What is the Cause of Painful Intercourse (Dyspareunia) and How to Avoid It

Dyspareunia is the medical term for the symptom of pain before, during, or after intercourse. It can be divided into superficial or deep, depending on the location of the pain:

• Superficial Dyspareunia – pain at the entrance of the vagina;
• Deep Dyspareunia – pain deeper in the vagina.

There are multiple causes for painful penetration, including physical, psychological, social causes, and more often a combination of them.

Lack of arousal/lubrication

Without arousal and lubrication, any kind of penetration can be painful. Some of the causes for it are:

• Anxiety
• Not enough warm-up;
• Hormonal factors / Medications / Systemic conditions;
• Arousal non-concordance.

Anxiety

Arousal is highly connected with our parasympathetic nervous system, that is related to a state of relaxation. If we are anxious or overthinking, our body is not able to fully relax, surrender and get aroused.

Sexual shame, body image issues, and performance anxiety can get in the way of arousal. And without arousal and lubrication, any kind of penetration can be painful.

Sex-positive sex education, working with sex coaches or therapists, communicating your fears or feelings of shame with your partner can be incredibly helpful in those cases.

Not enough warm-up

It takes time for our body to warm-up and get fully aroused. If we go straight for the genitals, chances are that our bodies will not be fully aroused yet, and penetration can be painful.

Spending time teasing, kissing, exploring different erogenous zones and different forms of sex, such as oral, can be life changing!

Hormonal factors / Medications / Systemic Conditions

Some life phases, such as menopause and after giving birth or while breastfeeding, can cause changes in our body’s hormones, leading to less lubrication and sometimes more fragile (atrophic) skin, with increased risk of tearing and pain. The use of some medications and some systemic medical conditions might also influence on arousal and lubrication.

In those circumstances, slowing down and investing in a lot of lube is fundamental.

 Arousal Non-Concordance

Sometimes, even though someone is turned on, their genitals might not react accordingly. This is called arousal non-concordance. The same way someone with a penis might have an erection without feeling aroused or not have an erection when really wanting sex, people with vulvas might experience the same.

That causes an increased risk of pain during penetration, as the genitals are lacking arousal and lubrication. In those cases, lots of lube, and exploring other ways of pleasure not involving penetration can feel great!

Physical causes/medical conditions

There are many physical conditions that can lead to both superficial and deep dyspareunia. The good news is that most of those conditions can be treated – and if not, there are ways to manage its symptoms, including pain during penetration.

 Superficial Dyspareunia

• Vestibulodynia
• Vaginismus
• Scar tissues after childbirth or surgical procedures
• Lichen Sclerosus
• Bartholinitis
• Different variations of the Hymen
• Female Genital Mutilation
• Congenital Abnormalities

Deep Dyspareunia

• Endometriosis
• Adenomyosis
• Ovarian cysts
• Uterine fibroids
• Bladder inflammation / infection
• Pelvic Inflammatory Disease
• Bowel conditions (e.g. constipation/IBS)
• Uterus/cervical position

 Both Superficial and Deep Dyspareunia

• Vulvovaginitis
• Sexually Transmitted Infections (STIs)
• Pelvic Organ Prolapse
• Overactive Pelvic Floor
• Vaginal Atrophy

While some of the conditions above can be treated with medications or surgery, others can be managed with physiotherapy, psychotherapy, or most often a combination of different therapies by a multidisciplinary team.

There are also different strategies to manage dyspareunia even when a definite treatment isn’t available or is still in progress. Lubricants can make penetration more comfortable and pleasurable, both for people suffering from superficial and deep dyspareunia. If the main symptom is pain on deep penetration, there are silicone rings that can be placed on a dildo or penis to control the depth of penetration. Education around the condition can also be of great help.

If you have been experiencing persistent pain at intercourse, getting a medical evaluation to exclude or possibly treat any medical conditions that might be causing your pain is very important.

A healthcare professional will ask you very important questions to have a better understanding of your condition, such as:

• How long have you had those symptoms for?
• Where in your body do you experience this pain?
• Is there any particular sexual activity or position that worsen the pain?
• Is it associated with any other symptoms, such as vaginal discharge?
• Do you have any previous surgeries, medical conditions, or use any medications?

They might also ask for your consent to perform a pelvic exam, such as a visual inspection of the vulva or assessment of the pelvic organs and pain by using fingers and other instruments such as a cotton swab or a speculum. You can, of course, stop the exam at any point if it feels too much for you.

They can also recommend other tests, such as vaginal or cervical swabs, or pelvic ultrasound.

If you ever experience a sudden, unbearable pain, or pain associated with fever, abnormal discharge, nausea, or vomiting, immediately seek for emergency medical assistance.

Although very common, pain during sex is not normal. There are multiple possible causes for dyspareunia, and many times it is caused by an association of different factors.

If you experience persistent pain during penetration, it is important to be assessed by a healthcare professional to treat any possible conditions associated with it and manage your symptoms.

Remember: sex can and should be a pleasurable experience!

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