Women are too often indoctrinated at a young age to believe that sometimes sex is painful as if it is some inevitable part of intimacy and the sexual experience. Think about every movie you’ve ever seen when a woman has sex for the first time: the wincing look on her face as her partner (usually a man) tries to penetrate. While pain with sex is a pretty common occurrence among women, it is absolutely not normal. Reports on the prevalence of women who experience painful sex are estimated at 3 to 18% globally, and lifetime estimates range from 10 to 28% (Weijmar Schultz). That means nearly 1 in every 3 women will experience painful sex at some point in her life. But if or when that happens to you, there are factors that you should keep in mind so that you can foster a better sex life with pleasurable, pain-free sex.
What follows is an introduction to female sexual pain. This is not to suggest that other people can’t experience pain, but for the purposes of our discussion and for the sake of brevity we will focus today primarily on women who experience painful sex. I hope in reading this, women better appreciate their anatomy and their right to engage in sexual activity without the worry of pain.
Terminology
Dyspareunia is the medical term we use for painful sex. Traditionally, this has referred to women who experience pain during intercourse with a man. Dyspareunia is divided into two subcategories: superficial dyspareunia and deep dyspareunia. Superficial dyspareunia refers to pain experienced with initial penetration, while deep dyspareunia describes pain with deeper penetration. More recently, some have broadened the idea of dyspareunia to include other types of sexual activity that can cause pain including anodyspareunia (pain experienced during anal sex) and ejaculatory/orgasmic dyspareunia (pain experienced with ejaculation and/or orgasm).
Women often describe superficial dyspareunia as a raw, burning, scratchy, electric, and/or searing pain. It is not uncommon to hear women use phrases like, “It feels like sandpaper” or “It’s like a hot poker when I have sex.” Sometimes women will report pain with initial penetration more as like “hitting a wall.” If you’ve ever experienced anything like any of these, this is not normal. Deeper dyspareunia is referred to differently. Mostly it is described as an achy sensation, but women can also experience stabbing like pain.
Anatomy
Understanding the relevant genital anatomy can help elucidate the cause of dyspareunia, so let’s take a minute to highlight your most important private parts. Many women (and sadly, their providers) do not appreciate the unique tissue compositions of the female genital tract. Allow me to underscore the areas that deserve special attention:
- Vulva – The most external part of the female genital tract. This includes the labia majora/minora and the clitoris.
- Vestibule – A thin rim of tissue between the vulva and vagina, which is adjacent to the urethra and home to major and minor glands that secrete lubricating fluid. The vestibule is often overlooked or passed by during routine pelvic exams, but it is one of the most common sources of pain.
- Vagina — The most internal part of the genital tract; an elastic, muscular canal with a soft, flexible lining that provides lubrication and sensation.
Aside from these three crucial genital tissues, the muscles of the pelvic floor often play a key role in dyspareunia. Collectively referred to as pelvic floor muscles, these are a confluence of many different muscles that help support our pelvic organs and facilitate activities like urination, defecation, arousal, and ejaculation. Women who experience dyspareunia often have some underlying pelvic floor muscle dysfunction (more on this later).
Hormones
When discussing painful sex and thinking of ways to nurture a healthy sex life, one should always think about hormones. Two hormones specifically, testosterone and estradiol, are extremely important at maintaining the health of your private parts. As women age and approach menopause these hormones often decline. Younger women, for a variety of reasons, can have deficiencies in these hormones as well. And when you’re deficient in testosterone and/or estradiol, your genital tissues suffer. They become easily aggravated from even minimal stimulation and chronically inflamed.
Let me pause for a minute to explain the difference between these two hormones. Testosterone is incorrectly referred to as the male hormone. But healthy women have testosterone in abundance. It is responsible for the development of external male genitalia and the equivalent structures in the female. In women, testosterone is crucial for maintaining bone health, promoting cognitive function, decreasing body fat, building lean muscle, sustaining sex drive, and supporting the health of the genital tissues. Estradiol, commonly referred to as the female hormone, is synthesized from testosterone and is important for vascular health, body fluid homeostasis, and emotional well-being. It too is paramount to genital tissue health.
The clitoris and vestibule are extremely sensitive to testosterone levels. Women with testosterone deficiency can develop atrophy (or degeneration) of these areas. When tissues are atrophied they become irritated and often painful to the touch. Because the vestibule sits at the entryway to the vagina, the area gets stimulated with attempted penetration. If the vestibular tissue is atrophied, then that stimulation will feel like the burning, raw pain we discussed previously. Moreover, women with clitoral atrophy will frequently report increasing difficulty with orgasm because the clitoris is less arousable in its atrophied state.
The vagina needs both estradiol and testosterone to remain healthy. Menopause is a stage in life when women stop producing these two hormones. As a result, the vagina (and vulva and vestibule) atrophies. This can lead to decreased lubrication and a decrease in elasticity, which can make sex hurt.
Causes of Painful Sex
Painful sex can be caused by a number of different conditions. Each of the conditions has unique characteristics and can present in a variety of different ways. Now that you have some basic knowledge of terminology, anatomy, and hormone physiology, we can explore the various causes of dyspareunia together.
Vulvodynia is a condition that describes pain confined to the vulva. In practice, however, it is mistakenly used as an umbrella term to describe any kind of genital pain. Chronic vulvar pain is fairly common with estimates around 16% (Harlow 2003). Certain dermatological factors can cause vulvodynia—conditions like dermatitis, lichen sclerosis, fungal infections, and sexually transmitted infections. Neurological conditions like pudendal neuralgia, chronic damage, or irritation of the pudendal nerve, can also cause vulvar pain. Trauma from things like childbirth or sexual abuse can also lead to vulvodynia.
Vestibulodynia is a pain condition confined to the vestibule. As I alluded to previously, the vestibule is one of the most ignored, yet common sources of dyspareunia. The vestibule is unique because of its abundance of androgen (testosterone) receptors and mucous-secreting glands as well as its proximity to the urethra. It is also a tissue that exhibits localized pro-inflammatory responses. Because of this, women with vestibulodynia may experience diffuse tenderness, sometimes with associated urinary symptoms such as burning with urination, urgency, and/or frequency. Women with vestibulodynia also tend to report chronic difficulty with lubrication. Vestibulodynia can be caused by a hormonal problem, whether that be due to menopause of the use or synthetic hormonal therapies like oral contraceptive and morning-after pills or treatments used for IVF. Recurrent urinary tract or yeast infections and certain auto-immune conditions can also lead to vestibulodynia. There is even a form of vestibular pain that women can be born with that involves an overgrowth of nerve endings, a condition called neuroproliferative vestibulodynia.
Vaginismus involves the involuntary contractions of the pelvic floor, particularly the muscles surrounding the vaginal opening. These contractions interfere with or prevent vaginal penetration and often lead to pain. Vaginismus is a fairly common problem with an estimated 5-17% experiencing this condition (Pacik). It doesn’t necessarily always have to do with intercourse either; vaginismus can also occur with insertion of tampons, during gynecological exams, with finger penetration during masturbation or foreplay, and with the use of vibrators or vaginal dilators.
Certain pelvic disorders are another common cause of painful sex. They can include endometriosis, adenomyosis, irritable bowel syndrome, pelvic inflammatory disease, ovarian cysts, etc. Almost all of these conditions involve hypertonic (extremely tight) or dysfunctional pelvic floor muscles. Pelvic disorders and concomitant pelvic floor muscle dysfunction are often to blame for deep dyspareunia but they can present with a multitude of other symptoms as well including painful or irregular menses, painful urination or defecation, abdominal bloating and nausea, chronic fatigue, constipation, and diarrhea, and even infertility.
Treatments
Thankfully many of the conditions we’ve discussed have reliably good treatments once the diagnosis has been made. Treating dyspareunia often requires a comprehensive, multimodal approach that should be tailored to a woman’s specific situation. If there are signs or symptoms associated with a hormone problem, specific hormonal therapies can be life-changing. If a problem with the muscles or connective tissue of the pelvic floor is discovered, physical therapy can be helpful. If a woman endorses a history of psychological, emotional, physical, or sexual trauma, then psychotherapy—both cognitive-behavioral and dedicated sex therapy—may be an important component of treating her pain. Acupuncture and mindfulness can be helpful. Vaginal dilators and vibrators may be useful and over-the-counter gentle lubricants like this one can help lessen your discomfort.*
Final thoughts
Yes, dyspareunia is experienced by a lot of women. But that in no way makes it normal or something you have to live with. As the incomparable George Michael once said, “Sex is natural; sex is good.” But if there’s one point I hope you’ve learned from all this is that there is one thing sex should never be: painful.
*ASTROGLIDE Glycerin & Paraben Free water-based lubricant is safe for use on toy surfaces including: silicone, rubber, plastic, glass, and stainless steel.
Weijmar Schultz W, Basson R, Binik Y, Eschenbach D, Wesselmann U, Van Lankveld J. Women’s sexual pain and its management. J Sex Med. 2005 May;2(3):301-16.
Harlow BL, Stewart EG. A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am Med Womens Assoc (1972). 2003 Spring;58(2):82-8. PubMed PMID: 12744420.
Pacik, Peter. Understand and treating vaginismus: a multimodal approach. Int. Urogynecol J. 2014; 25:1613-1620.