When sex hurts

Sex isn’t the easiest subject to talk about. However, while most people consider it a private matter, few topics rival it for public attention. Sex is both surrounded in mystery and intensely analyzed, often creating unrealistic expectations.

When something that is supposed to be pleasurable is instead uncomfortable, it can be doubly difficult to discuss. Painful sex, or dyspareunia, is more common than you think. According to one survey, close to 10 percent of women between 50 and 59, experience pain during intercourse. And more than 40 percent of women of all ages experience some sort of sexual difficulty.

Many factors such as anatomical changes, low estrogen levels, pelvic muscle problems, and relationship issues can lead to dyspareunia. In fact, it often results from interaction of factors. This is why talking to your doctor is important. He/she can help put the pieces of the puzzle together and come up with a solution.

Understanding the pain

Dyspareunia is persistent or recurrent genital pain that occurs just before, during or after intercourse that causes distress. The pain can be primary, meaning you’ve always had pain with sexual encounters, or secondary, meaning it developed after previously pain-free intercourse. You may have pain every time or just under certain circumstances.

The pain associated with this condition is typically divided into superficial (entry) pain, deep pain, or both. Most women with dyspareunia complain of superficial pain, which occurs upon penetration. It may be associated with:

• Inadequate lubrication, often caused by not enough foreplay or, especially in later life, by low estrogen levels.

• Inflammation or infection in the genital area or urinary tract.

• Injury or trauma such as from an accident, pelvic surgery or childbirth or a congenital abnormality.

• Involuntary spasms of the vaginal wall (vaginismus).

• Inadequate relaxation of pelvic floor muscles due to discomfort or stress.

• An improperly fitted diaphragm or cervical cap.

• An allergic reaction to birth control methods, such as foams, jellies or latex.

• A skin disorder such as eczema or lichen sclerosus, in your genital area.

Deep pain usually occurs with deep penetration and may be more pronounced with certain positions. It may be due to a number of factors, including:

• Inadequate relaxation of pelvic floor muscles.

• Pelvic organ prolapsed in which your bladder or uterus may slip through your vagina.

• A retroverted uterus, in which your uterus is positioned at an uncomfortable angle.

• Illnesses such as endometriosis or pelvic inflammatory disease.

• Infection of your cervix, uterus or fallopian tubes.

• Scar tissue or a tumor.

• Changes caused by radiation therapy.

Emotions are usually deeply intertwined with sexual activity and may play a role in pain. Underlying psychological factors might include mental stress, relationship problems, concerns about body image or fear of intimacy. Your pelvic floor muscles are very sensitive to these types of stress.

Most women with dyspareunia don’t have a history of sexual abuse, but abuse may also play a role. Sometimes, it can be difficult to tell whether psychological factors are a cause or result of dyspareunia. Initial pain can lead to fear of recurring pain, making it difficult to relax, which can lead to more pain.

Pain at midlife

The leading cause of dyspareunia after the age of 50 is thinning of vaginal tissue and loss of elasticity (vaginal atrophy), resulting from a drop in estrogen levels after menopause. Thinning vaginal tissue can make lubrication more difficult. In addition, your vulvar tissue may thin after menopause, exposing more of your clitoris. Greater exposure may reduce your sensitivity or cause an unpleasant tingling or prickling sensation when you are touched in this area.

Certain illnesses and their accompanying treatments can also affect sexual comfort. Diabetes can cause decreased lubrication, as well as more frequent vaginal and urinary tract infections. Cancer treatments, such as radiation and chemotherapy, can cause vaginal thinning and inflammation, as can the breast cancer drug tamoxifen. Scarring and fibrosis from surgeries that involve the pelvic area can sometimes cause tissue distortion, resulting in pain during vaginal penetration.

A number of medications can inhibit desire or arousal, which can decrease lubrication and make sex painful. These may include antidepressants, high blood pressure medications, and sedatives.

Getting your pain evaluated

If you have recurrent pain during intercourse, talking to your doctor is the first step in resolving it. After identifying the cause of your pain, you can pursue appropriate treatment. If your doctor is unable to address your concerns, ask for a referral to an appropriate specialist.

A medical evaluation for dyspareunia usually consists of:

• A medical history. Your doctor may ask when your pain began, where it hurts, how it feels, and if it happens with every sexual encounter. He/she may also inquire about your history of surgery and childbirth, and your sexual relationships.

• A pelvic examination. During a pelvic exam, the doctor generally checks for signs of skin irritation, infection or anatomical problems. He/she may also try to identify the location of your pain through gentle touch of the genital area and pelvic muscles, and a speculum examination of the vagina. If the prospect of an exam is uncomfortable for you, your doctor may give you a small dose of sedative beforehand to relax your pelvic floor muscles. In addition, you and your doctor should agree that testing be stopped at any time if it becomes intolerable.

Help is available

For physical conditions that may be contributing to your pain, treating the underlying cause may resolve your problem. Your doctor may also suggest changes in your medications to see if they’re affecting your sexual health.

For most postmenopausal women, dyspareunia is caused by inadequate lubrication resulting from low estrogen levels. Often, this can be treated with vaginal estrogen therapy. This typically comes in the form of a cream, tablet or flexible vaginal ring. Other forms of hormone therapy may also help.

Longer foreplay can help stimulate your natural lubrication. It may help to delay penetration until you feel fully aroused. A water-based lubricant, such as KY jelly and others, or a moisturizer, may also help. So can changing positions. If you’re on top, you usually have more control over penetration. If you haven’t had sex for a while, talk with your partner about taking it slowly to minimize your pain, or opt for other ways to be intimate.

Other measures include techniques to help desensitize your genital area to pain and relax your pelvic muscles. A physical therapist can help you learn vaginal muscle relaxation exercises that are often key to decreasing pain. Treating other physical factors that lead to poor muscle relaxation such as incontinence, hemorrhoids, or hip or spine problems is also important. In addition, minimizing psychological stress is helpful in achieving muscle control.

Last but not the least, sex therapy can assist you in breaking the cycle of negative response to sexual stimulation. Sex therapy may include an evaluation of your relationship and your medical and psychological health, and a focus on improving communication with your partner, addressing body-image problems, or practicing techniques to decrease anxiety and better enjoy the intimacy of a sexual experience.