Pain with sexual activity, also called “dyspareunia”, is a very common and distressing medical problem. Close to 3 out of 4 women have reported having pain with sex at some point in their lives. For some, it occurs only once or rarely, and for others, it is a chronic life-long problem.
During perimenopause, menopause, the postpartum period, especially when breastfeeding, women may experience symptoms related to having low estrogen levels, often experienced as dryness, burning, itching, irritation, and pain with sex.
Often, providers recommend starting with vaginal lubricants and moisturizers, however these often fail to improve symptoms. It could be argued that the first line of treatment should actually be vaginal estrogen for these patients.
Vaginal estrogen comes in many preparations, including a cream, a vaginal tablet or capsule, and a vaginal ring.
“The vagina does not have glands. You get lubricated aka "wet" when fluid leaves small blood vessels in the vaginal wall. This is called a transudate (or transudative fluid). When your estrogen level is low, you have less blood flow to your vaginal wall. Therefore, it will be hard to get lubricated no matter how mentally turned on you are...
Lubricants are like 'giving your vagina a fish.' Vaginal estrogen allows natural sexual responsiveness to return in people with low estrogen who struggle with this. "
Low dose vaginal estrogen primarily exerts local effects on the vaginal and vulvar tissue, without much absorption into the bloodstream or other parts of the body. Studies have shown NO increased risk of breast or endometrial cancer, nor any increased risk of cardiovascular disease or blood clots due to vaginal estrogen.
Unfortunately, there is a black box label on vaginal estrogen products warning of several of these risks, but they are based on studies in women using much higher doses of estrogen. In fact, vaginal estrogen can prevent serious urinary tract infections (UTIs) (which means for peri-or postmenopausal women with UTIs it's actually safer to be on it than not)! One group of patients- those being actively treated for breast cancer- should speak to their oncologist before using vaginal estrogen.
Check if you’re a candidate for vaginal estrogen by scheduling a free consultation with one of their compassionate, sex-positive providers.
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A lack of sexual interest or response, often with resulting vaginal dryness, can cause sexual activity to be painful. Often it may be rooted in a history of trauma, mental health issues, relationship problems, fatigue and stress, medication side effects, and medical or surgical conditions.
The following types of medication are known to sometimes decrease sexual interest or response:
It is important to share any history of the above with a trusted medical provider so you can work together to figure out the root cause of the problem and find a solution. This may include psychological counseling or therapy, reviewing your medications and seeing if a change may be appropriate, and treating your or your partner’s medical conditions appropriately to improve your sexual function.
Opening up about sexual trauma, mental health challenges, or relationship problems can be difficult and stressful. It’s important to make sure you are in a safe environment to share these concerns. Ideally, you would share these concerns with a clinician you know and trust. If you don’t have one, seek a professional who specializes in your concern. Typically, clinicians will list in their bio if they have experience with sexual trauma, depression/anxiety and other mental health challenges, and relationship counseling.
Here’s an example of what a trauma-informed mental health practitioner’s bio might look like.
When it comes to medications that reduce sexual interest, there may not always be alternatives or the option to stop taking these medications. In this case, the use of lubricants, sex toys, or other sexual stimulation may help to overcome the loss of interest. This can take some experimentation and time. Be patient and gentle with yourself. Don’t be afraid to ask your partner (if you have one) for support.
Here are some ethical, women-friendly sexual health & pleasure companies you can reference:
Acute vulvar pain can cause pain with sex due to irritation or inflammation of the vulva. This can be due to contact dermatitis, which is an inflammation related to a chemical exposure or allergic reaction, skin injury following a trauma, a skin disorder, such as eczema, or infections of the skin.
A medical provider can help you figure out the cause after a history and exam. Treatment of the underlying cause should resolve the problem fairly quickly.
Typically, treatment for acute vulvar pain involves supportive care, such as removing any offending agents, using hypoallergenic products, doing sitz baths, applying barrier creams, and possibly the use of topical steroids. Steroid creams are well tolerated for the most part, however overuse can sometimes lead to burning, stinging, redness, dilated blood vessels, stretch marks, and thinning of the skin.
A physical exam is likely the best way for a clinician to diagnose irritation of the vulva. However, if a telehealth visit works better for you, many clinicians now have secure ways to accept photos. Just make sure you confirm with your clinician if and where to send the photo before you do it!
Here are some reliable platforms for basic telehealth visits:
With insurance: Plushcare
Without insurance: Sesamecare
If you already know exactly which medication you need: Wisp
Note: Telehealth visits are offered free with many insurance plans, so make sure you check your benefit plan for their preferred provider.
Vulvodynia (vul-voe-DIN-e-uh) is chronic pain or discomfort around the opening of your vagina (vulva) for which there's no identifiable cause and which lasts at least three months. The pain, burning or irritation associated with vulvodynia can make you so uncomfortable that sitting for long periods or having sex becomes unthinkable. The condition can last for months to years.
Chronic vulvar pain, or vulvodynia, often requires a multi-pronged approach to treatment and can often be prolonged. This can include counseling, to try and reduce stress, pain, anxiety, and fear associated with sex, sex therapy and couples’ therapy, pelvic floor physical therapy, and at times, the use of prescription medications, such as topicals to reduce pain locally, or oral medications such as antidepressants or muscle relaxants.
Pelvic floor therapy can be an effective treatment for Vulvodynia. The therapists at Ruth Health are trained to support your healing journey with compassion and evidence-based advice.
Recent tweets from Alison Greenberg, Co-Founder of Ruth Health:
Perineal pain with sex can occur in women after childbirth when there is injury to the vagina at the perineum, where tears can often occur, or where an episiotomy may be done.
Chronic vulvar pain, or vulvodynia, often requires a multi-pronged approach to treatment and can often be prolonged. This can include counseling, to try and reduce stress, pain, anxiety, and fear associated with sex, sex therapy and couples’ therapy, pelvic floor physical therapy, and at times, the use of prescription medications, such as topicals to reduce pain locally, or oral medications such as antidepressants or muscle relaxants.
This can last several months after childbirth and can be treated with physical therapy, medications such as local anesthetic, and in some cases, may require surgery.
The best thing you can do to address an unknown cause of perineal pain is find a gynecologist you trust. We know this can be challenging and put together some tips and information on how to find that person here.
Infections of the genital tract, including urinary tract infections, vaginal infections, and sexually transmitted diseases, can cause pain with sex. Symptoms such as burning with urination, frequent urination, abnormal appearance of the urine, foul odor of the urine, abnormal vaginal discharge, foul-smelling vaginal discharge, itching, burning, rash, and pelvic pain should warrant a trip to your doctor for further evaluation and testing for infections. At times, pain with sex may be your only symptom.
Treatment for vaginal infections typically involves antibiotics or antifungal medication (either orally or via a cream).
Antibiotics, both oral and cream, require a prescription from a licensed clinician, as do oral forms of antifungal medication.
Antifungal creams, typically used to treat mild yeast infections, can be purchased without a prescription at a drugstore or grocery store.
The antibiotics commonly used to treat vaginal infections are considered quite safe and may cause temporary side effects. Some individuals may be allergic to some antibiotics and should discuss this with their provider.
Both oral and topical antifungal creams used to treat yeast infections are considered quite safe. Some individuals may be allergic to some antifungal medications and should discuss this with their provider.
Many vaginal infections can be diagnosed virtually, especially if it’s not your first time. Wisp is a virtual pharmacy that offers same-day telehealth visits and prescriptions for vaginal infections.
If you believe you have been exposed to a sexually transmitted infections, visit the POV Guide to STIs:
The Complete Guide to STI's by a Modern OBGYN
Vaginismus is an involuntary contraction of the vaginal and pelvic floor muscles that can often cause pain with sex. Like a lack of sexual interest or response and some cases of chronic vulvar pain (vulvodynia), this can be caused by a history of trauma, relationship problems, and stress.
Patients with this condition may benefit from counseling, to try and reduce stress, pain, anxiety, and fear associated with sex, and sex therapy and couples’ therapy.
Working with a physical therapist to learn muscle relaxation techniques has been shown to be effective. At times, treatment is aided with the use of vaginal dilators.
Other treatments for vaginismus include hypnosis, muscle relaxants, and even botulinum toxin type A injections (Botox).
Due to cost or lack of options, many patients attempt to treat vaginismus themselves via guides or videos found online. While the internet and social media can be a great source of information, Vaginismus is a tricky condition. Improper use of dilators and pelvic floor exercises is common and can make the condition worse.
HelloGina is the first ever clinically-validated digital course for Vaginismus.
They are truly the cutting edge in Vaginismus treatment, because they work with you over 12 weeks on both the mental and physical aspects of the issue.
This is not an online course made by influencers. HelloGina was designed by one of the world’s leading researchers on female sexual dysfunction, Dr. Anna-Carlotta Zarski.
Learn more about Hello Gina by checking out our in-depth review of their services.
Pelvic pain which can cause pain with sex can have many causes and can often be difficult to diagnose. Often the approach to diagnosis involves ruling out a wide variety of causes with your primary care, gynecologist, and other specialists, so that appropriate treatment can be given.
a brief but not exhaustive list of potential causes:
Treatments depend on the ultimate cause of the pelvic pain, and can include antibiotics, medications, hormone treatment, surgery, and counseling or therapy.
Because pelvic pain can have so many different causes, it can take awhile to diagnose and treat. This can be intimidating, but it’s important not to avoid care as these conditions can get worse over time and lead to serious health complications.
The best thing you can do to address an unknown cause of deep pelvic pain is find a gynecologist you trust. We know this can be challenging and put together some tips and information on how to find that person here.
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