Painful Sex Is Not Something to Put Up With

TL;DR: Around 1 in 13 sexually active women in Britain report painful sex lasting three months or more. Common causes include infections, vaginal dryness, vaginismus, endometriosis, vulvodynia, recovery after birth and menopause. Most are treatable with options like lubricants, vaginal oestrogen, pelvic floor and relaxation exercises, and talking therapies. Pain is a symptom worth raising, not a duty to endure.

Maybe it started after your baby was born. Maybe it has always been there and you assumed this is just how sex feels. Maybe it comes and goes, sharp at the entrance or a deep ache with certain positions, and you have learned to brace, distract yourself and get through it. Many women carry this quietly for years, sometimes because nobody ever told them it could be different, and sometimes because they were told, directly or not, that a good wife or girlfriend does not complain. Pain during sex has a medical name, dyspareunia, and it has causes that clinicians can find and treat.

How common is painful sex?

More common than most women think. A large British survey of more than 6,600 sexually active women found that 7.5 percent had painful sex lasting three months or more in the past year, and a quarter of those had symptoms very often or always, for six months or longer, causing distress. The same study found strong links with vaginal dryness, anxiety about sex and not enjoying sex. Those figures come from Britain, but there is no reason to think women in Lagos, Nairobi or Accra feel it less. They may simply talk about it less.

Why it gets endured instead of treated

In many of our communities, sex is something women are expected to provide rather than enjoy, and certainly not something to discuss with a doctor. A newly married woman may feel she cannot refuse her husband. A mother of three may feel her own comfort comes last. A young woman may worry that mentioning pain will mark her as having done something wrong. Faith, family and the fear of being judged by a clinician who knows your auntie can all keep the subject closed.

There is a cost to that silence. Pain can make you anxious about the next time, and the NHS notes that anxiety and past painful experiences are among the things linked to vaginismus, where the muscles tighten on their own. The British survey linked painful sex to poorer mental health and relationship strain, and to past experiences of sex that was not wanted. If any part of your story involves sex you did not choose, that matters too, and a good clinician will treat it with care.

What causes pain during sex?

There are many possible causes, and more than one can be present at once. The location of the pain, at the entrance or deep inside, gives useful clues. Common causes include:

• Infections. Thrush can cause soreness and stinging during sex. Pelvic inflammatory disease, which is often caused by a sexually transmitted infection, can cause pain felt deep inside during sex. Our guide to yeast infections and BV covers the signs.
• Vaginal dryness. The NHS lists menopause, pregnancy, breastfeeding, some hormonal contraceptives and antidepressants, cancer treatments and not enough arousal as causes.
• Vaginismus. The vaginal muscles tighten on their own when something is inserted, causing burning or stinging. It is often linked to anxiety, fear of sex, a painful past experience, or beliefs that sex is shameful.
• Endometriosis. Pain during or after sex is a recognised symptom, often a deep pain with penetration or certain positions. If you also have severe period pain, read our post on the signs of endometriosis.
• Vulvodynia. Pain in the vulva lasting at least three months with no specific cause found. It can be constant or triggered by touch, including sex or inserting a tampon.
• After giving birth. The NHS says pain during sex is very common in the first few months after a tear or episiotomy, and hormonal changes after birth can make the vagina feel drier than usual. If pain is still there at your postnatal check, raise it.
• Menopause. Falling oestrogen thins and dries the vaginal tissues. We go into this in detail in vaginal dryness after menopause.

The NHS also lists pain during sex as a possible symptom of fibroids and ovarian cysts. Our pelvic pain guide covers some of these.

How do I talk to a clinician about painful sex?

Say it plainly at the start of the appointment: "I get pain during sex and I would like help with it." Clinicians hear this often. If you would feel more comfortable with a woman doctor, you can ask for one, and you can also go to a sexual health or family planning clinic.

It helps to come prepared. Think about:

• Where the pain is: at the entrance, deep inside, or both.
• When it happens: on first penetration, during, or afterwards, and whether it happens with tampons or examinations too.
• How long it has been going on, and whether anything changed around that time, such as a birth, a new contraceptive or a new partner.
• Any other symptoms: unusual discharge, bleeding after sex, painful periods, itching, or pain when you pee.

You may be offered an examination and swabs to check for infection. You can ask for a chaperone, ask the clinician to explain each step, and ask them to stop at any time. If you feel brushed off, it is fair to ask for a referral to a gynaecologist or a specialist clinic. Our post on how to talk to your gynaecologist has more tips.

What treatments help?

Treatment depends on the cause, and it often combines a few approaches:

• Treating infections. Thrush, BV and STIs are usually cleared with antifungals or antibiotics.
• Lubricants and moisturisers. The NHS suggests a water-based lubricant before sex and vaginal moisturisers for ongoing dryness. Avoiding perfumed soaps and washes can also help.
• Vaginal oestrogen. For dryness linked to menopause, the NHS notes that oestrogen can be used as a cream or pessary directly in the vagina.
• Pelvic floor and relaxation exercises. For vaginismus, the NHS describes relaxation and pelvic floor exercises that help you gain control of the vaginal muscles, and a physiotherapist is one of the specialists who may help with vulvodynia. Our post on pelvic floor health explains more.
• Vaginal trainers (dilators). For vaginismus and vulvodynia, the NHS describes graded, tampon-shaped trainers used gradually under a therapist's guidance.
• Talking therapies. Psychosexual therapy, a type of talking therapy, aims to help you understand and change your feelings about your body and sex. If you are in a relationship, you can choose to involve your partner.
• Treating the underlying condition. Endometriosis, fibroids or cysts may need hormonal treatment or surgery. For vulvodynia, the NHS lists numbing creams and nerve pain medicines among the options.

Treatment can take time, and the NHS notes that for vulvodynia you may need to try several approaches before finding what works. That is normal, not a sign of failure.

When should I see a doctor straight away?

See a clinician promptly if painful sex comes with bleeding after sex or between periods, unusual or smelly discharge, fever, or new pelvic pain. Bleeding during or after sex is one of the symptoms the NHS advises seeing a GP about, as it can have several causes that need checking, including changes in the cervix. Our cervical screening guide explains more. After a birth, contact your midwife or GP if your stitches become more painful, or if there is smelly discharge or red, swollen skin around a tear, as these can signal infection.

Notice your pattern

If you are not sure what is driving the pain, a few months of notes can help a clinician see it. Some women notice pain is worse at certain points in their cycle, which can point towards endometriosis or cysts, or that it started with a new pill. Asele's cycle tracking and symptom logging let you record this privately, and the Health Brief turns it into a summary you can take to an appointment, so you do not have to find all the words in the moment. Amara can also help you prepare questions in Yoruba, Hausa, Igbo, Swahili, French or English. You can find us at Asele.

This post is education, not medical advice. Your comfort during sex matters, and a clinician can help you find out why it hurts and what will help.

References

1. Mitchell KR, et al. Painful sex (dyspareunia) in women: prevalence and associated factors in a British population probability survey. BJOG, 2017. pubmed.ncbi.nlm.nih.gov
2. NHS. Vaginal dryness. nhs.uk
3. NHS. Vaginismus. nhs.uk
4. NHS. Vulvodynia (vulval pain). nhs.uk
5. NHS. Endometriosis. nhs.uk
6. NHS. Sex and contraception after birth. nhs.uk
7. NHS. Episiotomy and perineal tears. nhs.uk
8. NHS. Menopause and perimenopause: treatment. nhs.uk
9. NHS. Cervical cancer: symptoms. nhs.uk
10. NHS. Thrush. nhs.uk
11. NHS. Pelvic inflammatory disease. nhs.uk
12. NHS. Fibroids. nhs.uk
13. NHS. Ovarian cyst. nhs.uk