When "Ouch!" Replaces "Ooh!" - Understanding Pain During Sex and What to Do About it

Though unfavorable, it’s common for almost every woman or person assigned female at birth (AFAB) to feel pain or discomfort during sex. Experiencing painful sex once or occasionally is ‘normal’ and usually due to, well, the occasion: inadequate foreplay, a new position, a larger partner. But for some women, painful sex is a chronic and persistent problem that can have far-reaching consequences on sexual, emotional, and mental health as well as relationships.

Among other things, painful intercourse can lead to decreased sexual satisfaction, fear and avoidance of sex, psychological stress and feelings of inadequacy, negative feelings about body image, and a decrease in sexual desire and arousal. How does painful sex affect relationships? Even strong couples with healthy communication habits might find a breakdown in communication over this issue and experience relationship tension that builds to become emotional disconnect and discord.

Painful intercourse, also known as dyspareunia, is a condition characterized by persistent or recurrent pain experienced by women during sexual activity, including non-penetrative sex. This discomfort can occur before, during, or after sexual activity and can vary in intensity. Pain is never fun, and this is especially true when it accompanies an activity meant to be pleasurable. Sex should feel good for men AND women. And just because painful sex is common, women don’t have to accept it as their norm.

Painful sex usually has an identifiable cause and usually is treatable. So, if you’re experiencing pain or discomfort during sex, it’s important to seek support and treatment. A thorough history and exam can often reveal a cause and illuminate a treatment. Sex can still be quite stigmatized and talking openly about this subject still proves to be an uncomfortable exercise for many people, women and men alike. But it doesn’t have to be.

Potential cause of pain during sex

Painful sex can have various causes, and it’s important to identify (along with your care provider) any underlying factors that might shape treatment. Here are some of the most common physical and psychological causes of painful sex:

Vaginal Dryness

Dryness is one of the most common causes of painful sex, and it can occur at any age for many reasons. Besides making sex uncomfortable, dryness can also disrupt the vagina’s balance of healthy and unhealthy bacteria, which can cause an infection. (This also causes painful sex.) Dryness happens for several reasons, including inadequate foreplay, decreased sexual desire, medications, relationship problems, anxiety, breastfeeding, and birth control. Perimenopause and menopause deserve special consideration since these phases are when the majority of women experience painful sex. The reason? The significant hormonal drop (especially estrogen) during this time in life can cause vaginal atrophy or thinning and shrinkage of vaginal tissue.

Infection

Many STIs can cause pain with sex, including chlamydia, gonorrhea, and genital herpes. Other common vaginal infections include: yeast infections, bacterial vaginosis (BV), UTIs, and vaginitis. If you have an infection, you will likely have other symptoms, such as discharge and itching.

Endometriosis

Endometriosis is caused by uterine (endometrial) tissue growing outside of the uterus in other areas of the pelvis, such as the ovaries and fallopian tubes. Endometriosis often makes sexual activity painful, especially with deep penetration.

Vulvodynia

Some women suffer from chronic pain of the vulva, which can cause generalized burning, stinging, soreness, itching and, of course, painful sex.

Vaginismus

Vaginismus occurs when the muscles surrounding and inside the vagina spasm. Sexual activity often triggers a tightening of the vagina that makes penetration difficult and painful.

Vaginal Injury

Injury or previous vaginal trauma can cause painful sex. Some common injuries include: recent childbirth, pelvic surgery, past sexual trauma, and accidents.

Interstitial Cystitis

Also known as painful bladder syndrome, this condition often causes symptoms that mimic a bladder infection, including pain, pressure, and frequent urge to urinate.

Pelvic Floor Dysfunction

Weakened or damaged pelvic floor muscles – the ones you tighten when trying to stop urinating suddenly – can cause several annoying and unwanted conditions, including incontinence, constipation, pelvic organ prolapse, and painful sex.

Ovarian Cysts and Uterine Fibroids

These fluid-filled sacs on the ovaries and non-cancerous growths on the uterus can cause heavy periods, pelvic pain and pressure, and painful intercourse.

Past Trauma

In response to past physical and sexual trauma, some women develop an increased sensitivity to pain or coping mechanisms, like muscle tightening, to counteract intrusive thoughts and feelings associated with the trauma they experienced. Clearly, this can make sex difficult and painful in physical and emotional ways, but many trauma survivors find comfort in talking to a therapist or counselor about their experiences and symptoms.

Stress and Anxiety

Emotional stress and anxiety can lead to muscle tension and pain with intercourse.

Relationship Issues

Unresolved conflicts and emotional distance between partners can contribute to dyspareunia.

Medical Treatments

Certain medical treatments, such as radiation and chemotherapy, can have side effects that impact sexual function and cause pain.

Allergies or Irritants

Allergic reactions to products like latex condoms, spermicide, or feminine products can cause irritation and pain during sex.

Ways to prevent pain during sex

The list of potential causes of painful sex is long. Thankfully, there are just as many strategies women can use to prepare their bodies and minds for sex beforehand. Great sex requires instinct and creativity, but it also demands planning and routine. It requires foreplay AND forethought. And this is especially true if one partner is experiencing pain or discomfort with sex. So, let’s look at a few strategies that might be useful in preparing for sex while also exploring lifestyle and health tips to promote overall sexual health and wellness.

Prioritize Foreplay

Surveys say both women and men want more foreplay. So, this is a great place to start! While there is no perfect amount or type of foreplay, sex experts generally recommend 20-30 minutes of foreplay – kissing, touching, cuddling, sharing a fantasy, sensual massage, or really any words or actions that promote safety, intimacy, and connection.

Lubricate

Buy a good lube and use it. Lots of it. Early and often. Not only can lubricant be a fun part of foreplay, it also reduces friction and enhances sensitivity and comfort. Water-based and silicone-based lubes are most popular, but there are oil-based and hybrid models that work wonders as well. Do your research and be picky. Your body and sex life deserve it!

Strengthen Your Pelvic Floor

Pelvic floor exercises, like kegels, can strengthen and tone muscles in the pelvic region, which can reduce pain during sex. Even some fitness classes are paying more attention to exercising the pelvic floor. As always, check with your physician before beginning an exercise routine.

Relax

Or at least try to. Put away your phone and to-do list and focus on being present with your partner. Take a bath or shower, listen to music, practice mindfulness, or do whatever works for you to put your body and mind in a more relaxed, less distracted place.

Communicate Openly and Honestly

One of the best ways to improve a sexual experience is by talking openly with your partner about your feelings, concerns, and anxieties related to painful sex. Establishing a supportive and understanding environment is crucial and checking in during sex is important too.

Experiment with Positions

Certain sexual positions may be more comfortable than others. Experimenting with positions that allow for better control over depth and angle can help minimize pain.

Explore Non-penetrative Intimacy

There are so many ways to give and receive pleasure during sex that don’t involve penetration. Study up! And go for it. This can help maintain emotional and physical connection without causing pain.

When to see a doctor

Seeking medical advice and understanding for painful sex is a critical and proactive step toward identifying, addressing, and resolving underlying causes of pain. Medical professionals can also rule out any serious conditions and provide education about sexual health, anatomy, and contributing factors.

Diagnosing and treating painful sex involves a comprehensive approach that includes a thorough medical history, a physical exam (including a pelvic exam), and additional testing. Besides taking a detailed sexual health history and performing a pelvic exam, your provider might order blood tests (to assess hormonal imbalances), take vaginal cultures (to rule out an infection), do imaging studies (to assess pelvic organ health), order allergy testing, and recommend a procedure to evaluate and treat endometriosis.

Treatment for painful sex depends on the underlying cause(s), and many women who experience pain with sex follow a personalized treatment plan that involves a combination of strategies, potentially including:

Topical Treatments

Vaginal estrogen therapy might improve dryness in perimenopausal and menopausal women while lubrication can be helpful for any woman experiencing dyspareunia. Lidocaine or another prescribed numbing agent may be recommended to alleviate pain and discomfort, especially for women suffering from vulvodynia or a vaginal injury.

Antibiotic or Antifungal Medications

If an infection is identified, antibiotics or antifungals might be prescribed to treat the underlying cause.

Physical Therapy

Pelvic floor physical therapy involves exercises and techniques to relax and strengthen pelvic floor muscles, which can be beneficial for vaginismus and pelvic floor dysfunction.

Surgical Intervention

Certain cases of endometriosis or structural abnormalities might require surgery to remove scar tissue and address anatomical issues.

Counseling or Sex Therapy

For psychological factors contributing to painful sex, counseling or sex therapy might be recommended to address emotional concerns, trauma, and relationship issues. Additionally, cognitive behavioral therapy and some medications can be useful for people experiencing anxiety, depression, and other mental illnesses impacting sex.

Lifestyle Changes

Making lifestyle changes, like managing stress, eating a healthy diet, staying hydrated, and getting regular exercise can have a positive impact on pain and overall sexual health.

Turn our "Ouch!" into "Ooooh!"

Painful sex is a complex issue that requires understanding, patience, and proactive efforts. It can have profound effects on a person's sexual health and relationships. So, seeking professional help, fostering open communication, and exploring appropriate treatments are essential steps toward addressing the physical and emotional aspects of this condition. Preparing your mind and body for sex when it’s painful involves a combination of physical and psychological strategies, including extending foreplay, practicing self-compassion, strengthening your pelvic floor muscles, making lifestyle changes, and counseling.