Sex hurts and I don’t know what to do about it, short of stocking up on lube. What gives?
Discomfort during sex can be super frustrating, especially when your libido hasn’t gotten the memo. But you should know that it’s a very common complaint, says Jennifer Lang, MD, an OB/GYN and gynecologic oncologist, who practices in Los Angeles.
The medical term for painful sex is dyspareunia and, unfortunately, it has many possible causes. “The whole field of pelvic pain and pain in general is a very complex subject and it’s very much a mixture of psychology and physiology,” says Dr. Lang, who’s also a fellow of the American College of Obstetricians and Gynecologists. “This could be a book.”
The culprits could be anything from where you are in your cycle to a gynecologic problem like a benign cyst, medications you’re taking to the kind of sex you’re having, the state of your relationship to a history of sexual trauma. To help suss out the answer, your doctor will want to know the type of pain you’re having, when and how you’re experiencing it, and if anything makes it better or worse.
First, though, and this may seem obvious, it’s worth remembering that women can take a little longer to get aroused than men and that foreplay serves a very distinct purpose. “Erections are pretty instantaneous, but women lubricate over a slower period of time. It’s important to make sure that a woman is in a high arousal state before penetration,” Dr. Lang says. So if you’ve only been having quickies recently, you might want to slow things down, grab the lube, or both.
And women’s vaginal mucus can change dramatically during the course of their natural cycle, or depending on what type of birth control they’re using, and that can, uh, certainly affect things. Women not using hormonal birth control will often find that their mucus is very slippery and pliable during the estrogen-dominant first two weeks of their cycle (with day one being their period), and less lubricating during the second half of the month when it’s under the effects of progesterone, she says. If women are using progestin-based birth control like the mini-pill or a hormonal IUD, they might notice that they have thicker, drier mucus or just less of it. And many of the very-low-estrogen birth-control pills can also have vaginal drying as a side effect. (But she points out that only some women using these methods will experience this.)
Here, again, is where lube comes in — assuming you’re comfortable enough to speak up. “The worst thing that can happen is you’re experiencing pain during intercourse and you’re too uncomfortable to say, ‘Hold on, we need to get the lube,’” Dr. Lang says. “You need to have a certain confidence in recognizing that sex should never been painful. For non-BDSM-type sex, pain is generally an indicator that there’s something that needs attention.”
Prescription meds can also change how things feel. Specifically, drugs that block androgens like spironolactone, which women take to treat polycystic ovary syndrome or help clear up hormonal acne, can affect the production of estrogen, too, which could leave your libido flagging. Also, narcotic painkillers can raise your brain’s dopamine threshold. As a result, “You would need more pleasurable sensations to get the same sense of an elevation above your baseline dopamine state,” so you may not get as turned on as before.
Other gynecologic causes of dyspareunia can include episiotomies during childbirth, scar tissue (a.k.a. adhesions) following abdominal surgery, and even garden-variety bacterial vaginosis or yeast infections. Toy users, take note: Toys need to be washed after each use and rinsed well, too, to get off any of the cleansing agents that could irritate you and lead to infection. And women in same-sex relationships probably shouldn’t pass toys back and forth because of the risk of swapping bad germs.
If you’re having pelvic pain at other times, not just during sex, your doctor will work to rule out ovarian cysts and possibly assess you for endometriosis, a condition in which the uterine lining sheds outside of the uterus, sometimes leading to painful adhesions connecting things that aren’t meant to be connected. Your gyno can usually reproduce this pain during a pelvic exam, Dr. Lang says. (Uh, thanks, doc?)
There are two less common conditions that can make sex painful: vulvodynia and vaginismus. Vulvodynia means pain in the external part of the genitals (the labia majora and minora), the clitoris, urethra, and the vaginal opening. It could be the result of nerve problems or simply too many nerves; women who have it may also feel pain with inserting tampons. It’s estimated to affect about 8 percent of women. Vaginismus, on the other hand, is when the muscles of the pelvic floor go into spasm and essentially lock the door to the vagina. It is less common, with a prevalence between 1 and 6 percent, according to ACOG. “Both conditions can be deeply troubling and upsetting for women, and if she doesn’t feel like she’s getting adequate answers or investigations by her generalist, there are specialty centers that address these,” Dr. Lang says.
If you don’t think your pain is either of those things and your doc has historically been generous with their time, then it’s something you could mention in your annual. But if you’ve mentioned painful sex before and gotten the brush-off, or you feel you have a lot to say on this subject, it’s probably best to make a separate appointment.
“These are conversations that almost by their very nature are complex and nuanced and require a bit of time,” Dr. Lang says. “My recommendation would be: Don’t try to tack this on at your annual visit when your doctor has allotted you 10 or 15 minutes to do everything. Make a special appointment for this chief complaint and, if possible, give your doctor a head’s-up.”
And just like you need to feel comfortable with your partner, ideally your doctor is open and understanding, too. “Doctors have gone through really rigorous academic training that has not necessarily been the best at preparing them for having these kinds of difficult conversations,” she says. “It’s also very important, particularly if your sexuality doesn’t fit into a heterosexual status quo, that you feel like your doctor is able to approach the conversation in a supportive, nonjudgmental way.” If it feels like your doctor is judgmental about the fact that you’re in a same-sex relationship or that you’re dating multiple people, that’s practically guaranteed to shut down any productive conversations you’d have, she says.
Let’s say you’ve gone through the ringer with your gyno and there’s nothing medically going on that could be causing your pain. Dr. Lang would then suggest talking to a sex therapist, and she’s referred lots of patients to the Center for Healthy Sex in Los Angeles. “The mind-body connection with sexuality is tremendous, particularly with women,” she says, adding, “Once you’ve essentially ruled out these physiologic things … having a 45-minute session just devoted to exploring [psychological] issues can be more beneficial to a woman than six doctor’s visits with quick prescriptions written for this agent or that agent.”