Painful Intercourse

Painful Intercourse

Bringing Back the Pleasure

You and your partner begin making love one night. You're in the mood and plenty excited, but when you start having intercourse, it hurts so much you can't continue. So you stop, leaving the two of you frustrated, unsatisfied, disappointed and concerned.

If this scenario sounds familiar, you're not alone. Many women experience painful intercourse. Doctors call it dyspareunia, and it's estimated that 10 to 50 percent of all sexually active women will have it at some time, says Richard A. Carroll, Ph.D., director of the Sex and Marital Therapy Program at the Northwestern Medical Faculty Foundation of the Northwestern University Medical Center in Chicago.

The problem--how it feels and what causes it--varies widely from woman to woman. Some women have pain during thrusting because of fibroids, chronic constipation, pelvic infections, endometriosis, hemorrhoids, pelvic inflammatory disease or surgical scar tissue. Others have pain with penetration because of insufficient lubrication, yeast infections, sexually transmitted diseases (STDs), allergic reactions to contraceptive products or an improperly healed episiotomy--the surgical incision that's made during vaginal childbirth. And some women can't even begin intercourse: They have vaginismus, a condition in which the opening of the vagina closes, making penetration painful or even impossible.

In all its different forms, painful intercourse is something women need to pay attention to. Yet not all do. Even today, a lot of women assume that discomfort during sex is kind of normal, says Jo Kessler, a licensed nurse-practitioner and certified sex therapist in San Diego. But women need to realize that intercourse is not supposed to hurt and that if it does, it's the body's signal that something is wrong.

When You're a Little Too Dry

A major cause of painful intercourse in women over 30 is insufficient lubrication, experts say. Hormone levels often have a lot to do with it. Estrogen plays a role in stimulating vaginal secretions, so when it's low, you may be drier. This can happen right after your period, while you're breastfeeding and during menopause, when the ovaries produce less estrogen. Medications can also be responsible. Cold formulas are one example; they contain antihistamines, which dry up mucous membranes throughout the body, including the vagina.

You also may have trouble lubricating properly if you don't become sufficiently aroused; this can happen if your partner isn't stimulating you enough or in ways that you need. "Sometimes a woman is not ready for intercourse and is not able to tell her partner what she's feeling," says Dr. Carroll. If she has sex, there can be friction and pain.

You need to be aware that it's possible for a vicious cycle to develop between physical pain and anxiety, says Dr. Carroll. "A woman may experience a little bit of friction or painful intercourse and that makes her more hesitant the next time," he says. So when she and her partner try to have sex again, she's more anxious and even less likely to become lubricated, and sex is bound to be more painful. This cycle can go on and on, often leading to a complete avoidance of sex, he says.

Insufficient lubrication can also be connected to feelings about your partner and the relationship, experts say. If you have repressed anger toward your lover or resent him, or you're just turned off that day, you may have trouble getting aroused and sufficiently lubricated, making sex painful.

When Your Body Says No

The connection between your emotions and the way your body responds to sex is even more apparent in the case of vaginismus. Here, a woman's anxiety about sex triggers a dramatic physical reaction: The muscles of her pelvic floor spasm and her vaginal opening closes, making sex difficult and often impossible.

Vaginismus is not usually caused by medical problems, says Dr. Carroll. "It's a learned physical response caused by anxiety about impending intercourse," he says. Women who've had traumatic sexual experiences, such as rape or sexual abuse, or who've been raised in households with very conservative, negative attitudes about sex, often develop it, says Dr. Carroll.

If Something's in the Way

While emotions can play a role in painful sex, sometimes the cause is strictly physical. Chronic constipation is one example. During sex, the wall of the vagina gets pinched between two hard objects, the man's thrusting penis and the stool sitting in the colon, says Kessler. Because the wall of the vagina is sensitive to this compression, it hurts, she says. Fibroids or endometriosis can cause similar problems. If there are growths in the uterus or endometrial tissue outside it, during sexual intercourse it can feel as if the penis is bumping against a bruised area.

Sometimes sex is painful because a woman's uterus is tipped backward or because her vagina is short, either congenitally or due to surgery or other medical treatments.

Another physical factor that can cause painful sex is childbirth. Some women find sex painful after they've had a baby, particularly if they've had a vaginal delivery that required an episiotomy. If sensitive scar tissue results, it can make penetration painful.

Vaginal infections, STDs such as trichomoniasis and genital warts, and allergies to contraceptive products can also cause irritation of the vaginal opening and make sex painful.

What You Can Do

There are things you can do to prevent painful intercourse or cope with it if you're already experiencing it. Here are some suggestions.

Stay healthy. Since painful intercourse can be caused by medical problems, including endometriosis and fibroids, it's important to have a gynecological exam annually, experts say. Yeast infections and STDs can cause pain as well, so protect yourself. Keep the vaginal area clean, use condoms to prevent sexually transmitted diseases and get immediate treatment for vaginal irritations and infections.

Nurture your relationship. Negative feelings about your relationship or your partner can affect your sex life, experts say. Deal with problems as they come along, instead of letting them accumulate. Talk to your partner using "I" statements such as "I'm having a problem with . . . " instead of "you" phrases like "You always . . . ," which can place blame and cause bigger rifts. Try writing about your anger as a way to express and defuse it, says Kessler.

Don't force it. "I talk to women about how not to have intercourse when they don't want to," says Kessler. There are other ways to be sexual. You can still have sex without putting the penis in the vagina. Talk about various options with your partner before you get in a romantic situation.

Stay lubricated. If you are not sufficiently lubricated, take steps to become so. Either extend foreplay until you are naturally lubricated or use artificial lubricants. Go with a water-soluble lubricant, like Astroglide, that's best absorbed by the body, says Dr. Carroll. And be aware that your ability to lubricate may vary from day to day, he says. If you are on medications like antihistamines that make you drier, use water-soluble vaginal lubricants while you're taking them, says Kessler.

Drink fluids and eat bran. If you are constipated a lot and it causes painful sex, try increasing the amount of fluids you drink, says Kessler. And add bulk to your diet with fresh fruits, whole grains, vegetables or some form of bran. "When you clear up the constipation problem, then you don't have firm stool in the colon for the penis to thrust against," she says.

With fluids, aim for six to eight glasses a day. If you're having trouble getting to the water fountain, try a sports fluid bottle, says Kessler. Many of them hold 16 ounces, and you can fill it up three or four times a day. "Have one at breakfast, one at midmorning, one at lunch, one at dinner and one at bedtime," she says.

Try different positions and techniques. Painful sex might be "something as simple as a position not being compatible with a woman's anatomy," says Kessler. If you're feeling discomfort with one position, try another. Having sex side by side or with the woman on top allows the woman to "control how fast and at what angle and how deep the penis is inserted into the vagina," she says.

Take it slow after pregnancy. Scar tissue left behind after an episiotomy can cause discomfort, so use lots of lubrication, says Susan E. Hetherington, Dr.P.H., a certified nurse-midwife and sex therapist and professor in the School of Nursing at the University of Maryland in Baltimore. She suggests that your partner put a dab of water-soluble lubricant on his finger, then, with your assistance, gently place that finger in the vagina. You should bear down, as if going to the bathroom, and that will release the muscle that stimulates the vaginal opening. This allows his finger to slip in more. Gentle touching will relax the vagina. Then, with proper lubrication, the penis will slide in. It should be a slow process with no deep thrusting initially, she says.

Keep a diary. If you are experiencing pain with sex, keep a record of what kind of pain you have and when, says Kessler.

Keep track for two to three months and look to see whether the discomfort occurs on entry or with deep thrusting, whether it only occurs while intercourse is going on or if it continues after the penis is withdrawn, whether the pain always occurs at the same time of the month and whether it happens with every position or only with one. And if a woman has multiple partners, she needs to pay attention to whether she has the pain with all partners or just one, says Kessler.

Find the right doctor. "The main thing is to know that if it hurts, that's a signal that you need to do something about it. I always want them to get a medical exam as soon as possible," says Kessler. It's important to find a doctor who understands the problem, too. Some will do a pelvic exam and say they don't see anything, leaving the woman with the impression that it's all in her head, Kessler says. "Women need to keep seeking an answer. If one doctor says, 'I don't see anything,' and offers no other options, be persistent and get a second opinion," she says.

Get help for vaginismus. Doctors do have a technique--called vaginal dilation--for helping women with vaginismus. With supervision, women first learn techniques to help them relax. Then, starting with a dilator about the size of the small finger, they learn to penetrate the vagina. Slowly, at a pace at which they are comfortable, they work their way up to a dilator that has a circumference equal to that of their partner's penis.

When women start the process, they're often anxious and scared, says Kessler. "Once they realize they won't have to jam something into the vagina and won't have to progress any faster than they are ready to, they relax, and that brings relief and results," she says.