Is Painful Sex Affecting Your Relationship?

The journey from “ahh” to “ouch” is unwelcome but not uncommon. Studies talk about millions (3-18 per cent worldwide) who are battling pain during intercourse. The agonising sex eventually makes you avoid intimacy, straining relationships and eroding your quality of life. But making love shouldn’t be a wrestling match; getting sore isn’t an option, right?  Breaking the silence over discussing dyspareunia (pain during sex) with your partner should be an excellent kick-off for you. Stay with us as we walk you through dyspareunia and the reasons for it. 

Let’s define dyspareunia in the simplest way. Pronounced as 'dis-Pah-ROO-nee-uh', it is the recurrent or persistent pain that one experiences before, during or after having sex. The pain may linger or subside right after. 

Usually seen in women, painful intercourse can be an issue in men too. The biggest aftermath of this 'not-so-discussed' bedroom problem is likely to be the mental anguish and poor self-image related to it. 

Dyspareunia can be superficial and deep or primary and secondary. 

Superficial dyspareunia is limited to the vaginal entrance (vulva), but the deeper variation affects the innermost areas of the vagina and the lower pelvis region. It happens only after deep penetration. 

Moving on, if you feel discomfort right from the beginning of intercourse, then it is termed primary dyspareunia, but if the pain starts after some time, then it is termed secondary.

If you have been having pain in and around your vulva for three months or more, with or without sexual intercourse, then science terms it as vulvodynia. Though used interchangeably by many, dyspareunia is distinctly different from it. Vulvodynia has no apparent aetiology, whereas we can pinpoint causes for dyspareunia.

Figuring out the root cause of dyspareunia is key to treating it. From physiologic issues in the pelvis and topsy-turvy hormones to emotional upheavals, painful sex has many reasons. Some of the causes of dyspareunia include:

• Structural Issues in the genitilia: Dyspareunia can stem from various anatomical and physiological issues, including pelvic floor muscle dysfunction, uterine retroversion, hymenal remnants, and pelvic organ prolapse.
• Vaginal dryness (lack of lubrication): This is common in reproductive years and can result from hormonal surges or sexual arousal disorders. The use of contraceptives in reproductive-aged females or poor estrogen levels in post-menopausal women can contribute to this issue.
• Endometriosis: A condition where the internal tissue of the uterus are seen outside the uterus. Endometriosis-related deep dyspareunia may result from indirect contributors like bladder or pelvic floor dysfunction too.
• Skin problems and infections: Inflammation from regular skin issues like lichen planus, psoriasis, etc can affect the genital region. Infections in the region, such as urethritis, vaginitis and pelvic inflammatory disease, can also make sex painful.
• Postpartum trauma: Dyspareunia after childbirth is often linked to the trauma of the vaginal entrance during delivery or apprehension due to healed episiotomy. 
• Vaginismus: This condition, more common in younger women, involves involuntary pelvic floor muscle contractions during attempted vaginal penetration, hindering penetrative sex and causing pain. It can stem from pelvic floor dysfunction or deep-seated psychosocial issues like sexual abuse history.
• Overlap with other pain syndromes: Dyspareunia and vulvodynia (pain in the vulva with or without penetrative sex) may overlap with other conditions such as irritable bowel syndrome (IBS), fibromyalgia, etc.

Underreporting is the most significant pain point with pain during intercourse. Despite its prevalence, dyspareunia is considered a physical drawback, with many women not discussing it with healthcare providers. Here are some red flags to look out for if you've been experiencing painful intercourse for a while. 

For instance, you might feel like the penis, tampon, finger, or toy is" hitting a wall," a barrier inside the vagina that stops anything from going further in. If pushed further, it initiates a stinging ache. This barrier is a contracted pelvic floor muscle inside the vaginal canal, causing vaginismus, a cause of painful sex.

The main symptom of dyspareunia is pain related to intercourse. However, the timing may vary. Some people may feel pain upon penetration (entry pain), while others may feel discomfort during deeper penetration or thrusting (deep pain). Knowing when the pain occurs is vital in diagnosing the condition.

The intensity of dyspareunia pain can range from mild discomfort to severe agony. None should be ignored. 

The pain can interfere with sexual enjoyment and intimacy, impacting the overall quality of life. Assessing the severity of pain is critical to strategising the investigations and the treatment plans.

If you have been suffering from transient or persistent pain during intercourse, it is best to navigate if you have related comorbidities. Here we are pointing to issues that you may already have, like endometriosis, vaginal infections (such as vaginitis), hormonal imbalances (leading to vaginal dryness or atrophy), psychological factors (such as anxiety or history of sexual trauma), or the need to see a gynaecologist right away. 

A medical assessment for dyspareunia typically includes:

• Comprehensive medical history: Your healthcare provider may inquire about the onset of your discomfort, its location, sensation, and its occurrence with different sexual partners and positions. They may also explore your sexual history, surgical background, and childbirth experiences. It's essential to answer truthfully without letting embarrassment hinder you, as these inquiries offer insights into the underlying cause of your pain.
• Pelvic examination: During this procedure, your healthcare provider examines for signs of skin irritation, infection, or anatomical abnormalities. They may gently apply pressure to your genital and pelvic muscles to pinpoint the source of your pain. Additionally, a visual assessment of your vagina may be conducted using a speculum to separate its walls. It's worth noting that some individuals experiencing painful intercourse may also find pelvic examinations uncomfortable. You have the right to request the cessation of the exam if it becomes too painful.
• Further tests: If your healthcare provider suspects specific causes of painful intercourse, they may recommend additional assessments, such as a pelvic ultrasound.

Options for treatment vary depending on the cause of the pain. If an infection or medical condition is found to be a factor in your discomfort, addressing the underlying cause could potentially alleviate your symptoms. Furthermore, adjusting medications that may be causing lubrication issues could also help alleviate your symptoms.

Some therapies that don’t involve medicine might also help with painful intercourse:

• Desensitisation therapy: In this therapy, you learn vaginal relaxation exercises that may ease pain.
• Counselling or sex therapy: Even after receiving treatment, if you've experienced prolonged painful sex, you might develop negative emotional associations with sexual stimulation. If you and your partner have avoided intimacy due to this discomfort, it may be necessary to work on communication and rebuild sexual intimacy. Consulting with a counsellor or sex therapist can aid in resolving these concerns. Cognitive-behavioural therapy is particularly useful in altering negative thought patterns and behaviours.

• Change positions: If you experience sharp pain during thrusting, experimenting with different positions, such as being on top, may help. This position allows you to control penetration depth, potentially reducing discomfort.
• Communicate: Openly discussing what feels good and what doesn't with your partner is important. If you require a slower pace, communicate this need.
• Don't rush: Engaging in longer foreplay can enhance natural lubrication, potentially reducing pain. Consider delaying penetration until you feel fully aroused.
• Use lubricants: Utilising a personal lubricant can enhance comfort during sex. It may be helpful to try various brands until you find one that suits you.

Explore alternative intimacy: While vaginal penetration remains painful, exploring varied forms of intimacy with your partner can be beneficial. Activities such as sensual massages, kissing, and mutual masturbation offer enjoyable alternatives to intercourse that may be more comfortable and fulfilling.

Though the focus of painful sex is on women, men too can suffer from similar conditions. Wayne JG Hellstrom, MD and Kenneth DeLay, MD, said in an article that “studies have reported that approximately 1 to 5 per cent of male patients suffer from pain with sexual intercourse. However, because of the social stigma associated with male sexual disorders, underreporting appears to be common.” 

Pain during sex in men primarily happens due to issues in the foreskin, penile yeast infections, STDs (sexually transmitted diseases), an episode of UTI (urinary tract infection), or more.

Medically reviewed by:

Dr Shilpy Lakhtakia, Obstetrician and Gynaecologist