Pain With Sex? There’s Support.
Painful Sex Isn't Something Your Need To Suffer Through Alone
Written by Dr. Fiona Callender, Naturopathic Doctor and Pelvic Health Therapist. Dr. Fiona supports our patients navigating pain and hormonal symptoms, helping them navigate the unknowns and cut through the online noise.
Pain during sex is incredibly common. Up to 3/4 of women experience pain with intercourse at some point in their lives, and for some it can become a persistent problem.
Despite how common it is, many people never mention it to their healthcare provider. It’s often assumed to be a normal part of their phase of life - having had a baby or navigating perimenopause. Others don’t reach out because they assume there’s nothing that can be done.
The good news? Pain with sex is something we can often improve, and it starts by figuring out why it's happening.
The WHY behind painful intercourse:
"Pain with sex" is a symptom, not a diagnosis. In medical terms, we call it dyspareunia.
Much like other types of pain, different causes require different treatments. For someone with headaches, we would investigate the cause, and adjust treatment accordingly - it’s the same here.
Many of the causes we discuss can contribute to a cycle that perpetuates pain, even once the original factor has been resolved. I often describe this as a wheel that keeps spinning. There are many factors that could be the first to push the wheel into motion, and many that keep it going. Often, the wheel continues moving on it’s own due to our own nervous system and muscular protective factors.
Common causes of pain during sex
1. Pelvic floor muscle tension
The pelvic floor can be the push or the momentum for our spinning wheel. Pain is a protective feature of our nervous system. When our body experiences pain, our nervous system responds in order to help us prevent harm. In the pelvic area, this response often results in muscles that tense and guard. They may clench involuntarily - like how you might notice your jaw or shoulders tense under stress. This tension and muscle shortening leads to tenderness, trigger points and pain. In many cases, it becomes a cycle where they cannot relax to allow comfortable penetration.
Tension in the muscles of the pelvic floor is often associated with more severe and consistent pain with sex. Many folks will experience pain or aching lasting through the following day.
Each painful experience reinforces the expectation of pain and sets us up for anticipatory guarding. The nervous system ramps up it’s vigilance in the area, perpetuating this cycle of guarding and tension. This response is not just “in your head”, this is a very real and physiological experience. Over time, the nervous system can become so sensitized that even light touch or anticipation can trigger pain.
The cycle of fear-pain-tension, can be entered at any point, which means that it can be interrupted at any point too. This pelvic floor muscular component shows up as a factor in many of our other causes of pain - even if it wasn’t the original inciting factor. Almost any source of genital or pelvic pain - whether this starts as an injury or tissue factor, nerves, hormones or an infection - can trigger a protective muscle guarding. This sensitivity and tension often continue even once the original factor is resolved. This is why we often need to address multiple factors together to help support you most fully. We know that the pelvic floor muscles are often involved, but they’re usually not the whole story.
2. Endometriosis
Endometriosis is a fairly common factor in painful sex. Endometriosis involves tissue similar to the uterine lining growing outside the uterus. For many of those (about 45%) with endometriosis, it can cause a deeper pain with intercourse. This pain is often thought of as being related to the growth or “lesions”, but it’s often more complicated than that. These lesions can cause inflammation in the area, scarring/adhesions, but also new nerve growth in the area. There is often more sensitive nervous tissue in these areas you feel pain.
This is also often the start of our pain cycle, as pain can lead to our body tensing and guarding those muscles of the pelvic floor. This adds an additional muscular layer of pain. Over time, the nervous system becomes more sensitive and amplifies these signals (what we call central sensitization). This is part of the reasons pain often persists, but also the reason that bladder pain, urinary symptoms, fatigue and bowel symptoms/IBS often exist alongside it.
Pelvic floor therapy can be part of the treatment plan, but treating endometriosis often requires addressing inflammation, nervous system sensitivity, and advocating for treatment/diagnosis in the medical system too.
3. Postpartum recovery: The Overlap of Healing Tissue and Hormonal Change
Pain with sex is very common in the months following birth - whether you had a vaginal birth or a cesarean. About 40% will experience pain at 3 months postpartum, and 20% at 6 months. Perineal trauma (especially episiotomy) may leave tender scar tissue and trauma to the perineaum. This is the strongest predictor of pain with sex postpartum, but many of those with pain have more than one factor causing it.
We also know that breastfeeding/lactation lowers estrogen, producing a temporary menopause-like state that leads to dryness and thinning of the vaginal tissue. This can lead to a burning or rawness sensation with penetrative sex.
Early attempts might be painful, which can lead to that protective response in the pelvic floor muscles. For some, this is why the pain can outlast the actual healing phase. Often there’s an overlap of factors, but there are also many supports that exist. Addressing parts of the cycle - scar tissue mobilization/desensitization, lubricants/moisturizer, hormonal options, pelvic floor therapy, as well as supporting overall healing with good nutrition, rest and movement - can all be important parts of treatment.
Remember, the six-week all-clear, doesn’t mean you are fully ready physically, emotionally, mentally for everything. It’s not a race and it’s OK to ask for support.
4. Genitourinary syndrome of menopause (GSM)
In perimenopause/menopause, falling estrogen can impact the vulvovaginal tissue. This tissue can become dryer, thinner, and less elastic - often leading to more susceptibility to tearing and fissures. The tissue has essentially lost some cushioning and the associated friction can now lead to stinging, burning and tearing. This impacts more than half of menopausal women!
This low estrogen factor can impact those who are breastfeeding - as mentioned above! - as well as those on anti-estrogen medications such as tamoxifen, aromatase inhibitors and GnRH agonists (often used in endometriosis treatment). Hormonal contraception may also impact vaginal dryness for some people.
The pain with GSM often triggers the same anticipatory tension and guarding that we see with other causes. It can be another push to set off our cycle, as well as perpetuate it. Breaking the cycle may involve local vaginal estrogen therapy, lubricants/moisturizer use, as well as pelvic floor therapy.
5. Infections
Vaginal infections such as yeast, bacterial vaginosis, and Trichomoniasis can all contribute to pain as well. An active infection can make the tissues feel inflamed and raw, leading to painful sex. Treatment should be timely to help prevent getting into our cycle of pain, as recurrent infections can continue re-triggering the cycle. For some, they feel like they have recurrent infections, but swabs and testing come back clear. This is a common symptom of vulvodynia - vulvar pain or discomfort, itching, burning, redness, irritation, that is not related to an infection, injury, skin condition, or hormonal concern. Symptoms can come and go, or be present all the time. For some, symptoms can impact using tampons, having sex, or even sitting or wearing tight clothes.
6. More causes:
Vaginismus is the persistent (has lasted longer than 6 months) tension at the vaginal opening that prevents - or makes really difficult/painful!- any sort of insertion in the vagina, whether thats for sexual activity, a speculum for a vaginal exam, or a tampon.
Antidepressant medications (Especially SSRIs) can reduce natural lubrication or dampen arousal, so intercourse is drier and more uncomfortable.
Skin conditions such as lichen sclerosus and eczema can impact the sensitive tissue in the vulvovaginal area, leading to pain.
The Take Away
There are many common entry points - or pushes - that can contribute to pain with intercourse. Many of them even overlap. Regardless of the trigger, we often need a multidisciplinary approach that supports you on various points of the cycle. My approach is to try to support the specific driver of pain (support healing, support lubrication/hormones, treat infections, discuss medications etc.) while also addressing the muscular and nervous system factors.
Knowing support is available is often the first step! Talking about it and getting support is the next one. If you would like to get started, or get more information, I’d love to chat with you.