11 Common Causes of Painful Sex
At its best, penetrative sex can produce the deepest level of pleasure. But if you have a form of pelvic floor dysfunction called dyspareunia, even the thought of something entering your vagina can cause pain and anxiety. Despite its obscure name, dyspareunia (pronounced dis-puh-ROO-nee-uh) is not a rare disorder — it's estimated that 1 in 5 women in the U.S. experience painful sex at some point in their lives. And given how hard it can be to talk to a doctor about sex, much less painful sex, it's likely that the actual number is much higher.
The impact of dyspareunia extends far beyond the bedroom. It can lead to chronic anxiety, depression, low self-esteem, and poor body image. Uncovering the cause of dyspareunia can be tricky, and it may feel nearly impossible to find a provider who takes your symptoms seriously, much less knows how to treat it. One of the best ways to get care is to work with a pelvic floor physical therapist who specializes in treating painful sex.
At Origin, we've helped hundreds of patients get relief from dyspareunia. If you're reading this and think you may have dyspareunia, don't hesitate to get in touch with us. If you're not ready to book a visit, schedule a free intro call so we can answer your questions and help you plan your next steps.
The Symptoms of Dyspareunia
In the search to get answers about dyspareunia, you may have come across a host of conditions such as endometriosis, vulvodynia, vaginismus, and more. While these are all diagnoses associated with pelvic pain, and sometimes dyspareunia, the nuances can be confusing.
With dyspareunia, persistent pain is typically felt in the vulva, vagina, or pelvic/abdominal areas. Pain can occur before, during, or after penetrative sex — either with a partner or with yourself. The same or similar pain may be experienced while inserting things like tampons or getting a gynecological exam.
Dyspareunia can feel a little different for everyone. It can produce a throbbing or dull ache, a sharp, stabbing pain, or anything in between. Symptoms may occur consistently with initial penetration and then subside, they may continue at a constant level the entire time, or they may even intensify during sex and linger for hours after.
Types of Dyspareunia
Depending on when symptoms first occurred, and where your symptoms are felt, the term dyspareunia can be further classified into superficial or deep dyspareunia, and/or primary or secondary dyspareunia.
Primary vs. Secondary Dyspareunia
The classification of primary or secondary dyspareunia describes when your symptoms started. Your dyspareunia may be described as primary if you had pain during your first experience of intercourse, and that pain stuck around. Dyspareunia is described as secondary if you had a period of comfortable, pain-free sex before your pain developed.
Superficial vs. Deep Dyspareunia
The terms superficial and deep dyspareunia more generally describe where the pain is occurring during sex. Superficial dyspareunia describes pain in the vulva or vaginal entrance (the introitus). Deep dyspareunia describes pain in the deeper vagina or lower abdominal/deep pelvic areas. Each person experiences dyspareunia in a different way. For some, it’s intermittent, while for others the pain is continuous.
11 Common Causes of Painful Sex
Let's get into the why behind the pain of dyspareunia. There isn't one common cause of dyspareunia and there may even be a number of factors that are contributing. Being able to understand the specific cause(s) of your pain will help to inform your treatment options. While dyspareunia can take a big toll on your quality of life, it doesn't have to always be that way. Keep reading for more information about some of the common causes of dyspareunia, and remember that for every cause, there is a way to get better.
Pregnancy and birth put your body to the test. 85% of people that deliver vaginally will experience some amount of injury to their vaginal or vulvar tissues. The scar tissue and muscle injury that remain can often be painful when returning to sex in the postpartum period. In addition to this, as mentioned above, breastfeeding can also contribute to tissue sensitivity and dyspareunia.
Just because you may have had a cesarean section does not mean you escape any risk of developing dyspareunia. Studies on sexual function after a cesarean are limited, but many of the other factors that contribute to dyspareunia in the postpartum period such as breastfeeding, increased stress, lack of sleep, and emotional trauma surrounding birth circumstances may all still be present. Plus, the pelvic floor is often overworked from the physical demands of carrying life for months. Properly caring for your injuries in the postpartum period, managing your scar tissue, and properly rehabilitating your pelvic floor after having a baby can really make a positive impact on your sexual function.
Endometriosis is a medical condition in which tissue that resembles the lining of the uterus (the endometrium) grows outside of the uterus. With endometriosis, the unruly tissue, which is in effect foreign to the body, causes chronic inflammation. This inflammation can lead to an array of issues including scar tissue, intensely painful periods, bowel and bladder issues, and dyspareunia.
With endometriosis, dyspareunia is often felt deep in the pelvis, and pain can intensify as the endometriosis progresses. The muscles in the pelvic floor and abdominal areas are often tender and overactive.
It is important to get to the bottom of your pain so that you can avoid the consequences of chronic inflammation in your body and minimize your pain. This is often difficult with endometriosis. People often aren’t diagnosed with endometriosis in their 30s and 40s, after years of pain and inconclusive doctor's appointments. Unfortunately, endometriosis is often misdiagnosed as conditions like Irritable Bowel Syndrome (IBS), interstitial cystitis (IC), or bladder pain syndrome (BPS).
Thankfully, research on endometriosis is growing, and healthcare professionals are becoming more knowledgeable on how to help. Once you have the proper diagnosis, your doctor can help you start to build your team of helpers, which often includes a pelvic physical therapist to help with any bowel, bladder, or sexual dysfunction.
3. Interstitial Cystitis (IC)/Bladder Pain Syndrome (BPS)
Deep dyspareunia and pelvic pain are sometimes accompanied by pressure in the pelvis and a frequency and urgency to pee. When infection is ruled out, yet bladder symptoms and pelvic pain persist, another diagnosis that may be causing dyspareunia is Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS).
The exact cause of IC/PBS is not well understood, but it is very common for those with IC/PBS to have an underlying pelvic floor dysfunction, which can lead to dyspareunia. Research shows that appropriate physical therapy treatment of this underlying muscle dysfunction can significantly relieve the associated symptoms, including dyspareunia.
4. Pelvic Inflammatory Disease (PID)
According to the CDC, Pelvic Inflammatory Disease (PID) describes infection of the internal reproductive organs. It is more commonly associated with sexually transmitted infections (STI), but can also occur after non-STI infections such as bacterial vaginosis (BV).
With PID, many people are asymptomatic at first but as symptoms progress, one may experience: fever/chills, belly pain, fatigue, heavier and more painful periods, and an unusual and odorous vaginal discharge. Inflammation and irritation of the internal sex organs can lead to pelvic pain and even dyspareunia. Once the infection is identified, PID can be successfully treated, and symptoms of dyspareunia often resolve.
Vulvodynia describes pain that's felt in the tissues of the vulva and isn't related to any another medical condition. The vulva includes the inner and outer labia, the introitus — which is the tissue surrounding the vaginal entrance (vestibule) —the urethral opening, and the clitoris. Vulvodynia affects about 16% of those with natal vulvar anatomy.
The symptoms of vulvodynia can vary. Pain can be felt in all the tissues of the vulva or they can be more localized to specific tissues (pain may only be felt in the clitoris for example). Pain can be present all of the time, only when touched, or both. The cause of vulvodynia is often unknown, but there are effective treatment options ranging from pelvic floor physical therapy and lifestyle changes to medication. With vulvodynia, it is common to also have dyspareunia.
Vaginismus is another pelvic pain condition that describes pain during or before penetrative sex. With vaginismus, there's an involuntary contraction of the outer portion of the pelvic floor muscles in response to anticipated or actual vaginal penetration. This involuntary contraction can prevent anything from being inserted into the vagina and contribute to pain, including a toy, tampon, or speculum. If it sounds a lot like dyspareunia to you, that's because it is. Vaginismus and dyspareunia are very closely-related Genitopelvic Pain/Penetration Disorders (GPPDs).
Just like with dyspareunia, there isn't a clear understanding of what causes vaginismus, but some causal factors may include a history of trauma, assault, or abuse; societal pressure and expectations; and religious beliefs. Thankfully, there are evidence-based treatments for vaginismus, like psychotherapy and the use of dilators combined with pelvic floor physical therapy.
Different infections may cause painful sex, along with symptoms like bloating, itching, bleeding, and others. There are many types of infections (not always caused by sex) that can impact the vagina, including yeast infections, bacterial vaginosis, and urinary tract infections (UTIs).
There are also infections contracted via penetration and touch, like sexually transmitted infections (STIs). Infections like trichomoniasis, herpes, genital warts, gonorrhea, or chlamydia may cause dyspareunia. Treatment of the infection is always the top priority.
8. Skin Conditions
Various skin conditions may also be the cause of dyspareunia. The skin and tissue of the vulva and vagina are very particular and sensitive. Things like laundry detergent, soap, body deodorant, or lotion can easily irritate this sensitive skin and cause dermatitis. The irritation, itching, and swelling in the vulva that go along with dermatitis can certainly be painful during sex.
Skin conditions such as lichen sclerosis and lichen planus can also contribute to dyspareunia. These skin conditions cause rashes and/or lesions and can lead to vulvar itching or burning. At times, these lesions leave painful scarring which may limit the vaginal opening from being able to stretch. Once identified, many of the skin conditions that can cause dyspareunia can be successfully treated.
9. Low Estrogen
The tissues in your vulva and vagina LOVE estrogen. Estrogen helps keep the skin of the vulva and vagina thick, hydrated, and maintains blood flow to the clitoris. When estrogen is low, tissue health is impaired and the skin in the vagina and vulva becomes thin, dry, and inflamed. As a result, the tissues can tear, bleed and cause pain during intercourse. In addition to properly moisturizing these tissues, your physician can help you work on your estrogen levels and optimize sexual function.
It is common to experience dips in estrogen while breastfeeding, when in perimenopause or menopause, when going through or after hormone-dependent cancer treatments, or even while on birth control pills.
10. Gender-Affirming Surgery
Gender-affirming medical care can also lead to dyspareunia. Factors such as the use of hormone replacement therapy (HRT) and the socioeconomic status of patients undergoing feminizing vaginoplasty surgery can raise their risk for pelvic floor muscle dysfunction.
In addition, gender-affirming surgery itself can lead to dyspareunia. The surgery creates a neovagina that doesn’t naturally lubricate itself, which can lead to dryness during penetration and dyspareunia. Also, scar tissue, muscle injury, and engorged erectile tissue around the urethra and vaginal openings can lead to pain.
A neovagina may have less elasticity, meaning that it doesn’t stretch to fit a penis or toy with deep penetration easily. Working with your medical provider and a properly trained physical therapist is critical to improving dyspareunia related to gender-affirming practices.
11. Cancer & Cancer Treatment
There is no doubt that cancer of any kind takes its toll on your entire life, but even after beating it you are often left with side effects of treatment which can impact your life for years to come. With gynecologic and breast cancers, the treatment options can significantly impact your tissue health and pelvic floor muscle function and lead to symptoms of dyspareunia. In a time that should be spent celebrating survival and second chances, you shouldn’t be suffering with dyspareunia when trying to reconnect with your significant other.
Exactly how the pelvic floor is impacted in cervical cancer is not fully understood. The minimal evidence that is available looks at how hormone therapy, surgery and radiation affect the pelvic floor muscle function in the presence of gynecologic and breast cancers.
Unfortunately, the vast majority of patients will experience symptoms of pelvic floor muscle dysfunction long after breast or gynecological cancers are gone. Thankfully, there are helpful, conservative treatment options such as pelvic floor physical therapy that can help you get back to feeling normal.
Talking to Your Partner
For many women, there’s a sense of embarrassment around letting their partner know they’re in pain. If you’ve ever held your tongue and dealt with the pain silently, you aren’t alone. According to a survey Ohnut ran in its community, about 75% of people don’t tell their partner when something is off during sex.
This is so understandable. It may feel impossible to communicate your sexual dysfunction with your partner when you don’t even know what is going on yourself. It can also feel scary if you are unsure how your partner will respond. We hope it's encouraging to know that, in Ohnut’s survey, 94% of partners did not respond negatively. Understanding your pain is such an important step, not just so you can get the treatments that you deserve, but also so that you can better understand how to communicate with your partner, and ask for their support.
Not sure how to start that conversation? If muscle dysfunction is contributing to your dyspareunia, Origin's physical therapists can work with you to create a pain communication plan. That way, talking with your partner will be less intimidating.
Pelvic Floor Tension & Dyspareunia
Speaking of muscle-related pain with sex, pelvic floor muscle dysfunction is a common cause of dyspareunia. In fact, musculoskeletal pain and dysfunction are seen in up to 90% of those with pelvic pain. Whether pain is from one of the above-mentioned conditions led to muscle dysfunction, or pre-existing muscle dysfunction is making sex painful, your muscles may be to blame.
With muscle-related dyspareunia, the pelvic floor muscles are often tense, tight, and unable to relax/stretch during penetration This can lead to pain and further muscle guarding as a result. When muscles are tense and overactive, they have poor blood flow, they lose coordination, and strength and function are compromised.
In these instances, pelvic floor PT is highly effective at improving sexual function and decreasing pain. In physical therapy, it is important for your body to relearn how to experience movement in a way that doesn’t cause tension or pain.
Pelvic Floor PT for Dyspareunia
If you have pelvic pain, it's important to calm your central nervous system and teach your brain that pain does not have to be the only outcome of movement, touch, or penetration.
Breathing techniques, yoga stretches, manual therapy, and graded exposure to penetration using biofeedback or pelvic trainers are all tools to help you in your pelvic pain healing journey. Origin makes finding a pelvic floor physical therapist easy. And the great thing is that our providers can see you virtually.
What to expect in your virtual PT appointment
You might be wondering how a virtual pelvic floor physical therapy appointment is different from an in-person one. First things first: You will not be required to bare it all in front of your laptop’s computer camera. Even with muscle-related dyspareunia, examining your muscles directly through your vagina is not the only way that a physical therapist is able to assess what is going on with your pelvic floor.
Your physical therapist will discuss which assessment techniques are best (and most comfortable) for you. These may include teaching you how to do a self-administered internal pelvic floor muscle screen in-between visits. They may also instruct you on how to assess other muscle groups, such as your deep abdominals or your glutes. Your PT will then create a personalized treatment program based on your needs and goals. At Origin, that includes a personalized exercise program that's updated weekly, prescribed resources, and tracking tools — so you can quickly begin to get relief from dyspareunia.
A Breathing Exercise for Dyspareunia
Diaphragmatic breathing is a basic, yet impactful exercise that can help you manage pain in a couple of ways:
- It helps improve general awareness. You are the expert of your own body. The more you harness mindfulness, the better you’ll get at listening to your body’s cues and understanding what it needs.
- It calms your central nervous system. You may have heard of “fight, flight, or freeze.'' Your central nervous system controls these impulses. When you have chronic pelvic pain and tension, it's a sign that your central nervous system is working on overdrive (in response to trauma, stress, or just plain life). Practicing diaphragmatic breathing can help you calm your nervous system and, in turn, your pain response.
Get detailed instructions on how to breathe with your diaphragm and pelvic floor here.
Dyspareunia Isn’t Forever
If you or a loved one experiences painful sex, it’s important to know: dyspareunia isn’t forever. Overcoming pain takes time and effort, but with expert support, you can make it happen. Consider booking a visit today. An Origin physical therapist can help you learn more about your pain, create a treatment plan, and find your way back to pleasurable sex.