For most women, sex is associated with feeling good, both physically and emotionally. The sensations associated with sexual behavior in general and sexual intercourse specifically are intended to be pleasurable, not painful. If a woman does experience pain with sexual intercourse, most often there is an uncomplicated and temporary cause. Perhaps she is not sufficiently aroused and lubricated, perhaps she has a bacterial or yeast infection, or maybe it’s the first time having intercourse after giving birth, and the area is still a bit sensitive. These are situations that many, if not most women will have experienced at some point in their lives. Fortunately, they are isolated episodes, which go away with simply using a lubricant or treating the presenting problem.

However, for an estimated 15-20% of women in the pre-menopausal age group (18-45), painful intercourse is the rule, not the exception. Often these women have been to several doctors and therapists and have tried every prescription and over the counter cream and lubricant available only to suffer from repeated pain and frustration every time they attempt intercourse. Adding to this frustration is the perception that in many cases nobody seems to know what the cause is, and the woman is left feeling as though the pain is all her in head. She begins to wonder, am I asexual? Am I with the wrong partner? Will I ever be normal?

Fortunately, in the past two decades there has been a great increase in our understanding of the causes and treatments of conditions, which may cause sex to be painful. Clinically termed “dyspareunia” (pronounced dis-pa-roo-nia), pain with intercourse is a puzzling condition. At one time it was thought that painful intercourse only occurred as a result of insufficient vaginal lubrication, or the presence of a medical condition such as an infection or disease. In the absence of these situations, the pain was considered to be psychological in origin. Today we are aware that various bodily systems are involved in creating a situation whereby intercourse is painful. For example, pain can result from vaginal (pelvic floor) muscles that are contracted, skin and connective tissue that is tight and not flexible, or scar tissue. There are many nerves that run through the pelvic area and a nerve inflammation can be another potential source of pain. We are also aware that dyspareunia is present due to the interplay of multiple factors. For example, a woman who experiences repeated episodes of painful intercourse will develop a response of contracting her pelvic floor muscles in anticipation of pain. She may lose her ability to concentrate on the pleasurable sensations and often her sex drive becomes diminished. This will perpetuate her pain, as decreased lubrication and tight, contracted muscles create more friction in the vagina. Emotional anxiety will increase her pain perception as well. Needless to say, the situation will impact negatively on her relationship with her partner, which is an additional cause of stress. This creates a vicious cycle, which needs to be addressed from multiple perspectives.

When a woman experiences repeated episodes of painful intercourse, or is unable to have intercourse because of pain, it is important that she undergo a comprehensive examination to determine the cause. Treatment should focus on the physical as well as emotional and relationship components. A physical exam may reveal that she has localized provoked vulvodynia, a common syndrome that is characterized by increased sensitivity to the touch at the entry to vagina that interferes with the ability to have intercourse. She may present with vaginal dryness or atrophy, or may have tight or contracted muscles or tightness of the tissue surrounding the vaginal entry. Treatment should address these issues and may include using oils or local hormone cream to improve vaginal moisture. Physical therapy may be suggested where treatment would be provided to relax the pelvic floor muscles and improve the flexibility of the vagina. Finally, a referral to a psycho-sexual therapist may be suggested as well, in order to address the emotional component related to painful sex and help the couple cope.

Pain that occurs regularly during intercourse is not the norm, and it should not be tolerated. If your doctor tells you that the pain is all in your head, find a doctor who specializes in sexual medicine, and knows how to examine and treat sexual pain disorders. The treatment approach should be multi-disciplinary and should address the physical and psychological aspects of the problem. With proper treatment, pain-free and pleasurable sexual intercourse can be achieved.