Are you experiencing pain when you have sex?

If so, you’re not alone. It is estimated that 3 out of 4 women will experience painful sex at some point in their lives. That’s a whopping 75% of women that occasionally (or maybe often) experience pain with intercourse.

One of the most disturbing facts about sexual pain is that it is still not completely understood by most doctors. That means if you mention this pain to your doctor, you might see that your doctor is dismissive, tells you that you’re over anxious or stressed, or simply says that pain is an unfortunate reality as you age. This is a tragic set of responses because you really shouldn’t have to experience pain with sexual intercourse.

Why do I have pain with sex?

Painful sex is known as dyspareunia, but this is a “catch-all” word that is used to describe any type of sexual pain regardless of why the pain is actually occurring. The following terms are descriptions of specific causes for sexual pain. Knowing the specific causes can help you better understand where your pain is coming from.

Provoked vestibulodynia (PVD): This term describes sexual pain that originates from the entrance to the vagina. Women who experience PVD could have a number of different medical conditions at play, but they all find that the pain is centralized in the vulvar vestibule (the entrance to the vagina). While there are several causes, the most common reasons for women to experience PVD are hormonal changes, tight pelvic floor muscles, and an increased amount of nerve endings in the vestibule.

Hypertonic pelvic floor muscle dysfunction: This condition is also sometimes called vaginismus. When a woman has this condition, she will experience muscle spasms around the vagina, bladder, and anus which can cause pain with vaginal penetration. If the spasms are happening often or are intense enough, you can also experience constipation and trouble with urination.

Vulvar and vaginal atrophy: This condition is due to hormonal changes in the female body. With menopause, the decrease in estrogen and testosterone can result in a thinning of the vaginal walls. This can lead to dryness, irritation, tearing and pain. The elasticity of the vagina shrinks and there can be a narrowing to the opening of the vagina. Lubrication during foreplay can take longer than it did in the past.

Vulvar and vaginal skin disorders: The vagina as well as the skin of the vulva can be quite susceptible to inflammatory skin conditions which can lead to pain.

Interstitial Cystitis (IC): Women with IC, (painful bladder syndrome), will find that they have issues with frequent urination due to inflammation of the bladder lining. Sex can be quite painful and can lead to an even greater frequency of urination.

Endometriosis and/or Chronic Pelvic Pain: With endometriosis, the uterine tissue grows outside of the uterus which can cause severe pain throughout the month that can increase with sexual activity.

Generalized Vulvodynia: This is most often caused by tight pelvic floor muscles and injury to the pudendal nerve. This condition causes women to experience vulvar pain even in the absence of trying to have sex.

Gastrointestinal Conditions: Two gastrointestinal conditions that can cause painful sex are irritable bowel syndrome and ulcerative colitis.

Pudendal Neuralgia: This is a condition that occurs when the pudendal nerve has become damaged. This nerve is responsible for carrying sensations from the external genitals, the lower rectum, and the perineum to the brain.

Other chronic pain issues: Even non-vaginal pain disorders can make sex painful. For instance, chronic pain anywhere in the body can mean significant discomfort no matter what positions you try. Jason Graves at My Beloved is Mine, vulnerably shares his marriage story and how he and his wife handle the pain in their sexual relationship due to a hysterectomy and fibromyalgia. His article is a must read if you and your spouse are in this category.

Non-medical reasons for pain with sex.

While the medical conditions listed above will require going to a doctor and getting treatment outside of a counseling relationship, I don’t want to neglect telling you that sometimes, sexual pain can be caused by non-medical issues. In these cases, getting some education about sexuality and seeking counseling can bring about some highly positive changes in your marriage.

Anxiety: Severe anxiety or stress related to sex can cause sexual pain for women, particularly early in their marriage. If a woman is a virgin when she marries and she heard friends or family talking about sex as painful, she may find that the anxiety that sex might be painful can actually cause her to experience pain. The fear basically becomes a self-fulfilling prophecy. Women with anxiety disorders can find that sex is painful because they can’t calm their thoughts or feelings before making love.

Inadequate Foreplay: Many women need about 10-15 minutes of active foreplay for the vagina to be ready for sex. If adequate foreplay and lubrication is not happening, the vagina is unlikely to lubricate properly which can make sex painful. Sometimes, when women have experienced painful sex in the past, they will shy away from foreplay because they would rather “get it over with” in regards to sex. But rushing through sex can actually make it more painful.

Treatment options to consider.

1. First of all, see a medical provider. In particular, if the descriptions of any of the medical conditions sounded familiar to you, talk to your gynecologist about possible treatment options. Look for a doctor that specializes in women’s health and who understands the complexity of working with female sexual pain.

2. Consider seeing a pelvic floor specialist. Pelvic floor specialists work with women experiencing painful intercourse and can help you understand where the pain is coming from and what steps to take to work on healing. They’ll tell you specific treatments that will be helpful based on the location of your pain and when your pain occurs.

3. Communicate, communicate, communicate. Make sure that you are speaking openly to your spouse. Let your husband know that the pain exists and work together to seek treatment. If your spouse is not supportive or fails to understand how sexual pain is impacting you, ask your spouse to seek counseling with you. A certified sex therapist will understand the dynamics of sexual pain and how your relationship is impacted, and can provide you with tools and strategies for staying bonded in the midst of the sexual difficulties.

4. Expand your sexual repertoire. Sex really isn’t just about vaginal penetration. There are other ways to engage in sexual intimacy with your spouse other than just penile-vaginal penetration. You can watch this five minute video where I answer a reader question about painful sex and offer tips for expanding your sexual repertoire.

5. Adjust your self-talk. Lower self-esteem and negative self-talk are two ways that sexual pain impacts a woman. It is natural to wonder if you’re being a good wife or what it will mean to your husband if you can’t have sex. But, go back to point four (expanding the sexual repertoire) and feed yourself true messages. “My husband loves me. My husband wants to work with me so that I get well. My husband didn’t marry me just for sex. While sex is not what we want it to be right now, I can still enjoy my husband’s body and he can enjoy my body.”

6. Refuse to give up on your marriage. While a lack of penetration can feel like a sexless marriage, please know that research actually shows that you can still feel quite connected when you both have the right perspective. For tips on feeling more connected when penetration isn’t possible check out Chris Taylor (of the Forgiven Wife)’s posts on the subject here and here.

7. If you haven’t grabbed your copy yet, you can check out my free guide with tips for increasing overall intimacy in your relationship. While there is a focus on sexual relating, there are also tips for loving one another well and for becoming better friends.

8. Consider actually working with a sex therapist that can help you focus on both healing from sexual pain through talk therapy while also helping you improve your relationship overall. You can learn more about sex therapy here.

9. Check out my favorite book on this subject, “When Sex Hurts: A Woman’s Guide to Banishing Sexual Pain” by Drs. Goldstein, Pukall, and Goldstein. They list the following five reminders in the introduction:
   –Sex should not hurt.
   –Sex should feel good.
   –Sex should occur when and how you want it.
   –Sex should be part of a healthy relationship.
   –Sex should not be the centerpiece of a healthy relationship.

You can read more about their five fundamental truths and learn techniques for ridding yourself of pain by following the treatments outlined in their book. (By the way, the link for the book is an affiliate link. If you decide to purchase through the link, it costs you nothing, but helps me support my chocolate addiction.)

Their book gives you tips for talking to your doctor so you can better explain what’s going on with your pain. The more prepared you are to talk about exactly what is happening in your body, the more likely it is that your doctor will be able to help you.

Please know that painful sex does not mean that you are going to lose your relationship. Work on improving the pieces that you can work on now (communication, conflict resolution, and just generally feeling more connected) while you seek out the specific treatments for sexual pain.

Praying God’s greatest blessings on you, your marriage, and your sex life.

Be well, friend!

Dr. J.