Sex Hurts: What Is Actually Going On, and What Helps

Painful sex is one of the most common things women come to a gynaecologist about, and one of the last things they say out loud. It usually arrives at the end of the appointment, after the reports have been discussed, in a lowered voice.

In a national survey of more than 84,000 married Indian women, 12.6% reported painful intercourse — and the authors were clear that in a culture where this is difficult to discuss, that figure is almost certainly an undercount. Nearly all of it has a physical explanation, and most of it is treatable.

The first question: where exactly?

This single question does most of the diagnostic work, so it is worth thinking about before the appointment.

The other useful questions: has it always been there, or is it new? Does it happen every time, or only in some positions? Is there also pain with periods, with tampons, or at a smear?

Pain at the entrance

• Not enough lubrication. Sometimes simply time and arousal; often hormonal. The pill, breastfeeding and menopause all reduce natural lubrication.
• Genitourinary syndrome of menopause — thinning, drying and loss of elasticity after oestrogen falls. It causes burning, bleeding after sex, urinary urgency and repeated urine infections, and it gets worse, not better, if left. Local vaginal oestrogen works well for it.
• Infection — thrush and bacterial vaginosis both cause soreness. See white discharge: what is normal and vaginal infections.
• Skin conditions of the vulva, such as lichen sclerosus or eczema. These are frequently treated as thrush for years, and they need the right diagnosis and the right cream.
• Vestibulodynia — a specific, exquisitely tender spot at the entrance, with a normal-looking vulva. Real, recognised, and managed.
• Scarring from a tear, an episiotomy or surgery.
• Vaginismus — the pelvic floor muscles tighten involuntarily when penetration is attempted. The tightening is a reflex, like a blink, not a decision.

Deep pain

• Endometriosis and adenomyosis. Classically deep pain in certain positions, worse around periods, with painful periods too. See endometriosis and adenomyosis.
• Pelvic inflammatory disease — current or past infection, sometimes with discharge, fever or bleeding between periods. It needs treating promptly, because untreated it damages the tubes.
• Ovarian cysts and fibroids, depending on size and position.
• An overactive pelvic floor. Muscles that never fully relax cause deep ache, and often also constipation and urinary urgency.
• Bladder or bowel conditions — bladder pain syndrome and irritable bowel both refer pain into the pelvis.
• Adhesions after surgery or infection.

After childbirth

Discomfort for the first weeks or couple of months is expected, particularly after a tear or a cut, and dryness while breastfeeding is almost universal because oestrogen is low. What is not expected is pain that is still there at six months, or pain at one specific point in a scar. Both are treatable — with scar therapy, pelvic floor physiotherapy, local oestrogen, or occasionally a small procedure. Our page on the first six weeks after delivery covers the early part.

Vaginismus, and unconsummated marriage

In this clinic, one of the commonest reasons a young couple comes in is that penetration has never been possible. It is often carried silently for months or years, with both partners assuming something is badly wrong with one of them.

Usually nothing is anatomically wrong at all. What is happening is a protective muscle reflex, set off by pain, fear of pain, or the sheer pressure of expectation. Treatment works: education about the anatomy, pelvic floor relaxation and breathing, graded self-directed dilator work at your own pace, treating any dryness, and sometimes counselling for the couple together. The great majority of couples get there, and it is much easier when they come early instead of after several years.

Rarely there is a physical cause, such as an unusually rigid hymenal band or a vaginal septum, and that is dealt with simply.

What an examination actually involves

Fear of the examination keeps many women away, so it is worth being plain about it. It begins with talking, not with an examination. When we do examine, it is with your consent, one step at a time, with everything explained before it happens, and it stops the moment you ask. Often the first visit involves only a look at the vulva, or nothing at all.

A cotton swab test can map exactly where the tenderness is. A speculum is not always necessary, and a smaller one is available. Swabs can be taken to check for infection. A scan, where it is needed to look at the ovaries and uterus, is arranged by referral.

What helps

When to be seen sooner

• Bleeding after sex — always assessed. See bleeding after sex.
• Pain with fever, or an offensive discharge.
• New pain after a new partner, which raises the question of infection.
• Pain that is worsening, or waking you at night.
• Pain after menopause, which is common and very treatable, and should not be accepted as the price of age.

What happens at the clinic

Consultation, examination at your pace, swabs and blood tests, treatment of infections and skin conditions, prescribing local oestrogen and other treatment, and referral for pelvic floor physiotherapy all happen at the clinic. Scans are arranged by referral, and any surgery, such as for endometriosis, is carried out at an NABH-accredited hospital in Gurugram.

You do not need to have a diagnosis in mind, or a way of saying it politely. "Sex hurts" is enough to start the conversation, and it is a conversation this clinic has every week.