Everybody Hurts Sometimes… Or Do They? Understanding Female Genital Pain

Many girls grew up thinking that their first intercourse might be painful. We’re told that we’ll probably bleed, and it will hurt. For some, the message ended there, perhaps leaving us anxious or stressed about what was to come. For most, we received other messages about how “mind-blowing” and “passionate” and “pleasurable” sex will be, once we get through that first time. So what happens when sex continues to be painful? Painful sex, also known as “dyspareunia” is reported by 10 to 28% of reproductive aged women in the United States.1 For some of these women, sex is painful at the entrance to their vagina, an area called the vulva (a pain known as “vulvodynia”), for others, the pain is deeper inside. Regardless of the pain presentation, these women are all left wondering, “Is this normal?” “Will the pain ever go away?” Some tell their partners, many do not. For some women the pain is limited to intercourse, but for others, they can experience unprovoked genital pain, or pain with activities such as bicycle riding or wearing a tampon.

Many women who suffer from dyspareunia don’t reach out for help, finding it a topic that is too shameful or embarrassing, too difficult to speak about, or perhaps even believing the pain is “normal” or that they will not be believed. While the sexual consequences may seem obvious: less desire, harder to have an orgasm, if at all… there are also many consequences outside of sex. Relationships can be impacted, and multiple studies show that women who suffer from pain during sex are more likely to also report anxiety and depression.

So, why does this sexual pain happen? More importantly, what can you do about it?

Causes of genital pain and pain during intercourse are numerous; many are medical, but as with any pain, there is also a lot of overlap with psychological factors. If a medical cause is identified, which isn’t always the case, it’s important to receive the appropriate treatment for that particular condition (e.g., endometriosis, a vulvar/vaginal infection, pelvic floor injury). Good treatment plans start with the least invasive treatment, and often include a multidisciplinary, or team, approach. Professionals you might expect to interact with over the course of your treatment can include a gynecologist, a pelvic floor physiotherapist, and a psychologist/sex therapist or pain management specialist. If a medical cause is not identified, it is important to remember that this does NOT mean that the pain isn’t real. We have many chronic pain conditions for which we still do not understand all of the underlying causes, but we do know that the pain is there, and it is real!

In assessing and treating the pain, learning more about what is going on for you is the first step. You can expect questions about your medical history, psychological history, sexual history, and about how the pain feels (many women describe the vulvar pain, for example, as “burning” or “sharp”). While just the thought of someone asking these questions can be overwhelming, it is important to know that, when you find a good health care provider, the questions are asked in an environment that is safe, welcoming, and non-judgmental.  While a psychologist/sex therapist will not conduct their own physical exam, it is important that a physical exam is completed by a gynecologist for appropriate and comprehensive diagnosis of the problem. If this is too scary, you can work with a psychologist toward feeling more comfortable.

When the cause of the pain is not known, or even if it is, professionals can work with you to explore different potential irritants for your pain. Below is a check list of a few things to think about, if you haven’t already. None of these suggestions means your pain is not serious or real or that it is “that simple” to fix, but some of them may useful for decreasing the intensity or frequency of your pain.

-        Change to 100% cotton underwear, and no thongs

-        Use a non-irritating lubricant during sex – sometimes it takes a while to find the best fit for you, but it’s a good general rule to stay away from gimmicks such as scents or flavors

-        Use a detergent for sensitive skin when washing your clothes

-        Use a scent-free soap for sensitive skin when washing your genitals

-        Wear clothing that is more loose fitting around the genital area and allows room to breathe

-        Change positions during sex to see if any are less painful

When you see a sex therapist, or any other professional about your pain, you’ll also be educated about your pelvic floor anatomy and physiology, as well as about how chronic pain develops and is maintained in the body and in the brain and about sexual response and female sexuality. What therapy offers, in addition to other potential treatments, are strategies to manage your pain, and any anxiety or fear that comes with anticipating the pain and the activity (sex) that most often causes the pain. Cognitive Behavioral Therapy helps by identifying how your thoughts, feelings, and actions interact to increase pain responses and avoidance of sex and then, uses strategies to break this cycle, and, if you so desire, to help increase your desire and your sexual satisfaction.