Dyspareunia (Pain During Sex - Pain After Sex)

The term dyspareunia is used to describe the pelvic pain which is felt during or following sexual intercourse.

It is not clear how common dyspareunia is, as a significant number of women avoid seeking medical help. Nonetheless, questionnaires enquiring whether women suffered from any symptoms would indicate that roughly 1 to 4 women in 10 encounter it. More frequently, it is during the early part of their sex lives and after the menopause.

There are numerous reasons why dyspareunia occurs, out of which the majority are not typically severe or damaging, although, in their entirety, they could be harmful to your sex life and in the long run cause problems for your relationship.

It can feel like you are in a never-ending circle, with the discomfort making you nervous about having sexual intercourse, which in turns leads to dryness and additional pain.

It is quite common that following treatment for dyspareunia the problem remains, mainly if there has been no treatment for some time. With this in mind, it is fundamental you seek medical assistance early on so that the causes can be determined, treated and managed.

What is dyspareunia?

Dyspareunia is defined as the discomfort felt either in the pelvis or external genitalia during or following sex (deep penetration or external or superficial). There is an assortment of causes and remedies, and while it is conceivable that both can be experienced simultaneously, the majority of women largely suffer from either dyspareunia, not both.

Superficial dyspareunia

With superficial dyspareunia, the discomfort is felt at the introitus (lower section of the vagina) upon penetration or the initial stages of intercourse. The soreness is instantaneous and is swiftly eased by ending penetration. However, you may feel some subsequent soreness when you touch for a short time afterwards. The reasons for superficial dyspareunia are usually linked to local vaginal and perineal skin issues (perineum is the region of skin in between the vagina opening and the anus).

Deep dyspareunia

This term refers to the discomfort felt in the deeper region of the pelvis during or following sex. It can also encompass front part of the thighs. I can either be intense or dull, and may come to an end once penetration has stopped, or continue for several minutes and sometimes hours. This kind of discomfort is caused by and large from deeper within the pelvis.

Causes Of Superficial Dyspareunia

Skin bridge

It is quite common following childbirth for scar tissue (skin bridge) to form on the back of the introitus (vaginal entrance), especially if you have had an episiotomy, which is a procedure where an incision is made in between the vagina and anus (back passage). The scar tissue has highly sensitive nerve endings, and consequently, discomfort is felt on penetration. The discomfort is likely to intensify as intercourse continues because the rubbing from the continued penetration aggravates the skin bridge.  

Intact hymen

The membrane which surrounds or partly covers the entrance to the vagina is known as the hymen. Early on during your sex life, the hymen is broken down through sexual intercourse. In countless female adolescents, it has likely already been stretched from using tampons. The name can be somewhat misleading because, in fact, the hymen has a tiny hole which is formed at birth. As a young girl matures, the hole gradually becomes larger. Nevertheless, the membrane can be fairly thick and the hole slightly too small. This may result in the fact that during the early stages of her sex life, when the hymen is pushed open during her first sexual encounter, she may experience pain. It is when an attempt at penetration is made that the pain is felt superficial – at the entrance to the vagina – which may stop it from happening altogether.

Vaginism (Vaginismus)

Vaginism refers to the powerful muscle (pubococcygeus muscle) contraction which occurs at the vaginal entrance which can on occasions be painful. It can cause penetration to be painful or not possible. Sometimes it prevents tampon use and any gynaecological check. The vaginism contraction cannot be created consciously; it is beyond your control. It may appear to start for no specific reason, but may also occur from an uncomfortable or distressing sexual experience, which it automatically becomes like a defensive reaction. Nevertheless, vaginism is disconcerting and disheartening for a couple because it can bring a halt to the pleasures of enjoying sex for countless years, and on occasions even put a stop to sex entirely. Once it starts, a feeling of displeasure and anxiety about the inability to have sex adds to the problem. It is therefore crucial that you seek medical help to stop the never-ending circle of anxiety and discomfort.

Bartholinitis

The Bartholin's glands are located in the tissue on each side of the vaginal walls. When they inflame and become tender, it can cause Bartholinitis which can bring about discomfort during sex. Sometimes, during sex, the glands will swell but remain painless, but as intercourse continues, the pain develops.

Vestibulodynia (Vulvar vestibulitis)

Vestibulodynia can be a problematic condition. Discomfort develops in the vulvar vestibule making it highly sensitive to touch and any form of pressure. It is also possible that acute pain is felt when penetration is attempted, it is painful to the touch, day to day living and during other activities. It can cause immense frustration and despair, as the symptoms can be long-term. Although the cause of Vestibulodynia is uncertain, it possibly involves infections in the vulvar vestibule such as candida (thrush) or other viruses.

LSA (Lichen Sclerosus et Atrophicus)

LSA is a long-lasting, chronic skin disease which has an unknown cause and can affect children and women of all ages. Typically, it appears following menopause. It brings about the thinning of the skin in the genital region as well as the appearance of white patches. The immune system could be the cause, and it brings with it itching and discomfort, which can be long-lasting. It is misidentified as candida due to the itching and soreness suffered on many occasions. LSA carries a minor risk of cancer developing in the genital skin. Due to this, diagnosis and treatment, typically by way of cream application, should be undertaken.

FGM (Female Genital Mutilation)

FGM, also known as female genital cutting, consists of varying levels of surgery for removal of a woman’s external genitalia. With the more excessive types, the vagina is entirely stitched together. After FGM, permanent scarring is usual, which can bring about nerve damage and discomfort. Each of these problems can bring pain during penetration and cause sexual intercourse to become impossible.

Vaginal abnormalities

Seldom do vaginal abnormalities cause sex to become painful or impossible. These can consist of vaginal septa (extra pieces of tissue which are present at childbirth in the interior of the vagina).

Causes Of Superficial And Deep Dyspareunia

Vaginal trauma

A woman’s vagina is supple and strong and mends quite quickly after it stretches and occasionally tears during childbirth. Nonetheless, with considerable trauma, for instance, during a traumatic birth or mutilation, it may cause scarring which in turn may lead to discomfort and problems during intercourse.

Infections: Vaginal or genital

Vaginal infections and the area surrounding it may cause tissue swelling and generally cause discomfort during sex. The infection can be from candida (yeast infection residing in the bowel), diseases like herpes, and bacteria (germs). A broad range of bacteriological infections can affect the vagina. Several (but in no way all) are transmitted sexually.  Before sex, the vagina is not necessarily tender or itchy, but it can persist after sex. Frequently, a coloured and smelly discharge is present.

Vaginal dryness

A little discomfort during intercourse is owing to the absence of lubrication, meaning that there is vaginal dryness. Typically, secretions are emitted from the vagina which helps to maintain its moistness, which increases with sexual stimulation. If foreplay is limited, or you do not feel sufficiently aroused, your vagina may not produce sufficient lubrication for penetration to be comfortable.

Nevertheless, it is not always that straightforward. There could be other underlying emotional elements which stop you from producing enough secretion, like nervousness due to sex previously being uncomfortable; worrying about falling pregnant or waking up your children who are sleeping. Vaginal dryness can also be caused by physical elements, for example, post menopause the vagina can become drier. Some medication can be attributable to dryness, for instance, some means of contraceptive like IUS (intrauterine system). Sjögren's syndrome is similarly related with vaginal dryness, where the moisture-secreting glands are affected. Rheumatoid arthritis is also another ailment associated with dryness. Lastly, during pregnancy, the vagina can become dry during sex, (even though it can have the reverse effect too!).

Atrophic vaginitis (Vaginal Atrophy)

Post menopause, hormone levels in the body drop -  predominantly oestrogen levels. Oestrogen is a hormone secreted by the ovaries that keeps the wall of the vagina strong and resilient. It raises the supply of blood and secretion levels causing the vaginal wall to soften and stretch. Consequently, when the levels of oestrogen drop following menopause, the tissue becomes thinner, less flexible and not so well lubricated, and on occasions, the vaginal tissue can be as delicate and fragile as that of a young girl (those who have not yet gone through puberty and started menstruating). The cause of such changes is sound: Mother nature doesn’t anticipate women post-menopausal to attempt to have sex because they cannot have babies

Causes of deep dyspareunia

The genital organs are usually the cause of deep dyspareunia, although it is possible for it to be caused by other elements within the abdomen, that may be bumped during intercourse. So, there are some probable causes of deep dyspareunia (deep pain) in the stomach during sex.

Pain in the Cervix

The cervix (neck of the womb) is not generally meant to be painful. Although, a number of bacteria can infect the cervix just as they can the vagina, for example, herpes. If the neck of the womb becomes swollen, then a penis knocking it during intercourse could well cause deep pelvic pain or on occasions pain in the front of the thighs. (Cancer of the cervix is fortunately rare and will not typically cause pain during intercourse). The cervix may become sore and sensitive to the touch if you have a contraceptive IUS, and if it is positioned too low. During sex, it may cause a sudden pain within the cervix.

Endometriosis

The condition of Endometriosis is caused where small pieces of the uterine lining (womb) embed themselves in another part of the body. In the majority of cases, this occurs in the ovaries, fallopian tubes which connect the uterus and the ovaries, and cervix. The pieces of tissue haemorrhage each time you have a period. The blood generally causes scar tissue to form, organs fastening to each other and the pelvis becoming painful.

Endometriosis is characteristically seen in younger women, and might only become noticeable when they initially stop taking their contraceptive pill. The Endometriosis

is suppressed by “the pill” which is in effect also its treatment. The condition produces pain during sex which usually occurs during deep penetration and lasts for a while once penetration has ended. Endometriosis also causes painful menstruation, and women with the condition may find it hard to fall pregnant.

 

Ovarian Vein Reflux (Pelvic venous congestion)

Ovarian Vein Reflux manifests as swollen or enlarged veins inside the pelvis. It can bring with it a lower back and abdomen aching, especially following a long period of standing. The pain often becomes more intense following intercourse and may last for several hours. Those women who suffer from ovarian vein reflux also tend to encounter painful periods with heavy bleeding and stomach bloating.

Ovarian cysts

Ovarian cysts can bring about pain while having sexual intercourse since the ovaries can be bumped by the penis during sex which can make the cysts leak fluid. It is not uncommon for you to have ovarian cysts, as their formation is a routine part of the menstrual cycle. Nonetheless, the biological cysts are characteristically small. With larger cysts, there is more chance of them leaking more and causing greater pain, which can be one of the symptoms of polycystic ovary syndrome or endometriosis, particularly in adolescent females. In females who are post-menopause, ovarian cysts are a concern as they may be a sign of ovarian cancer.

A further inoffensive type of ovulation pain is known as 'Mittelschmerz'. This refers to when the ovary releases an oocyte (egg). Discomfort from Mittelschmerz does not have to be sex-related, and it can generally last for 2-3 days half way through the month – although it may be worsened by sex when it occurs.

Uterine fibroids

Uterine fibroids are benign (non-cancerous) growths in the womb’s muscle, which can make the womb quite large. It is not necessarily painful, but it may cause discomfort during intercourse. On rare occasions, uterine fibroids grow quickly and become malignant (cancerous), thereby triggering more noticeable discomfort. This, nonetheless, is quite rare.

Uterus positioning

Some women’s wombs tilt backward as opposed to forward; meaning the ovaries fall backward as well. With them being so far set back, the position leaves them vulnerable to being knocked during deep penetration. This may lead to deep pelvic discomfort which is more evident with deeper penetration but slowly diminishes after it stops or there is a modification of position.

Bowel discomfort

During sex, the bowel can be shifted and knocked. In the event of a tender or sensitive bowel, it could be the source of discomfort while having sex. This is explicitly likely to occur in women with IBS (irritable bowel syndrome), Crohn’s disease or UC (ulcerative colitis), which are the reasons behind the bowel being painful.

PID (Pelvic inflammatory disease)

PID is the infection and swelling of women’s reproductive organs (fallopian tubes, womb and occasionally the ovaries). Since all these organs undergo some form of movement during intercourse, they sometimes cause pain. This discomfort is routinely felt deep within the pelvis and becomes more intense during deep penetration, but slowly settles after penetration has stopped. PID can similarly make you feel ill and induce a fever and discharge from the vagina.

Bladder discomfort

The bladder is located above the top of the womb, slightly behind and over your pubic bone. Similar to the womb, the bladder moves and sustains pressure during sex. Consequently, if there is inflammation of the bladder, it can hurt. The usual reasons for discomfort are bladder infections as well as interstitial cystitis. Characteristics of this are the bladder becoming painful and sensitive. It acts similar to infectious cystitis without the presence of infection.

Summary

Dyspareunia and its symptoms (discomfort in the pelvis during or following intercourse) can be distressing and demoralising. Your sex life can be impacted, as well as your fertility and your relationship. A number of the causes have a very straightforward remedy/treatment, so it is vital that you seek medical assistance if you are undergoing problems.