What doctors wish patients knew about pain during sex

AMA News Wire

What doctors wish patients knew about pain during sex

Aug 30, 2024

Experiencing pain during or immediately after sexual activity—known as dyspareunia—is a condition affecting many women, yet it remains a topic often shrouded in silence. This medical issue, which can affect both physical and emotional well-being, is more common than many may realize. Understanding and addressing this condition is crucial for promoting overall sexual health and quality of life.

Dyspareunia can affect men and women, but it’s more common in women. Pain during or after sex can affect about 10–20% of women in the U.S. This may be a low estimate, though, as many women don’t seek medical help for painful sex and therefore underreporting is likely.

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The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.

In this installment, Amber Savells, MD, an ob-gyn in Paducah, Kentucky, at Baptist Health, took time to discuss what patients need to know about pain during or after sex. Baptist Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

It happens during or after sex

“Dyspareunia is any time women report pain with intercourse,” Dr. Savells said, noting it can also “be defined as anytime there is pain with sexual activity because that doesn’t always involve a partner.”

It is typically painful during sex but can also “include time immediately following that, so in the next several minutes, not a day or two later. That would be something else,” she explained.

Keep an eye out for these symptoms

“Symptoms can be external irritation—around the clitoris or around the opening of the vagina—but a lot of the time it is inside the vagina,” Dr. Savells said. “And that can be with initial contact or foreplay, or it can be with penetration.

“Some patients can even specifically differentiate the difference between pain that occurs as soon as a partner tries to enter versus that which occurs from deep thrusting,” she added. “Being able to provide these kinds of details to your doctor can help them determine the cause.”

Menopause is a main cause

“The causes of dyspareunia include the thinning of skin and lack of estrogen that both occur with aging as women go through menopause,” Dr. Savells said. “This is very common. Probably about 40% of all menopausal women say they have difficulty with their intercourse, their intimacy.

“That can be due to both vaginal atrophy—which is thinning of the skin—and it can also be due to vaginal dryness,” she added. “A lot of women have both of those, but they are two distinct problems.”

There are other causes

“Patients who have pain with intercourse can also have muscle spasms in the muscles around the vaginal wall. These muscle spasms can cause pain with sex but can also be a cause of chronic pelvic pain that is unrelated to intimacy,” Dr. Savells said. “If they’ve had a painful intercourse experience in the past, it can cause them to be tense because there’s fear that pain will occur again.”

“It can be due to just stress and anxiety. Or it can be due to post-traumatic stress disorder from a previous traumatic event, such as assault or rape,” she said. Vaginismus, which is an involuntary tensing of the vagina that is often experienced at the start of sex, while inserting a tampon or while getting a pelvic exam, is another reason.

“Some patients can also have pain with sexual activity due to a skin condition called vestibulitis, which is an irritation of the skin at the posterior portion of the vaginal opening,” Dr. Savells added. “Unlike several of the other skin changes which can cause sex to be painful, this condition is often treated with surgery instead of topical creams.”

“Less commonly, some patients can have scar tissue from previous surgeries to their labia or their vagina. And yet another cause for dyspareunia can be an enlarged uterine fibroid, which can also cause pain with intercourse,” she said. “There are even some bladder conditions that can cause pain with intercourse.”

Additionally, “some patients as they get older will have something called vaginal stenosis or vaginal narrowing and the same vagina that worked with that partner 10, 15 years ago is now too small,” Dr. Savells said, noting patients will say, “I’ve got the same partner, why don’t we fit together anymore?”

“It’s because the vagina is actually getting smaller,” Dr. Savells said.

Dyspareunia is also common for women post-pregnancy if they had a traumatic vaginal birth or issues with prolapse.

Vaginal dryness is a concern

“Stress, anxiety and depression can all cause patients to have difficulty with the arousal component of their sexual function,” Dr. Savells said. “But as far as pain goes, a lot of times that’s due to the dryness.”

For example, “a lot of patients with cancer will have dryness due to their chemotherapy or other treatments they’ve had,” she said. “If patients have had pelvic radiation for uterine cancer or cervical cancer, they may have dryness and pain due to that.

“They may have scar tissue due to that, but even patients who’ve had chemotherapy for nongynecologic reasons can have a lot of vaginal dryness as a side effect of their medication,” Dr. Savells said.

Treatments vary depending on cause

“There are a lot of things that we can do to help patients who are having pain with sex. I don’t ever want anybody to feel like it’s their fault or they’ve created the problem,” Dr. Savells said. One of the most- common causes is “when a woman is having problems because they are estrogen-deficient. Lack of estrogen is the definition of menopausal and for most women, that is about 50 years old.

“But there are also much younger women who are also estrogen-deficient; if they have had an early hysterectomy or if they have had breast cancer and had to have their ovaries taken out,” she added. “For most women who are estrogen deficient, the primary thing we start with is estrogen cream. There are women with contraindications to estrogen therapy, however, so it is essential for patients to consult with their physician about whether or not this is appropriate for their individual situation.”

“If your vagina is out of estrogen, you just add back more estrogen. And for a lot of women that is very effective and fixes their problem,” Dr. Savells said. “There are also nonhormonal therapies for vaginal dryness and vaginal atrophy, so we have options even for those women who cannot take estrogen replacement too.”

For example, Dr. Savells’ practice has a MonaLisa Touch laser, which she said is “super effective.”

“Mona Lisa Touch treatments include lasering of the vaginal tissue and the tissue that surrounds the vaginal opening on the outside. As a result, all the skin in the treated area becomes thicker and stronger. This helps those women lubricate more-naturally when they become aroused, and also reduces the microscopic tears which cause many women to feel a burning sensation after sex,” she said. “For both pre-menopausal or estrogen deficient women, these treatments can be very beneficial. For patients who have vaginal spasms, pelvic floor therapy is helpful for them.

“But therapy is not a quick fix,” Dr. Savells added. “For immediate help, sometimes those patients will get injections into the muscles around the vagina to help relax those muscles so that they don’t spasm and have so much pain.”

“We also utilize compounding pharmacies to make vaginal suppositories that have muscle relaxers in them to help relax those muscles,” she said. “And sometimes patients will insert a vaginal suppository with a muscle relaxer in it a little while ahead of when they anticipate intercourse might happen. That will help relax them a little bit so that they don’t have as much discomfort.”

“For someone who has a condition called vestibulitis, which is a specific type of irritation in the skin at the posterior portion of the vaginal opening, surgery is necessary. Fortunately, this is a relatively minor procedure and simply involves excision of superficial skin in the affected area,” Dr. Savells said. “Sometimes I’ll see patients who just need a little bit of help, they’ve just had a little bit of narrowing and a very short course of dilator therapy, from four to six weeks, gets them back to where they want to be.”

Dilator therapy is a treatment that is used to gently stretch and expand your vaginal tissue over time. This improves its elasticity and reduces the pain you may feel during sexual intercourse.

“If your pain with intercourse is due to uterine prolapse or the uterus falling down, then a hysterectomy may be necessary,” she said.

It can affect your mental health

“Lots of women feel insufficient in their relationship at home. A lot of women feel less sexy or attractive and it causes significant relationship conflict in some households,” Dr. Savells said. “So, it’s kind of the chicken-and-the-egg discussion.”

“For some people, the anxiety, stress, a previous trauma, history of PTSD can lead to pain with intercourse,” she said. “And then for some patients, some other medical condition was the initial culprit of the pain with intercourse.

“But because of that, now they have anxiety or depression or feel like they’re less than,” Dr. Savells added.

Try pelvic floor physical therapy

“I’m a huge fan of pelvic floor physical therapy,” Dr. Savells said, noting that “physical therapy is great for patients whose pelvis floor muscles have gotten too relaxed as they get older and they may be having urine leakage, some stress incontinence, things like that.

“But it’s just as helpful for patients whose muscles are too tight, which is really where it plays into this discussion,” she added. “So, those patients with vaginismus—where they have lots and lots of tension in their pelvic floor muscles—a physical therapist is good at helping them learn to relax those muscles.”

“We don’t pick how we exhibit our anxiety or our stress or our attention and some patients just tend to have a lot of tightness in their pelvic floor muscles just like other patients report neck tightness or stiffness,” Dr. Savells explained. “A physical therapist can help patients learn to isolate those muscles—it’s not intuitively obvious—and help them learn to be intentional about relaxing those pelvic floor muscles.”

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Continue treatment to prevent return

If dyspareunia is treated appropriately, the pain “shouldn’t recur as long as the patient is continuing their treatment,” Dr. Savells said. “Patients have had really good success. If they get the right diagnosis and the right treatment, most of them don’t have problems again as long as they maintain their therapy.”

For example, some “menopausal women will use their estrogen cream, get better and then feel like they are cured, and they will quit using their cream. Then a year later the problem comes back,” she said. “In the beginning it’s hard to convince people this is a chronic thing. This is your new normal.”

Set realistic expectations for sex

“If you surveyed thousands of women, about 40% of them across the board will say that they have concerns about their sexual function,” Dr. Savells said. “But a lot of times, especially in younger women, they have concerns that their body isn’t quite normal because of what they’re comparing themselves to or their partner is telling them that their sex drive is not as good as it should be, that their frequency of intercourse is not as good as he would like for it to be.”

“A lot of their concern about their sex life has to do with setting realistic expectations for them, reassuring them that their anatomy is normal, that their sexual frequency is in fact normal despite what television or social media tells them,” she said. “So, about 40% of women will say that they have sexual concerns, but only 15% of women have true sexual dysfunction, which means it’s interfering with their ability to perform—they can’t have intercourse, they don’t enjoy intercourse.”

Include your partner in the process

“If someone’s doing dilator therapy, that can involve a partner. If you’re doing marital therapy or sex therapy, obviously those involve a partner,” Dr. Savells said, noting “sometimes partners are affected by a woman’s treatment course in other ways, although not directly involved. If a patient requires gynecological surgery for her painful intercourse, then she will be required to abstain from sexual activity for a period of four to six weeks. This is a great opportunity for a partner to be emotionally supportive of her feelings and sexual health.”

“It’s important to include them in the communication so that they understand why this is hurting. A lot of times, it’s often important for patients to reassure their partner that it’s not you,” she said. “Men are often very affected by this problem as well because as soon as the woman is feeling pain, she’s withdrawing a little bit and not as eager to initiate sexual contact. … So, it very much becomes a problem for both of them.”

Don’t be embarrassed

“This should be something that your gynecologist is super comfortable having a conversation about,” Dr. Savells said, noting that “I probably have this conversation multiple times every day, so don’t be embarrassed.”

“Your gynecologist should be super comfortable talking to you about your sex life, the parts that are good, the parts that are bad, the parts that need improvement,” she said. “We have lots of options for how to help.”