Is Vaginal Pain during Intercourse Normal?

Dyspareunia, or genital pain that occurs just before, during, and/or after intercourse, is always a cause for concern. Although this issue can be common during certain phases of a woman's life, such as during perimenopause, once postmenopausal, or during the postpartum period, this symptom indicates an underlying issue that should be discussed with a healthcare provider. There are effective treatment options available depending on the location of pain, as well as the cause. This blog will help readers be aware of possible causes, as well as solutions to improve sexual comfort and health.

Common Causes of Vaginal Pain During Intercourse

Vaginal pain during intercourse can either be superficial (at the opening of the vagina), deep (deep inside the vagina or abdominal pain with intercourse), or mixed. The location of pain offers insight into the possible cause.

Superficial Dyspareunia Causes

Physical Factors

Vaginal Atrophy - So, what is vaginal atrophy? This condition happens when the vaginal tissues become dry, thin, and inflamed as estrogen levels decrease. This is common with perimenopause/menopause, while breastfeeding, or while using low dose birth control or progestin-only birth control. Vaginal atrophy makes insertion during intercourse extremely uncomfortable. Other symptoms could also include a chronic burning or itching sensation in the vaginal area.
Chronic Vaginal Irritation - chronic irritation can occur by placing soap inside the vagina (normal vaginal pH is moderately acidic whereas soaps are slightly basic and disrupt the natural pH balance), douching with formulas that contain fragrance, using scented products/soaps inside the vagina, wearing tight underwear/clothing, and/or not changing out of wet clothes quickly.
Vaginal Infections - vaginal infections, such as yeast, bacterial vaginosis, chlamydia, gonorrhea, trichomoniasis, and genital warts can cause discomfort with intercourse. It’s important to be screened for infections if other symptoms, such as bleeding/spotting after intercourse, abnormal vaginal discharge, abnormal vaginal odor, or vaginal itching occurs.

Psychological Factors

Lack of Arousal - arousal is critical for proper lubrication of the vaginal area. It’s important to be relaxed, manage stress, and have a good relationship with your partner.
Past Trauma - prior sexual trauma can contribute to a lot of anxiety and stress surrounding intercourse. This can cause involuntary tensing of the vaginal muscles when intercourse is attempted. If intercourse has been painful before, the mind can start to associate the experience with automatic sexual discomfort. This leads to a cycle of the fear of pain causing tensing, which then causes further pain.

Anatomical Factors

Vaginismus - vaginismus is when involuntary muscle spasm occur when insertion is attempted. This often causes issues with even tampon insertion and pelvic exams/pap smears. Vaginismus is commonly seen in those with a history of trauma.
Vulvodynia - vulvodynia is chronic genital pain that lasts for at least 3 months and has no known cause. This could be due to chronic irritation, inflammation, hormonal factors, muscle spasm or weakened pelvic floor muscles.
Childbirth Lacerations - prior lacerations from childbirth can lead to scarring and sexual discomfort when penetration is attempted. Perineal massage and pelvic floor therapy during the postpartum period can help.

Deep Dyspareunia Causes

Physical Factors

Endometriosis - endometriosis is a medical condition where tissue similar to the lining of the uterus (the endometrium) grows outside of the uterus in other parts of the pelvic area. In addition to deep pain during sexual intercourse, this condition often causes debilitating menstrual cramps and gastrointestinal issues.
Pelvic Inflammatory Disease - pelvic inflammatory disease is an infection of one or more of the upper reproductive organs, such as the uterus, fallopian tubes, and ovaries. This is commonly caused by a sexually transmitted infection that went untreated and spread from the vagina to the organs. It’s important that this is treated as soon as possible as it could cause permanent damage to the reproductive organs.

Anatomical Factors

Uterine Fibroids - uterine fibroids are benign tumors in the uterus. Depending on the size and location of the fibroid(s), it can cause pelvic pain during sexual intercourse. Other symptoms may include heavy periods, painful periods, chronic pelvic pain, and bleeding in between periods.
Retroverted Uterus - a retroverted uterus is when the uterus is tipped backwards towards the rectum as opposed to forward towards the abdomen. This can make certain positions uncomfortable, which results in positional dyspareunia. Open communication with a partner is imperative to ensure comfort throughout sexual activity. Optimal positions often include hands and knees, side-lying, and pillow propped under buttocks.
Prior Surgery - prior surgery on reproductive organs can lead to adhesions, which can often cause chronic pelvic pain, including pain during sex. This includes surgeries, such as cesarean section, dilation and curettage, fallopian tube removal due to ectopic pregnancy, myomectomy (fibroid removal), and more.
Congenital abnormalities - some malformations of the uterus and other reproductive organs can lead to pain during sex, as well as issues with the menstrual period and fertility. This includes uterus didelphys (double uterus), bicornuate uterus (heart-shaped uterus), septate uterus (uterus with septum in the middle), unicornuate uterus (one-sided uterus), and arcuate uterus (uterus with a dent on the top part).

Diagnosis and Medical Consultation

Initial Steps

The first step to receiving proper diagnosis and care for pain with intercourse is to speak with a healthcare provider. Although the topic can be difficult to talk about, healthcare providers who specialize in gynecological care have experience managing these conditions. It’s important to connect with a provider who makes you feel comfortable and heard. There is treatment available and sometimes it may take a second (or third) opinion to find the right fit. The first part of the visit should start with a detailed medical history, including chronic medical conditions, gynecological history, prior surgeries (especially those involving the reproductive tract), obstetric history (and any lacerations), mental health history, and current medications. A thorough provider should also screen for past trauma and discuss current relationship dynamic. A pelvic exam is NOT necessary to be treated for pain with intercourse and should never be a barrier for accessing care. It is every patient’s right to refuse a pelvic exam if desired. If signs of a vaginal infection are present, a urine sample can be collected as opposed to a vaginal swab. A pelvic ultrasound can also offer insight into any structural issues.

Specialist Referrals

It is actually best to start with a gynecologist or women’s health nurse practitioner, as most primary care providers may not have as much experience treating pain with intercourse. If a visit with a primary care provider is required first (per insurance plan), they will often first refer to a gynecological specialist. For certain conditions, such as vaginismus, vulvodynia, and endometriosis, a pelvic floor therapist would be helpful. This would be different from the type of pelvic floor therapy that is done during the postpartum period, which focuses on strengthening the pelvic floor muscles. This type of therapy would focus on relearning how to relax the pelvic floor muscles and may be combined with diaphragmatic breathing. If past trauma or anxiety is the root cause, meeting with a mental health therapist is a critical component that shouldn’t be overlooked.

Treatment Plans

Treatments should be individualized based on the underlying cause, as well as each patient’s comfort level and ability to fit recommended interventions into their lifestyle. Often, a holistic approach that combines medical, physical, and psychological therapies offers the most effective treatment plan. Pain with intercourse is a complex condition and it is normal for multiple, follow up visits to be needed before improvement is made. It is usually not solved after one visit alone.

Treatment Options and Relief Strategies

Medical Treatments

There are a variety of medications that can be used depending on the cause. Here are some examples below.

Vaginal atrophy - vaginal estradiol cream, systemic hormone replacement therapy if postmenopausal
Vaginal infections - appropriate antibiotics or anti-fungal based on actual infection; cryotherapy can be used to freeze off warts
Vulvodynia - vaginal estradiol cream or vaginal lidocaine gel
Endometriosis - hormonal therapy
Pelvic inflammatory disease - antibiotics
Uterine fibroids - hormonal therapy

In severe cases, surgery could be considered, such as to remove a uterine fibroid or endometriosis lesions. This should never be seen as first line therapy as surgery could actually cause adhesions to form, leading to more pain over time.

Holistic Solutions and Lifestyle Changes

If a more natural route is preferred, there are an abundance of options that are available over the counter. Lubricants can be used at the time of intercourse to help make insertion more comfortable. This includes water based lubricants, as well as coconut oil. Vaginal moisturizers are a great tool to hydrate and moisturize the vaginal tissues over an extended period. These are water-based and formulated to mimic the body’s natural lubrication. Compared to lubricants, moisturizers provide longer-lasting relief and are intended for regular use as part of a daily routine to manage vaginal dryness during sex. Options include pH-D Feminine Health’s vaginal moisturizing gel and moisturizing suppositories.

A well balanced diet full of unprocessed and whole foods, as well as regular exercise, can also make a huge difference in keeping hormones balanced. Adequate hydration is important to help relieve vaginal dryness. Consistency as opposed to perfection often leads to sustainable improvement over time. Proper vaginal hygiene, such as using pH-balanced wash or cleanser, and avoiding scented products can help with chronic irritation. Since stress management is critical for arousal, incorporating relaxation techniques, such as yoga, meditation, and diaphragmatic breathing can help as well.

Therapies and Alternative Treatments

As discussed above, working with a pelvic floor therapist and regularly engaging in pelvic floor exercises can help improve certain conditions by relearning how to relax the pelvic floor muscles. Vaginal dilators can also be used at home to become more comfortable with penetration. It is advised to start with the smallest size and slowly increase, using lubrication to aid with insertion. Cognitive behavioral therapy has been shown to help manage pain and anxiety, especially for vaginismus and vulvodynia. This can be done by working with a mental health therapist or sex therapist. Acupuncture is another avenue to explore to help manage stress and chronic pain. These therapies often require ongoing sessions before improvement is noticed.

Enhancing Comfort and Intimacy

Communication with Partner

A critical component that should not be overlooked is having open and honest communication about any pain or discomfort that is experienced during sexual intercourse. Maybe it’s a positional issue or maybe more foreplay and a slower pace is needed. Intercourse should be enjoyable for both parties, so it’s important to speak up and voice any concerns as they arise. Focusing on intimacy outside of the bedroom with date nights, screen-free time together, and connection can also make a huge difference in terms of arousal. Sometimes, it can be helpful to be intimate without the pressure or expectation of intercourse. That can include massage, kissing, oral, or mutual masturbation.

Sexual Health and Education

Education on sexual health and anatomy (for both parties) can enhance the experience. The act itself can be educational and communicating what feels good (and what doesn’t) can help with learning what works over time. Switching things up in terms of positions and techniques can offer insight into ways to reduce pain. Although intimidating at first, sex toys can be used to enhance comfort and pleasure by helping with arousal.

Self-Care and Emotional Well-being

Experiencing pain with intercourse can be distressing. Seeking support from friends, support groups, or online communities can help decrease isolation. It’s easy to think that this medical condition is unique, but it does affect most women at some point in their life. Hearing other’s stories can help provide comfort and tips for managing pain. Prioritizing self-care, stress management, and relaxation can also help manage anxiety and pain. Often, being relaxed is the first step to having a comfortable and pleasurable sexual experience. Painful sexual intercourse can affect self-image and sexual confidence, which then leads to more anxiety surrounding sexual activity. Working with a mental health therapist or sex therapist can help rebuild confidence.

Conclusion

Vaginal pain during intercourse is a symptom that should never be overlooked as it indicates an underlying issue. This blog discussed possible causes, the importance of speaking with a healthcare provider, and a variety of treatment options available. Implementing the suggested strategies and maintaining open communication with partners can help women reclaim comfort and pleasure in their sexual lives. Being knowledgeable and proactive can help empower women to overcome this condition and improve sexual health.

Katrina Rollins CNM, ARNP, MPH

Katrina Rollins, CNM, ARNP, MPH is an expert in holistic Women’s Health as a board certified Nurse Midwife/Nurse Practitioner. She completed her undergraduate nursing training at Johns Hopkins University, while also working as a doula for low-income and refugee women. Alarmed at the maternal health disparities plaguing our nation, Katrina decided to become a Nurse Midwife/Nurse Practitioner in order to address these issues from the front lines. She received a Master of Science in Nursing with a specialty in Midwifery/Women’s Health from Emory University as a Robert W. Woodruff Clinical Fellow. Additionally, she studied public health to better understand the causes, as well as solutions for the frightening inequalities present in health care. Her studies have taken her to South Africa, the United Arab Emirates, India, and Haiti to explore Women's Healthcare in various cultures.