Is it normal for sex to be painful?

No, sex should not be painful.  Pain with sex is called dyspareunia and is a symptom that has many different causes.  The pain can be felt in different sites: just at the entrance to the vagina; only with deep penetration, in certain positions; or everywhere.  People use lots of different words to describe what they feel – stinging, tearing, stabbing, dryness, friction, cramping, pulling, aching, and many others.  The pain can be difficult to describe or locate.  Some people have pain at the beginning of sex that gets better after they finish, but others find the pain begins after they stop having sex and lasts for hours or days.  Orgasm might make the pain worse.

Could the pain be due to not being ‘turned on’ or not having enough natural lubrication?

Sometimes the main problem is inadequate arousal – not enough foreplay or not feeling ‘turned on’.  The skin of the vulva and vagina is sensitive and has lots of nerve endings.  Many changes occur in the vulva and vagina during foreplay to make it more comfortable to put something inside the vagina.  More blood flow goes to the labia and clitoris, making them bigger and a bit firmer.  Vaginal fluid increases to provide some lubrication.  The pelvic floor muscles relax and upper vagina enlarges.

People have to get to know their own bodies to know which activities make them feel ‘turned on’ and help them to achieve orgasm.  Many people find that masturbation with or without toys is the best way to find out what they like.  Once they know themselves, they can explain to or show their partner what works for them.  A good and caring partner will be interested in how to give pleasure and avoid pain.

It is common that the natural vaginal fluids do not provide enough lubrication for sex to be comfortable or fun.  There are a couple of options if this is the case.  If condoms are needed to protect against sexually transmitted infections or pregnancy, choose a water-based or silicone-based lubricant.  There are many brands on the market, but you will need a lubricant with a low osmolality.  Test the product out beforehand on other skin to make sure it doesn’t cause a reaction.  Oil-based lubricants work well for people who don’t need to use condoms (see Vulval care advice).  Avoid perfumed and dyed products.  Lubricants are NOT a replacement for foreplay with a gentle and knowledgeable partner.

Is menopause the cause of my pain with sex?

During the perimenopause and after menopause, oestrogen levels go down. Oestrogen helps the vulval and vaginal tissues to be more elastic, thicker, and have more blood flow.  All of these things improve comfort during sex.  After menopause, it is common for people to feel that their skin is dry or fragile.

Vaginal oestrogen creams or pessaries help prevent or reverse these changes.  Oestrogen applied into the vagina is safe for nearly everyone with minimal absorption into the bloodstream.  So, it is a possibility even for people who have had blood clots or cancer in the past.  If your doctor does not have experience in this area, seek out an opinion from someone with a special interest in sexual health and menopause.  The low-dose vaginal pessary sometimes is not strong enough to improve the vaginal skin.  Some people need higher doses of creams or pessaries. Other people need to combine these with system-wide hormone replacement to improve their menopausal symptoms.  Again, guidance from an expert can help to find the combination that works for you with the lowest level of risks or side effects.

There has been a lot of discussion about vaginal laser devices.  Companies that make these machines say they have a similar effect on vaginal tissues as oestrogen.  Doctors who buy these machines might recommend laser procedures instead of creams or pessaries.  Right now, there are not enough studies of the laser device to know if it is a safe and effective way to deal with menopausal changes to the vagina.  It is not clear if it offers any benefit over oestrogen.  It is also unknown how long any effects might last, and how lasered skin responds to future injuries or surgeries.  There are some people who wish to go ahead with laser without long-term studies and full safety information.  At the moment, it seems the best candidate for laser is someone with normal skin whose vaginal symptoms disappear while they use oestrogen creams/pessaries, but they want to stop those medications.

Doctors who own a laser machine may recommend it for many other problems, like urine leakage or lichen sclerosus or painful sex.  Right now, there is no science to back up the use of laser in these situations.  If you see someone who recommends a laser procedure for pain during sex, seek out a second opinion from an expert in vulval conditions.  People can spend a lot of money on a procedure that does NOT help their symptoms and might cause them harm.

Vaginal moisturisers like Replens are another option for people with a sensation of dryness after menopause.  These have to be used regularly.  If they don’t improve symptoms, see your doctor to find out if something else might be going on.

What skin problems cause or contribute to painful sex?

Any vulval skin condition can cause pain with sex.  Often, this is the first symptom people experience after they develop a skin problem.  This is especially common in lichen sclerosus, lichen planus, psoriasis, and chronic candidiasis (see information sheets).  If people keep trying to have sex with an untreated skin condition, this may cause skin tearing and lead to nerve and muscle pain.  Heat, moisture, friction, and sweat may cause flares of the skin problem.  So, it is important to avoid sex until the condition is under control.

If you see a doctor or women’s health nurse about pain with sex, they should take a close look at the skin.  They might also take a swab or biopsy if they think the skin might be a cause of symptoms (see Biopsy).  If there is a skin problem, focus first on treating that before considering invasive things like surgery or laser.  Often, the pain goes away once they skin issue it sorted out.

What nerve and muscle problems cause or contribute to painful sex?

Nerve and muscle problems are probably the most common reason for painful sex.  These can occur at any age and in healthy people with no medical problems.  Many different things that can trigger a nerve or muscle problem.  Anything that affects the spine, hips, coccyx, legs, or feet can cause a problem with the nerves and pelvic floor muscles (see Pelvic floor anatomy).  Injuries to these areas are common and can occur through car accidents, repetitive strain in the workplace, falls, broken bones, uneven weight-bearing, unequal leg lengths, spine curvature, favouring one side of the body over the other, horseback riding, long-distance bicycling, and many other activities.  Other things that may cause nerve and muscle pain include pregnancy and childbirth, pelvic and vulval surgeries, traumatic sex, recurrent urinary tract infection, vulvovaginal skin conditions, and recurrent vaginal or pelvic infection.

Some people are born with nerves that send more pain signals than is necessary to keep us out of harm’s way.  People born with overactive pain nerves might have had issues with headaches or abdominal pain as a child.  As a teenager they might discover they can’t use tampons because of pain during insertion.  They might find they can’t wear tight jeans or use a bicycle.  Then, when they try to have sex they might discover it is not possible due to pain.  This is a distressing situation and can produce anxiety about relationships and the ability to have a baby.

What pelvic organ problems cause or contribute to painful sex?

Pain felt in the abdomen with deeper penetration may be due to an issue with the pelvic organs.  These include the uterus and cervix, tubes and ovaries, bowel, and bladder (see Pelvic anatomy).   People with pelvic organ problems often have other symptoms, like painful periods, pain or bleeding with bowel motions, urinary urge, pain or bleeding with urination, or a change in their vaginal bleeding pattern.

Pelvic infection is a common cause of painful sex.  Often there is an abnormal discharge and a change in the bleeding pattern.  It can occur at any age and can happen even if people haven’t had sex for many years.  Pelvic infection can happen any time the cervix opens more than usual.  This includes having a biopsy of the uterine lining (endometrial biopsy), placement of an intrauterine device, miscarriage, abortion, childbirth, and procedures like hysteroscopy with dilation and curettage.  Pelvic infection can also occur in association with bacterial vaginosis, mycoplasma, chlamydia, and gonorrhoea.  Sometimes pelvic infection has mild symptoms and lingers for months after the event that triggered it.  Pelvic infection often does not show up on an ultrasound and vaginal swabs may be negative.  Doctors might think there is a urine infection, but culture of the urine is negative.  The best way to diagnose a pelvic infection is to do an internal examination.  If there is pain with movement of the pelvic organs, there may be a pelvic infection.

Endometriosis can also cause pain with deep penetration.  People with endometriosis often have years of painful periods.  They tend to feel better if on medication that prevents their period.  People with endometriosis often develop nerve and muscle issues due to ongoing pain, previous surgeries, and related bowel and bladder problems.  Surgery to remove endometriosis deposits can help some people’s pain, but usually needs to be combined with other treatments like hormonal medications, nerve pain medications, and pelvic floor physiotherapy.

What treatments are available for painful sex?

The first step is to not have painful sex.  The next step is to take good care of the vulval skin (see Vulval care advice).  Then, it is important to find out what might be causing or contributing to the problem.

Skin problems need to be diagnosed so the correct treatment can be given.  Sometimes this means seeing an expert in vulval conditions.  It is not a good idea to apply lots of different creams hoping something will work.  If a doctor or nurse doesn’t take a look and just tells you to buy something at the chemist, get an opinion from a doctor with an interest in sexual health or the vulva.  Products like antifungal and oestrogen creams do more harm than good unless you have the conditions they are designed to treat.  Anaesthetic gel (lignocaine) may cause problems by tempting people to attempt sex even though their condition has not been treated.

Nerve and muscle problems usually require a combination of treatments.  If there is an underlying issue, like unequal leg lengths, that should have specific treatment.  Nerve pain tablets, like amitriptyline, gabapentin, and duloxetine, gradually turn down the volume of pain signals going to the brain.  The goal of pelvic floor physiotherapy is to identify and resolve pelvic problems through techniques like breathing exercises, active relaxation, behavioural changes, TENS machines, vaginal trainers, and internal physiotherapy work.

Pelvic organ problems require treatment based on the diagnosis.  Pelvic infection requires 2 weeks of broad-spectrum antibiotics.  Endometriosis usually needs a hormonal control like the progesterone-releasing intrauterine device, progesterone rod or injection, or continuous combined contraceptive pill.  Some people need surgery, but this should be done by a surgeon with expertise in endometriosis.  It is usually better to avoid having multiple laparoscopies because each additional surgery may be more difficult, carry higher risks of injuries to vital organs, and increase the likelihood of nerve pain.  Non-surgical treatments are often needed for nerve, muscle, bladder, and bowel issues that accompany endometriosis.

What is a Fenton’s procedure?

A Fenton’s procedure involves making a vertical (up and down) cut at the posterior fourchette, where the labia minora join at the back (see Vulval anatomy).  This cut is sewn together horizontally (side the side).  This idea behind this procedure is to enlarge the vaginal entrance.  It is usually done under general anaesthetic in the operating theatre but can be done with local anaesthetic in the rooms.

If the vulval skin is normal, a Fenton’s procedure is unlikely to help with painful sex.  It does not help underlying nerve and muscle issues.  Some people are told they have scarring at the posterior fourchette, or that they were sewn together ‘too tight’ at the time of childbirth.  Vulval specialists often see people who were told this, and when they take a look they find out the vulval anatomy is normal.  It is also common for people to have no change in their symptoms after a Fenton’s procedure.  If someone recommends this procedure, seek an opinion from a vulval expert.

Lichen sclerosus or lichen planus can cause scarring at the posterior fourchette.  In this situation, the most important thing is to apply enough topical steroid ointment to that area.  This may soften scarring and allow tissues to release on their own.  Applying gentle pressure with the fingers or a vaginal trainer might help over time.  Your vulval specialist may direct you in how to do this.  If this is not enough to relieve the scarring, the specialist might suggest a minor procedure to release it.  This may or may not require any stitches.  It is vital to use plenty of steroid ointment until everything is healed, have close review with the doctor who did the procedure, and continue with a steroid ointment regimen so scarring does not re-form.

Should I see a physiotherapist?

Physiotherapists are experts in the structure of the human body and its movement.  They are a vital component to the care of many different conditions, including recovery from sports injuries, rehabilitation after surgery, pain management, and coping with chronic medical conditions.  The philosophy of physiotherapy is to look at the whole person and develop a holistic plan that incorporates lifestyle, posture, day-to-day movements, use of aids and appliances, exercises for relaxation, strength, and flexibility, and much more.  Pelvic floor physiotherapists do additional study and training in this area after they qualify as a physiotherapist.

Many people with pelvic and sexual pain benefit from seeing a pelvic floor physiotherapist.  Some say it is the thing that brought them the most relief.  Your physiotherapist will listen to your story and ask questions about bowel and bladder activities, sexual function, medical problems and surgeries, emotional well-being, and your fitness routine.  They examine you and this usually includes an internal examination.  They consult with you about a plan to improve your symptoms and then follow your progress over time.  The people who enjoy the most benefit from physiotherapy are those who commit to making changes in their activities and lifestyle and doing the exercises regularly.

Should I see a psychologist or a sexual counsellor?

There are many issues that come up as a result of painful sex.  It can cause relationship difficulties, problems with self-esteem, depression, anxiety, a feeling of not being a ‘real woman’, questions about gender identity, and concerns about fertility and childbirth.  Some people are in relationships that are not supportive or caring, and they have sex out of fear or obligation.  Some people have trauma during their lifetime that impacts on relationships and sexuality.  People might also feel so busy and stressed that they are not able to ‘let go’ and relax during sex.

Psychologists are trained to help people with these issues.  Sexual counsellors have expertise in dealing with anxiety around sex and can guide people to activities and experiences that make them feel safe and give them pleasure.  If sexual problems persist after medical issues have been diagnosed and treated, it is important to find a psychologist or sex counsellor you trust.  Mindfulness, meditation, regular exercise, good sleep, and healthy diet help to achieve the goal of a rewarding sexual life.

How do I know if I am better?

If people have pain only with sex, and they avoid sex during treatment, they might be unsure about how treatment is progressing.  A good place to start is to apply a soothing oil or ointment and touch the vulva gently with the fingers or a vaginal trainer.  This lets people know where they can be touched without pain.  They can use that knowledge to start exploring activities with a partner.  Checking in with a doctor or physiotherapist provides information about how things are going.  Sometimes it seems like progress is slow, but with time they notice improvements.

Before trying penetration, make sure it is possible to insert a trainer, toy, or fingers without pain.  Choose a situation that is relaxed and spend plenty of time on foreplay.  Use a familiar lubricant that will not produce any reaction.  Choose a position that allows control over the direction and depth of penetration.  If unsure about how to do this, consult with a sex counsellor or pelvic floor physiotherapist.