Around 20% of women will experience painful sex at some time during their lives. Many women never seek help, either because they think it’s normal to feel pain or because they’re not sure who to ask. Pain during sex is not normal, and in most cases is completely curable.
So says Dr Careen Rascher, a sexual medicine expert and psychiatrist. In this article she explains everything that you need to know about painful sex, medically termed dyspareunia and how to cure it.
Why Does Painful Sex Occur?
Painful sex may be due to:
- physiological or,
- psychological causes.
“Women who experience pain during intercourse describe their pain in different ways. Some women experience superficial pain at the opening of the vagina when penetration is initiated. Other women feel pain deep in the pelvis during thrusting or deeper penetration,” Dr Rascher Explains.
She adds that: “Determining whether the pain is superficial or deep is important to understanding what may be causing the pain.”
- Some women have always experienced pain with intercourse from their very first attempt.
- Other women start to feel pain after an injury or infection, or cyclically during menstruation.
Painful Sex Can Be A Catch 22
Dr Rascher examines the cycle of painful sex more closely:
- When sex hurts, women are distracted from feeling pleasure and don’t become normally aroused.
- Without arousal, lubrication and vaginal dilation do not occur.
- When the vagina is dry and not dilated, penetration is more painful.
- Fear of being in pain can make the pain worse.
- Even after the original source of pain has disappeared, many women still feel pain simply because they expect to.
“Medical causes of painful sex far out weigh psychological ones. However, more often than not they occur simultaneously,” she notes.
Dr Rascher shares a few examples:
- fear of pain,
- feelings of guilt or shame
- ignorance of sexual anatomy and physiology is surprisingly common,
- fear of pregnancy,
- relationship difficulties and
- traumatic experiences earlier in life
“In our cohort at My Sexual Health Clinic only 2,5% of patients experiencing painful sex had a purely psychological cause. In all other cases a medical cause was found,” shares Dr Rascher.
Common medical causes
Dr Rascher shares a few examples:
- hormonal imbalances, and
- tissue injury
- pelvic inflammatory disease
- lower genital tract infections like candida, chlamydia, and particularly herpes,
- urinary tract infections
“Although the last two tend to cause a more superficial pain. In most cases this pain is short lived and resolves with treatment of the infection. Pelvic inflammatory disease causes deeper pain with intercourse. Endometriosis also causes deep pelvic pain with sexual intercourse,” says Dr Rascher.
“Frequently, painful sex is caused by the hormonal imbalances that occur during a woman’s lifetime,” Dr Rascher explains.
- Estrogen deficiency causes sexual pain related to vaginal atrophy.
- Low estrogen is common in women taking the oral contraceptive pill, those who are breastfeeding, and postmenopausally.
- Estrogen deficiency is associated with lubrication inadequacy which leads to painful friction during intercourse.
“Any form of tissue injury may cause sexual pain,” Dr Rascher notes. She shares a few examples:
- Pain is common after childbirth if there has been an episiotomy or tearing.
- Even after an uncomplicated delivery sex may be painful if tried too soon.
- Similarly after gynaecological surgery or radiation therapy painful sex is common.
- Female genital mutilation is seen in some cultures and this has multiple long term sequelae including sexual pain.
Dr Rascher shares the anatomical causes of sexual pain:
- A retroverted uterus usually causes deep pain during sexual intercourse.
- Hymenal remnants can cause painful sex, however, it’s usually not necessary for a hymenectomy to be performed.
- Painful bladder syndrome, formerly called interstitial cystitis. In this instance, women may develop bladder discomfort during or after sex.
- Provoked Vestibulodynia.
“Provoked Vestibulodynia is a common but infrequently recognized cause of painful sex. This is characterized by a painful sensation in the vestibule which is elicited by a non painful stimulus. This condition can be debilitating and women typically seek help from multiple medical practitioners before a correct diagnosis is made and appropriate treatment initiated,” says Dr Rascher.
How To Receive An Accurate Diagnosis?
Dr Rascher explains: “In the assessment of painful sex the primary goal is to identify the underlying cause or causes of the pain and treat accordingly, for example treatment of an infection, or hormone replacement. In addition we need to identify possible psychological problems or relationship difficulties.”
She recommends going straight to an expert in sexual medicine and discussing the importance of a multidisciplinary approach. Even though an expert may charge more, they will give you an accurate diagnosis the first time around.
Dr Careen Rascher
Dr Careen Rascher is a Sexual Medicine expert and Psychiatrist. She recently became a Fellow of the European Committee of Sexual Medicine, and has started consulting patients with sexual problems at the Wits Donald Gordon Medical Center. Her practice is called My Sexual Health. Here she works with a multidisciplinary team which includes doctors who are specialists in sexual medicine, pelvic floor physiotherapists and psychologists or sex therapists.