In Your Business with Dr. B: Painful Sex

Woman covers herself

We’ve written at length about women experiencing painful sex during menopause or because of endometriosis, but there are a variety of other reasons why women who are sexually active may experience painful sex at any age. The good news is, many of these issues are treatable. We asked our favorite women’s health expert, Dr. Rebecca Brightman, to explain some of the reasons why pain may happen during sex, and what you can do about it.

When should you see a doctor about painful sex?

It’s not unusual for sex to be a little uncomfortable. It can be awkward. It’s not always perfect like it is in the movies, so don’t hold yourself to that standard. But if you’re experiencing pain from the get-go, or new pain, you should see your healthcare provider. If you have persistent pelvic pain, especially if it’s associated with a fever and unusual discharge or the presence of any lesions, that should also set off an alarm bell to see a doctor right away.  

What is the most common cause of pain during sex?

Often it’s because a woman is not well lubricated. Everyone’s body is different when it comes to the amount of moisture and lubrication it provides, and that doesn’t necessarily reflect how turned on somebody is. There should be no shame involved with buying vaginal lubricant, and I encounter women of all ages who need to use a lubricant. Beyond that, you need to look at exactly where the pain is. In younger women who are sexually active, there could be a structural issue. For example, some women have a rigid hyman, meaning it can’t stretch, which makes penetration very difficult. I also see cases of vulvodynia in patients of all ages, which is pain surrounding the vulva that isn’t caused by a clear infection or skin disorder. 

What causes vulvodynia?

It’s not clear exactly what the cause is, but it’s a combination of dysfunction of the pelvic floor muscles and the firing of nerve fibers. This might happen because of injury to the nerves, irritation, or muscle spasms. Women can overcome it, but it takes work. I find that with vulvodynia, my patients typically do incredibly well with pelvic floor physical therapists. I see a lot of pelvic floor dysfunction, especially among my younger patients, and this is something practitioners weren’t even really looking at until about ten or fifteen years ago. It’s exciting that there are people now who have focused their careers on pelvic floor physical therapy. These specialists can teach women to gain control of their muscles to help with pelvic pain, painful sex, and even urinary issues. When a woman feels pain during sex, the natural tendency is to sort of clench the pelvic floor muscles. Pelvic floor physical therapy teaches women to relax them instead— it’s almost like doing a reverse kegel exercise. For a patient to know if they would be a good fit to see a pelvic floor therapist, they would first need to be evaluated with an internal exam to rule out any sort of infection. 

If pelvic floor therapy requires you to relax your pelvic floor, then what are Kegel exercises for?

Kegel exercises are typically done to strengthen the pelvic floor muscles. This is important particularly for women who have incontinence issues because the pelvic floor holds up the bladder. Some women have very tense pelvic floor muscles— especially athletes. It’s important for people to have good pelvic floor musculature, but there are times that the pelvic floor muscles can spasm and cause discomfort. A very strong pelvic floor might lead to painful sex because when those muscles tense it’s almost like pushing against a brick wall. Also, during childbirth, those muscles have to be relaxed in order to push the baby out. So I think it’s important for women to identify how to strengthen those muscles, but learning to relax them is also key.

What about ovarian cysts? Can these cause pain during sex?

When a woman is in her reproductive years, sometime during the course of her menstrual cycle the ovary makes a small cyst, or fluid-filled sac, which bursts mid-cycle to release an egg. That’s ovulation. Sometimes the release of this egg results in the release of fluid that can irritate the pelvis and cause discomfort. As long as that’s a brief pain, that’s ok, but if it’s something that persists, then you should see your healthcare provider. There’s a term for it called mittelschmerz, which is cycle-related pain. It doesn’t necessarily relate to sex, but you might be more aware of it during sex. 

Remember that the uterus, the ovaries, and the fallopian tubes are not fixed structures. So during penetration, all of those things move around a little bit, and during an orgasm, the uterus contracts. So if somebody has a large ovarian cyst, they may experience that as discomfort during sex. 

What are your thoughts on over-the-counter yeast infection treatments? 

My feeling is if a woman has previously had a yeast infection, so she is familiar with and can easily recognize that infection, she can try a short course of over-the-counter medication for treating yeast. That said, not all yeast infections respond to over-the-counter medicine, and not all vaginal itches are caused by yeast. I’ve seen patients try to treat themselves repeatedly for a yeast infection using over-the-counter medication when their symptoms were actually caused by new-onset herpes. You may also have bacterial vaginosis, which requires either an oral or vaginal antibiotic. So if you really feel like you have a yeast infection, I think it’s fine to first try something over the counter, but if the symptoms continue, don’t just do another round. Go in and get evaluated. I don’t think people realize there can be resistant yeast strains. In an office, we can do a lab test to confirm whether you truly have a yeast infection or not, and if so, does this yeast respond to standard therapy? Or, is a second-line treatment needed?

Are there any other obvious reasons why women might experience pain during sex?

Sometimes it’s related to the relationship. I’ve seen women who have had terrible, terrible pain with a partner; the term we use is dyspareunia. Then all of a sudden I’ll see that woman back in a year, and she is in a new relationship and has no pain. It’s a very complex problem. 

Finally, some women may feel more comfortable in certain positions. This could be because of the positioning of your uterus, or where you are during your cycle. You’ll figure this out from trial and error. You have to figure out and vocalize what feels good for you and what doesn’t.