Painful Sex – Women

Painful sex is distressing. 

As well as the physical pain, there is the emotional pain women feel when they are unable to enjoy sex with their partner.

No one feels like having sex if it hurts, but it’s easy for your partner to feel like you don’t care.

There are lots of possible causes but with some help, you and your doctor can usually work out what the problem is.

Common causes of pain with intercourse include sensitive skin at the opening of the vagina (called provoked vesibulodynia), painful pelvic muscles, a painful bladder, a painful uterus or endometriosis.

The vulva is the area between your legs and the labia are the folds of skin near the opening of the vagina. If the skin is sore, good ideas include:

• Use QV cream, or sorbolene/glycerine cream instead of soap when you wash.
• Avoid waxing the hair on the labia.
• Ask your doctor to check for a vaginal or thrush infection. If you have a lot of trouble with thrush, then a weekly tablet of fluconazole 200mg for 6 weeks or longer if needed often helps.
• Try a low dose of amitriptyline.
• Use a 2% amitriptyline cream if you are tender just at the opening of the vagina.
• See a ‘vulval dermatologist’ (skin doctor) if you still have problems as there are some skin conditions (not infectious) that can make the skin sore.

The pelvic floor muscles are the ones you tighten when you want to stop passing urine quickly. They can become tight, strong and painful.

Often there is an ache in the pelvis much of the time, sometimes with sudden crampy spasms. Intercourse, examinations, or using tampons are very painful and sometimes the pain lasts for hours or days afterwards. There may be sudden sharp or stabbing pains up the vagina or bowel when the muscles cramp. Pain is often worse with exercise and isn’t helped by normal pain medications.

You can check your pelvic muscles yourself by inserting one finger just inside the vagina. Push backwards towards the bowel with your finger, then push sideways towards your hip on each side. Does pushing these muscles cause the same pain you get with intercourse?

If intercourse has been painful, the pelvic floor muscles, which wrap around the vagina, tighten up and close the vagina protectively. That could be a good idea initially, but not if they don’t let go again. Intercourse won’t be fun! It might all start with something pretty harmless, like a thrush infection, dry sex or bladder infection, when the sensors in the skin or bladder start sending lots of messages to the brain. If the brain decides there’s a ‘threat’ or ‘danger’, things start to spiral out of control and a cycle of chronic pain begins.

• Use a heat pack or a hot bath when the pain is severe.
• See a specialised womens physiotherapist to help the muscles re-learn how to relax and move normally.
• Keep moving, but avoid exercises that hurt you. Your muscles are already tight and short, and core-strength exercises such as pilates may aggravate the pain. Avoid prolonged sitting.
• Explain to your partner that you  should avoid vaginal intercourse until the muscles improve. Sexual activity without penetration is fine.
• Use a vaginal trainer (dilator) to slowly teach the muscles to relax – a range of dilators are available from the Online Shop  This is best taught by a woman’s physiotherapist.
• Use a pelvic muscle relaxation audio such as the one available from our Online Shop 
• Use a small dose (5-25mg) of amitriptyline (from your doctor) early each evening.
• Continue regular gentle exercise, such as walking.
• Treat other causes of pain so there is less need to hold muscles tightly.
• Think about how you hold yourself and avoid holding tension in your pelvis.
• Consider an injection of botox to the pelvic muscles if the pain is severe. This is often helpful. The botox is injected as day surgery under anaesthetic, lasts 4-6 months and stops the muscles cramping. It also makes physiotherapy easier.

• Use a water-based vaginal lubricant such as KY Jelly^®, or the special ‘Olive and Bee Intimate Cream’ if you find lubricants irritating. Olive and Bee is available from our Online Shop.
• Ask your partner to go slowly and wait until you are ready.  Using the relaxation audio each day for a couple of weeks beforehand can teach you how to relax these muscles. Using a slow gentle finger first allows you to get past the initial muscle spasm, before penetration.
  
• Try to avoid the time around periods when you are more sensitive.

• If pushing the front wall of the vagina causes pain and you have bladder troubles, then the pain may be due to painful bladder syndrome. Treating the bladder problems often helps.

• Endometriosis can cause painful intercourse deep inside, especially if it lies between the uterus and the bowel. However, this is difficult surgery, and you will need a gynaecologist skilled in difficult laparoscopic surgery.  A laparoscopy will not fix pain from pelvic muscles.

• Sexual abuse was once thought to be a major cause of pelvic pain. We know that most women with pelvic pain have not been sexually abused. Even so, sexual or physical abuse is common, is always wrong, is not your fault and is something that can make getting better more difficult.