When Sex Hurts

For millions of women who deal with pain during sexual intercourse — also known as dyspareunia — treatment requires more than a tube of lube.

“The easiest diagnosis is for postmenopausal women because vaginal tissues are estrogen-dependent,” said Mitchell Levine, MD, of WomanWell, in Needham, Massachusetts. “Without estrogen, the tissues can become thin and dry and less flexible. It can be quite painful, but is usually pretty easily fixed with different kinds of vaginal estrogen.”

“Then there’s the other whole category of women who are not menopausal, but who have painful intercourse or painful sexual relations — and that can be caused by a whole host of things, the most common of which is endometriosis…a very common cause of painful intercourse or painful sexual relations.”


Endometriosis is a condition in which cells from the endometrium — the lining of the uterus — take root in tissue and organs surrounding the uterus, sometimes forming adhesions that can affect the peritoneum, ovaries, fallopian tubes and the outer surfaces of the uterus, bladder, ureters, intestines and rectum. Common symptoms include pain during and after sex, incapacitating menstrual cramps, chronic lower back pain, painful bowel movements and bleeding or spotting between menstrual periods.


While its cause remains unknown, the U.S. Department of Health and Human Services’ Office on Women’s Health estimates 11 percent of women (including more than 6.5 million women in the U.S.) have some degree of endometriosis — and many remain asymptomatic. While the condition can begin as early as a woman’s first menstrual cycle, the diagnosis is most common from age 30 through the late 40s.

Advances in treatment

The good news: Endometriosis is highly treatable, and medical advances in the last 10 to 15 years have reduced the rate of recurrence. In some cases, the treatment is as simple as using birth control pills on an ongoing basis. Because birth control pills tend to thin the lining of the uterus and cause light periods, they have a similar effect on endometrial tissue growing outside the uterus. Surgical intervention is an option in cases that don’t respond to medication.

“We now know more clearly how to find the tissue, which is more subtle than we used to think,” said Levine. “Sometimes these surgeries can take three, four or five hours as we go inch by inch through the entire pelvis to strip off the endometrial tissue, but it can be very effective, and because it’s minimally invasive laparoscopic surgery, recovery shouldn’t be too long.”

Other causes of painful sex

While most instances of painful sex are related to symptoms associated with endometriosis and/or the decreased production of estrogen during menopause, other physical causes can range from contact dermatitis (allergic reactions to personal hygiene products, lubricants or even latex condoms) to vaginismus (the involuntary contraction of muscles around the opening of the vagina that makes sexual intercourse, or any sexual activity that involves penetration, painful or impossible).

Both the Office on Women’s Health and the College of Obstetricians and Gynecologists offer comprehensive lists of physical conditions that may lead to painful sex, including:

• imperforate hymen (a congenital condition in which the hymen covers the entire opening of the vagina);

• a genital or urinary tract infection;

• ovarian cysts (fluid-filled sacs or pockets in an ovary or on its surface);

• retroverted uterus (the uterus is tipped backward, pointing toward the rectum rather than forward, toward the belly);

• eczema or other skin problems in the genital area;

• a tear or episiotomy during childbirth that has caused scarring;

• uterine fibroids (benign muscular tumors that grow in the wall of the uterus);

• uterine prolapse (a condition in which the muscles and ligaments supporting the uterus stretch or weaken, allowing the uterus to slip from its natural position);

• vaginitis (inflammation of the vagina caused by a yeast or bacterial infection);

• vulvar vestibulitis syndrome (pain is confined to the vestibule, or the area around the opening of the vagina); and

• vulvodynia (a pain disorder affecting the vulva).

To get to the root of the problem, be honest with your doctor about your symptoms. Expect a full physical examination, often including an ultrasound and/or exploratory laparoscopic surgery. And keep the faith. Once diagnosed, many physical conditions can be treated with medication, surgery or a combination of both.

Emotional health

We’d be remiss if we didn’t touch on the psychological and emotional issues that can play havoc with a woman’s sex life. In instances when a physical examination and additional testing do not reveal a cause for dyspareunia, it makes sense to explore emotional issues.

An author, lecturer and longtime women’s health advocate, Levine practices a gentle approach to women’s health issues. He believes in viewing every patient as a whole person, embracing a holistic approach to diagnosis and treatment.

“Unfortunately, there is a large category of women who have suffered some kind of abuse in childhood or as an adult…even by an insensitive doctor doing a medical exam,” said Levine. “Having had a traumatic experience, the body naturally defends itself by closing up and contracting. It creates a vicious cycle because the woman has already been hurt once, then she tries to be intimate and it hurts again, so she is even more nervous the next time.

“It can start as emotional, but it becomes physical,” Levine continued. “It’s a hard pattern to break.”

Trust is key

Finding a doctor you trust and a therapist who is tuned into the very real psychological barriers to a fulfilling sexual relationship is key to diagnosing, treating, and building or rebuilding a satisfying sex life.

“Sex is an important part of life, and not just in the way it’s portrayed in American culture and movies,” said Levine. “It has the potential for deep spiritual connection and personal growth.

“It allows you to feel closeness. When your needs are met, it raises your energy. You don’t have to have an active sex life, but it’s nice to have the option.”


American College of Obstetricians and Gynecologists

U.S. Department of Health & Human Services
Office on Women’s Health

Want to learn more about sex and pain? Read “Maintaining a Sex Life With Chronic Pain.”

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