When Intercourse is Painful

Nothing that hurts is very fun. That’s why it’s so frustrating when your intimate moments are interrupted with an “ouch!”. Along with this pain can come many feelings including worry, embarrassment, and self-consciousness. Many also feel as though they are alone when they experience this. Women should be reassured that they are not alone in feeling pain with intercourse. This is medically known as “dyspareunia” and it affects 3 out of 4 women of any age at some time in their life, but most particularly, dyspareunia affects women who are of menopausal age and older. Up to 22% of postmenopausal women regularly experience dyspareunia, though some studies have found that this number can be as high as 46%.

Though painful intercourse is not dangerous or life threatening, it can severely affect a woman’s sexuality and confidence, cause relationship problems, and reduce her quality of life overall. This problem is more than just physical. It is a complicated and intertwined with many facets of life, and thus, affects all women differently. Contributors to dyspareunia include emotional factors, hormones, personal history, medical history, and much more. This week, I hope to bring awareness to this common issue, discuss the many potential causes, talk about methods of prevention, ways to treat/overcome dyspareunia at home and at the office.

Don't listen to them - it's not all in your head

Women. It’s all in their head….That’s what many used to believe. Painful intercourse used to be classified as a sexual disorder, rather than a pain disorder. Many attributed sexual pain largely to a result of subconscious aversion, fear, anxiety, depression, and other psychological issues. Recently studies have shown that dyspareunia is actually a complicated subject and though psychology plays a part, it is not usually the biggest contributor to sexual pain. Studies have had very different results. Some show that women with dyspareunia did have more depression, anxiety, and fear, while others showed that women with dyspareunia were no different than the general population in terms of these psychological traits. Another interesting find is that previously, women with a current or previous history of sexual abuse were thought to have more pain with intercourse, but several studies have shown that this is not true. Again, it is possible for this to be a factor in pain with intercourse, but it is not a determinant. All of these studies and more are beginning to shift the popular opinion away from the thought that women who experience pain with intercourse have this pain because of some psychological issue.

Multiple Factors to Pain

Biopsychosocial. It’s a long word to describe how pain with intercourse should be viewed as an issue with multiple contributing factors. The word is a combination of three different main factors that contribute to dyspareunia: “bio” for biology or physical conditions, “psycho” for psychology and emotions, and “social” for all the social aspects that contribute to pain such as relationship comfort. It’s also not just these three separate factors that contribute to dyspareunia. These three factors affect and simultaneously worsen each other. Your social situation may affect how you feel which may cause you to produce less lubrication and have more painful intercourse. Or, you may have a painful incident which causes you to become stressed which then causes your relationship to suffer which then causes you to become disinterested in sex. As you can see, it’s a complicated interwoven network of causes.

When you come to the office, taking your history and doing an examination will allow us to find out the cause of your painful intercourse together. Because the topic is complicated and involves several aspects, it is important to be upfront about your specific issues and history so that when combined with a physical examination, the answer is clear.

Physical Causes

There are many potential physical causes of dyspareunia. First, it may be best to determine if pain occurs at the opening or outside of the vagina, or if the pain occurs deep inside. These are respectively referred to as Superficial Pain and Deep Pain. ​If you have already been diagnosed with one of these, it may be the cause of your pain. If you have not already been diagnosed but experience some of these symptoms, it's a good idea to come into the office.

Superficial Pain

Vulvodynia: This refers to pain anywhere in the vulva, or the external vaginal area that includes your inner and outer lips, clitoris, etc., and it is a difficult problem to tackle.  Often it is associated with other pain syndromes like fibromyalgia and interstitial cystitis. Typically pain occurs first with sexual contact, but may also be present in other activities such as wiping after the bathroom. Vulvodynia is different from other causes of vaginal pain and is not related to yeast, bacteria, vulvar skin problems, or others. Women will usually have tried many treatments that have been unsuccessful in the past. Calcium Citrate is a supplement that may help Vulvodynia. It may also be treated sometimes with antidepressants or medications for a condition called neuropathy. Lastly, physical therapy can sometimes improve vulvodynia.

Vulvar Vestibulitis: This is a type of vulvodynia and it is a constant and painful swelling of the vaginal opening. Women will commonly feel pain with penetration if this is the cause. Vulvar Vestibulitis may occur for several reasons, but much is still unknown. Experts suspect that yeast and Human Papillomarvirus (HPV) may contribute to this type of pain.

Skin Problems: There are several vulvar skin disorders that may be a cause of pain including ulcers, eczema, cracks in the skin, and allergies to substances like soaps, lubricants, synthetic underwear, etc. Another skin problem that may cause dyspareunia is a condition called lichen sclerosis.

Vaginitis: Vaginitis means inflammation of the vagina and there are many types and causes of vaginitis. The most common causes are yeast, bacteria, and trichomonas. These three causes of vaginitis may be treated. There are other types of vaginitis as well, some that may be treated with medication and others that need a change in lifestyle.

Urethritis: This refers to inflammation or swelling of the urethra and is another potential cause of superficial pain.

Vaginal Atrophy: Vaginal Atrophy is actually a type of Vaginitis and it is the thinning and tightening of the vaginal walls due to loss of estrogen. This is a common problem for menopausal women or women who are breast feeding. Vaginal atrophy is well managed and treated with vaginal Estrogen creams or a system wide estrogen replacement. Other nonhormonal options are available, however these are usually less effective. Osphena is one nonhormonal option that may improve vaginal moisture. Virgin coconut oil may also help bring some moisture to the area, and Replens is another over the counter vaginal moisturizer. One last and newer option for treating vaginal atrophy just approved by the FDA this year is the Mona Lisa Touch CO2 laser. This laser treatment restores healthy moisture and elasticity to your tissues.

Inadequate Lubrication: Inadequate lubrication may occur for several reasons, and large players are psychological factors. If you are disinterested in sex, distracted, anxious, or another emotional or mental reason, you are much less likely to produce your own natural lubrication that is necessary for intercourse. Some women will also complain that birth control pills with high Progestin levels will cause them to be more dry, vaginally. Over the counter lubricants are an excellent way to combat this cause of pain. My favorite lubricant to recommend is the original Astroglide.

Childbirth: During childbirth, it is possible to have some tearing. This is typically repaired with a few stitches and is referred to as an episiotomy. This pain will usually resolve, but sometimes it may take up to several months after giving birth.

Sexually Transmitted Infections (STIs): Some infections may cause pain at the vaginal opening. These include Syphilis, Herpes, HPV, and more. If you have had unprotected sex or have had multiple sexual partners and have not been recently examined, this may be a potential cause of your sexual pain.
​
Bartholin Gland Cysts (or Abcess): Bartholin glands are two glands that are on either side of the vaginal opening and are responsible for providing the vagina with lubrication upon sexual stimulation. Sometimes these glands become inflamed and/or infected. When this occurs, they become tender and painful. Thus, this may be a cause of dyspareunia at the vaginal opening. 

Deep Pain

Endometriosis: Endometriosis is a condition where the lining of the uterus moves outside the uterus, typically still in the pelvic region. Most commonly, endometrial tissue can be found on ovaries, fallopian tubes, and other structures in between. This endometrial tissue can occasionally be found in other areas, however this is rare. Endometriosis suspected through history and exam but can only be confirmed via surgery (at my office I recommend laparoscopy). Sometimes an ultrasound will discover endometriosis cysts on the ovaries, but typically ultrasound is a poor method to diagnosis endometriosis.

Adenomyosis: Adenomyosis is a condition similar to endometriosis, however rather than endometrial tissue leaving the uterus, endometrial tissue begins to grow within the layers of muscle of the uterus.. Adenomyosis, like Endometriosis, is always suspected with history, exam, and ultrasound, but ultimately confirmed and diagnosed via laparoscopy surgery.

Pelvic Adhesions: Pelvic adhesions are usually cased from scar tissue that attaches and binds to other organs. When this occurs in the pelvic region, it may be a cause of dyspareunia. If you have had surgery in your pelvic region, especially non laparoscopic surgeries, it is possible that you may have scar tissue and adhesions. Adhesions can also be caused by endometriosis or a previous pelvic infection such as PID.

Ovarian Problems: Some ovarian problems such as certain ovarian cysts may cause dyspareunia with deep penetration. All women will normally have ovarian cysts that come and go because it is a natural part of ovulation and menstruation, but other cysts are abnormal. A physical examination/palpation may be able to locate an ovarian cyst, however a pelvic ultrasound may be necessary.

Retroverted Uterus: Retroverted Uterus is a uterus that is tilted toward your spine, rather than your belly button like the average uterus. Though it is normal to have a retroverted uterus, and many women do have one, it may be a cause of sexual pain with deep penetration. No treatment is necessary for a retroverted uterus. Pain for this reason may be prevented by avoiding the sexual positions that cause the pain.

Bladder or Urinary Tract Infections: When you have a bladder or urinary tract infection, these structures are typically inflamed and swollen. This will cause them to feel discomfort if bumped during sexual intercourse. Typically these have other symptoms including frequent urination and burning after urination and is easily treated with an antibiotic.

Pelvic Inflammatory Disease (PID): This is caused typically from a bacterial infection and is commonly caused by the STIs, gonorrhea and chlamydia. It is a problematic condition that is dangerous if left untreated. Therefore, if you have had unprotected sex, multiple sexual partners, or a non-monogamous relationship, you are at a greater risk of these STIs and PID. Thankfully it is treated with medication, but you need to be tested at the office or at a sexual health center.

Pelvic Congestion: Pelvic congestion syndrome is a syndrome where the pelvic blood vessels become abnormally dilated and swollen and is a rare cause of dyspareunia. This, more commonly, causes pelvic pain rather than dyspareunia. This condition is difficult to diagnose and treat. Some suggest the possibility of cutting of blood blow to the dilated veins in order to treat pelvic congestion.

Irritable Bowel Syndrome: Irritable bowel syndrome is a condition that is not specifically gynecologic, but that can cause pain during intercourse. The colon and rectum are close in proximity to the vagina. When the bowel becomes swollen and irritated due to irritable bowel syndrome, it is possible that during intercourse, deep penetration may bump and irritate these sensitive tissues. Controlling irritable bowel syndrome, if you suffer from it, is one way to reduce the possibility of dyspareunia.

Structural Vaginal Changes: Another cause of pain with intercourse is structural changes that have occurred to the vagina. Like adhesions, sometimes scar tissue can cause the shape and structure of the vagina to change. The vagina can close in and adhere to itself, become smaller or shortened, or close up completely. It is possible to attempt a manual or surgical repair of this problem, however it is still possible for the vagina to become closed again.

Prolapse: Prolapse is when the pelvic organs begin to move out of the body through the vagina. It sounds gruesome, but it is a very common problem that women experience and is typically a result of childbirth. The structures that hold up and support the uterus, bladder, and/or rectum can become weak. This causes them to fall down with gravity. The vagina is an opening to the outside world, therefore, these organs try to escape from here. When these organs are bumped during intercourse, it can cause pain. Other symptoms of prolapse include a sensation of pelvic heaviness, incontinence, or a bulge inside the vagina or at the vaginal opening. Prolapse can be repaired surgically or with a pessary, however a pessary prevents the possibility of sexual intercourse so in this case it would not be recommended.

As you can see there are many potential physical causes of dyspareunia. Some of these you may be able to determine on your own, while most will require a physical examination/palpation at the office.

Psychological Factors

The next part of the biopsychosocial approach to dyspareunia is psychology. Sexuality is naturally a combination of how you feel and how your body works. If there is something on your mind or if you are not comfortable with sex, that can cause your body to have a physical reaction. Also, pain may initiate negative feelings and the negative feelings are then more likely to cause sexual pain. Being uninterested in sex, having difficulty becoming aroused, and other similar feelings will cause you to produce less lubrication. Certain conditions and medications may also cause a similar problem with lack of lubrication. These include depression, anxiety, and more.

Fear, anticipating pain, and a history of pain with intercourse are also psychological factors in dyspareunia. If a woman has had a history of sexual abuse, there is a possibility that she may have pain with intercourse related to this. For those with a history of trauma or pain with intercourse, they begin to tie pain and intercourse together. This makes them anticipate pain before an action occurs, then when the action of penetration occurs, their pelvic muscles involuntarily contract and painfully spasm. This is referred to as Vaginismus. Therapy is an effective method to overcome vaginismus. By overcoming the past, practicing relaxation techniques before and during penetration, and by getting to any other roots to the issue, vaginismus can be treated.

Social Factors

Social factors also play a role in dyspareunia. Everyone has a different social environment, so it is important to consider your unique circumstances and how they may play a role in your sexual enjoyment.

Potential social factors:

• Relationship happiness
  
• Societal pressure
  
• Societal guilt and shame with sexuality
  
• Friends and family and their relationships
  
• Perceptions about how sex should be
  
• Perceptions about how relationships should be
  
• Fidelity issues
  
• Aging issues: kids leave home, parents aging, etc
  
• Money matters
  
• Work and career pressures
  
• Lack of privacy
  
• Religion
  
• Culture

Conclusion

Sexual pain is complicated. It’s a combination of so many different factors and thus, everyone is different. Oftentimes these factors play back on one another. For example, you feel pain with intercourse, this makes you feel embarrassed, then this causes a decrease in relationship happiness, then the embarrassment and relationship issue both cause more sexual pain. It’s a vicious cycle. Tackling the roots of the issue is the first step in helping to treat sexual pain. An examination at the doctor’s can help determine if there are any physical conditions that may be causing the dyspareunia. At the office, a history can also help you and your gynecologist work together to figure out why you may be experiencing pain. Most of all, it is important to know that you are not alone in feeling pain with intercourse. Not even close. And, there is a way that we can help.

References

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Seehusen, D.A., Baird, D.C., Bode, D.V.Dyspareunia in women. Am Fam Physician. 2014 Oct 1;90(7):465-70.
Heim, L.J. Evaluation and Differential Diagnosis of Dyspareunia.
Am Fam Physician. 2001 Apr 15;63(8):1535-1545.
ACOG. Female Sexual Dysfunction. ACOG Practice Bulletin 119. 2011.