovaries, Fallopian tubes, and rectum. It is often painful and surprisingly common, affecting around 1 in 10 people with vulvas.

Symptoms of endometriosis can vary, but usually include very painful periods starting in a person’s teen years. Many people with endometriosis also experience persistent pelvic pain, difficulty with defecating or urinating, gastro-intestinal symptoms, and infertility. 

An unfortunately common experience for people with endometriosis is painful sex. Not only can the lesions themselves be painful with different pressures and positions, but the muscles of the pelvic floor can become sensitive and reactive. This can create a vicious cycle of escalating pain and distress. 

Luckily, REP Physio’s pelvic floor therapists can help with these symptoms and provide an active treatment plan to make sex less painful and more enjoyable.

Ovarian cysts

Ovarian cysts are common and usually benign. Healthy ovaries will often produce functional cysts through their cycle that usually go away on their own. However, even a “normal” ovarian cyst that becomes too big can cause pain, typically on one side of the lower abdomen. Other ovarian cysts, such as dermoid cysts, can become quite large. Often these larger cysts can be bumped during sex and may cause a sharp pain in certain positions. 

Other ovarian cysts can be cause for concern. It is important to visit your healthcare provider if you experience new positional pain that lasts more than a few months. Women who have passed menopause should seek help even sooner. 

Birth control

Today, women have incredible choice when it comes to birth control options, so it is important to understand the potential unwanted side effects of each. Fortunately, most women will experience an enhanced sex life while using birth control pills and IUDs, but some can experience problematic sexual dysfunction. 

Various birth control pills use different formulations of estrogen and progestin, or can be progestin only. Recent studies have found that pills and rings containing a low dose of estrogen can lower overall levels of estrogen and testosterone. This can reduce lubrication even when aroused, resulting in dryness that can be uncomfortable and may result in painful intercourse. These lower hormone levels can also result in thinning of the skin around the vulva, making it more prone to inflammation and chaffing. Both issues can be greatly improved with an unscented silicone or water based lubricant.

IUDs also come in several forms, including several progestin only options, like Mirena and Kyleena, as well as ParaGard which is made from copper. Since the hormonal options do not contain estrogen, there is little risk of dryness or thinning of the skin. All types of IUDs can, however, cause pain if they have moved to your cervix or the lower part of your uterus. It may be indicative of a wandering IUD if you notice you can no longer feel the strings of your IUD, have abdominal pain, or abnormal bleeding. While most will move back into place within 3 months, don’t hesitate to contact your doctor if you are concerned. 

Pelvic inflammatory disease

Pelvic inflammatory disease (PID) results from an infection of female reproductive organs. It is usually due to sexually transmitted bacteria (most commonly gonorrhea or chlamydia) spreading from the vagina to the uterus, Fallopian tubes, or ovaries. This can also occur when the cervix is disturbed or compromised, for example during menstruation, after childbirth, miscarriage, or abortion. Rarely, this can occur with IUD insertion.

You may be at increased risk of pelvic inflammatory disease if you have multiple sexual partners, have sex without a condom, or have a history of sexually transmitted infections. Douching regularly can put you at a higher risk of infection due to upsetting the balance of good bacteria that keep harmful bacteria at bay. 

The symptoms of PID can vary widely from case to case. Many women do not have any signs or symptoms and it can be difficult to recognize. One common symptom is painful intercourse that can range from mild to severe. You may also experience bleeding during or after sex as the internal tissue is more vulnerable and inflamed. You may also notice a change in vaginal discharge and odour.

If you are suspicious of pelvic inflammatory disease, you should see your doctor as soon as possible. If pain lingers after medical treatment, pelvic floor physiotherapy can help with residual effects, like spasm, scar tissue, and tissue sensitivity.

Menopause

Sex becoming painful after menopause is an unfortunately common experience, affecting as many as 45% of women. This is usually because of the drop in estrogen levels that occurs. As estrogen levels drop, vaginal tissue tends to become more fragile, less stretchy, and can be torn more easily. Many also experience vaginal dryness.

As women age, issues like pelvic organ prolapse become more common and may also contribute to painful or uncomfortable sex. Other issues related to the pelvic floor, like urinary incontinence, may affect not only tissue health, but a person’s confidence and desire. 

A vicious cycle can result from these changes. Sex becomes painful, so you have less of it, and vaginal tissues become even more tight and sensitive. The expectation of having pain with penetrative sex can also make it very difficult to relax your pelvic floor. Anxiety can reduce lubrication even further. Painful spasms, or vaginismus, is not uncommon if painful intercourse becomes the norm.

Sexual health becomes no less important through menopause. It can have a profound effect on a person’s wellbeing and relationships, which is why it is important to discuss these issues with your medical provider and seek help sooner rather than later.

Painful sex treatment options

You may be starting to see that there are many potential causes of pain during sexual intercourse. This is why it’s so important to consult with a women’s health specialist. The pelvic floor physiotherapy offered by the experts at REP Physio is safe, effective, and beneficial to your quality of life long term.

Common treatment options may include some of the following:

• Education. When it comes to painful sex, knowledge is power! With a thorough assessment, your physiotherapist can walk you through what is contributing to your pain and help build an action plan towards recovery. This will look different for everyone!
• Relaxation exercises are key when pelvic floor muscles are tight and tender. Your physio can help you get connected to your pelvic floor, build awareness, and learn to let those muscles go. 
• Pelvic floor strengthening is important when weakness may be contributing to issues like pelvic organ prolapse and urinary incontinence. Strengthening is also great for improving blood flow to the pelvic floor and can help improve pleasure.
• Desensitization and stretching of sore muscles or scar tissue can be very helpful over time. This can be done manually by your therapist and taught to you as well. Modalities like electrical stimulation and dry needling can also be utilized.
• Mindfulness, meditation, and other stress relieving practices can help you break the vicious cycle of pelvic pain by calming the nervous system and reconnecting with your body.