Painful sex, known medically as dyspareunia, can have a variety of causes. Most affect women of all ages, although some women experience its onset during or after menopause. A variety of conditions, including endometriosis and a thinning of the vaginal wall, can be to blame — and sometimes, the pain has no discernible cause.
The pain can range from the discomfort of vaginal dryness to painful pelvic contractions or burning vulvar pain during penetration. Physical causes range. A lack of arousal or low estrogen can cause vaginal dryness and soreness. Infections or inflammation can lead to painful contractions of the pelvic muscles or burning pain during penetration. Birth control pills have also been linked with vulvar pain and uncomfortable intercourse.
Endometriosis, which is thought to affect up to 11 percent of American women of reproductive age, can be the culprit. In a nationally representative 2012 survey, 29.5 percent of women with endometriosis reported dyspareunia, too. The condition, which causes the cells that line the inside of the uterus to grow in other parts of the body, can cause bleeding, stabbing pain or cramping that can last for days after sex.
Other women experience vulvodynia: genital pain that burns, stings or throbs and makes sex uncomfortable or impossible. Although it’s correlated with past vaginal infections and pelvic floor weakness, the disease is still not well understood and there is no known cause. Treatments range from psychological interventions to pelvic floor therapy and vestibulectomy, a surgery that removes painful tissue along the vestibule, which surrounds the openings of the vagina and urethra.
A history of sexual trauma is also linked to painful intercourse, including genito-pelvic pain or penetration disorder. Previously known as vaginismus, the condition can involve painful vaginal spasms when something enters the vagina and is thought to be caused by a fear of penetration.
For many women, painful sex begins with menopause. During menopause, the ovaries produce less estrogen, the hormone that helps ensure vaginal lubrication and keep the lining of the vagina flexible and thick. Decreased estrogen can cause painful dryness, thin the vaginal walls and even shrink vaginal tissue. Those changes are known as vaginal atrophy. Vaginal estrogen therapy can help; so can vaginal moisturizers and the use of silicone-based lubricants during sex.
Azmia Magane, a 34-year-old social worker from Orlando, experienced painful intercourse early in her marriage. A variety of symptoms made sex challenging and, often, impossible. During and after sex, pain would shoot through her abdomen or radiate from her bladder. Sometimes, uterine polyps led to painful bloating after sex. And vaginal dryness made seemingly pleasurable acts feel more like torture.
In Magane’s case, endometriosis, polyps and other chronic health challenges were to blame. Vaginal dryness was one of the biggest obstacles between her and physical intimacy with her new husband, she says. “It just feels like shards of glass,” Magane says. “It’s very, very uncomfortable.”
Painful intercourse can affect self-esteem, body image and relationships. But despite its prevalence and importance, says Leah Millheiser, its highly personal nature means it can go unspoken and untreated. Millheiser, a clinical assistant professor at Stanford University and director of the female sexual medicine program there, says social taboos can get in the way of diagnosis and treatment.
“Some people are just uncomfortable talking about that area,” she says.
No matter the cause, self-esteem and relationships can start to hurt along with sexual intercourse. In a 2014 survey, 58 percent of postmenopausal women with vaginal discomfort said they avoid intimacy; 78 percent of their male partners agreed. Thirty percent of women surveyed said vaginal pain caused them to stop having sex entirely.
“It has caused some strain on my relationship,” Magane says. “It can really destroy your self-confidence.”
Silence in the doctor’s office can make matters worse, delaying treatment or causing women to seek out unproven treatments on their own.
“[Doctors] need to learn to step outside of our comfort zone and really address the issue of sexual function with our patients,” Millheiser says.
The conditions that can make sex painful are common — vulvovaginal atrophy, for example, affects up to 50 percent of postmenopausal women. Yet only 7 percent of women receive treatment for the condition.
Women who experience uncomfortable sex may also feel uncomfortable bringing up their complaints during a routine appointment. Doctors can share that discomfort, or not think to ask about sexual health, Millheiser says.
They can also minimize or ignore symptoms of sexual pain. It can take years for patients to receive a diagnosis of conditions that affect sexual health; with endometriosis, for example, patients wait an average of 6.7 years.
That’s what happened to Magane, who experienced excruciating pain, unsympathetic providers, and a botched laparoscopy before she was diagnosed with endometriosis. She recommends that women look for sympathetic providers — and that they insist on answers.
“I know my body,” she says. “I am an expert in my body. [Doctors] may have a medical degree, but I’ve lived in my body for 34 years and I know what’s normal and what is not. Painful intercourse absolutely is not normal — sex shouldn’t hurt.”
Millheiser says women shouldn’t suffer in silence. Patients may not think painful sex is worth bringing up, or worry that they’ll offend their health-care provider by discussing sex.
These days, Magane supplements her treatment with meditation and yoga. She has found some relief through pelvic floor therapy, too. It’s a form of physical therapy that can reduce pelvic pain and make physical intimacy more pleasurable.
“I actually had my husband come to one of my appointments,” she says. “It kind of gave him a visual of what I was going through.”
Although her ordeal has been painful, she says it has reminded her that “intimacy is about more than intercourse. Continuing to nourish the other intimate aspects of your life is important.”
Nonetheless, she says, women should experience everything their bodies are capable of. “Sex is a really important part of the human experience,” she says.
Millheiser agrees. “Sexual health is as important as any other part of your health. It’s about relationships. It’s about self-esteem.”
And luckily, she says, “there are effective treatments out there.”