Sex should never be painful

Read about the author Samantha Evans

Sexual intercourse should never hurt, but many women suffer sexual pain, chronic pelvic pain unrelated to sex or pain during sex. The ‘Sex in America’ survey estimated that sexual pain affects 20% of American women, 15% pre menopause and 33% post menopause (2009).

New research published in the British Journal of Obstetrics and Gynaecology ( 2016) found that nearly 1 in 10 women experience painful sex, known as dyspareunia but don’t seek help because of embarrssment or they think they have to put up with it. The study of 7000 women aged between 16-74 found women in their late 50s and early 60s were mainly affected and younger women aged 16-24.

A new survey by the British Menopause Society (2017) found that 51% of women said sex is off the menu due to menopausal sexual symptoms. These can include vaginal dryness, vaginal atrophy, vaginal tightness, all of which can cause painful sex, decreased libido, decreased sexual sensation and body confidence.

Pain during sex should never be ignored unless it is consensual BDSM. Many medical professionals dismiss women if they complain about this problem, but sex should never hurt, this is not normal.

It should be a pleasurable experience for both the woman and her partner. If you do experience pain during or after sexual intercourse, you should always seek medical advice as it is your body’s way of telling you something is wrong. Often your doctor can diagnose the problem and it can be easily resolved.

Rough sex or not being well lubricated can cause post coital bleeding, however if you notice any bleeding during or post intercourse, please seek medical advice as there may be an underlying medical reason which need to be checked.

Many reasons for post coital bleeding are often simple to resolve but always seek medical advice, do not ignore it.

A multidisciplinary team approach is the best course of treatment help women overcome many of the issues that make sex feel painful. This includes GPs, gynaecologists, womens health physiotherapists and psychosexual therapists.

Being Honest can help your relationship

Discussing the problem with your partner is important and can help you both understand what is happening and make changes to the way in which you have sexual intercourse.

Many women avoid sexual intercourse, which can lead to marriage and relationship breakdown.

Most male partners want you to enjoy sex. They may worry they are hurting you or avoid sex which, in turn, may lead to you feeling rejected or that they do not desire you anymore which could not be further from the truth.

Reasons Why Sex May Feel Painful

There are many reasons as to why sexual intercourse may be painful: some of which can be easily treated, others which may take more time to resolve.

Lack of lubrication

This is a major reason as to why sex can be painful. The idea that you are instantly wet when touched needs to be knocked on the head. Lack of arousal can mean less vaginal lubrication, but many women do not produce enough vaginal lubrication, including younger women. Vaginal dryness is always linked to menopausal women, but younger women can be affected too due to the contraceptive pill, monthly hormonal changes, stress and anxiety and not being turned on by their partner.

Vaginal dryness is a common condition during the menopause, but the use of lubrication can really help. Often GPs will prescribe a hormonal cream or pessary and many gynaecologists advocate using vaginal lubricants to help nourish the delicate tissues of the vagina.

YES organic vaginal moisturiser is a long lasting natural vaginal moisturising gel, pH balanced to match and maintain vaginal health.

YES VM is free from glycerine, parabens, glycols and preservatives which are common ingredients found in many vaginal lubricants which irritate the delicate tissues of the vagina and vulva.

SUTIL LUXE is a silky smooth water-based lubricant that moisturises, nourishes and soothes our most intimate areas, as well as lubricating for sexual pleasure. Feeling like a silicone lubricant without the silicone, this fabulous water based lubricant gently cushions and glides, blending seamlessly with your own natural lubrication during sex. Being water based it is easy to wash off too.

Free from irritating ingredients and hormone free it is perfect post treatment, not only as a sexual lubricant but also as a vaginal moisturiser and can be used with any sex toy or dilator.

Made with eco certified ingredients, SUTIL is committed to creating natural and organic cosmetics that are not only great for your skin, but also derived from renewable resources and manufactured using environmentally friendly processes.

Some people prefer a silicone lubricant which feel more slippery and can be used with condoms, making it a great alternative to oil based lubricants. Silicone lubricants should not be used with silicone sex toys as they can damage the material of the toy.

However just saying “use lubricants” is not good enough as many commercially available lubricants contain substances which upset the balance of vagina flora. This is something so many health websites including NHS advice recommend and is unhelpful, there are so many lubricants available and you need to know if they are good or bad for your sexual health, including some available on prescription. Alway check the label and ask your GP what is in the product they are prescribing.

Always try a skin patch test on your vulva – if it burns, stings or leaves you feeling sore, discontinue use.

When prescribing a sexual lubricant, many HCPs are not aware of what some of them contain, such as glycerin which promotes the growth of thrush. When advising their patient to buy a commercial lubricant they need to inform them that don’t just go for the cheapest one on the shelf or products in your kitchen cupboard, check the ingredients for glycerin and parabens as these both cause imbalance to the vagina flora leading to infection or irritation, exaccerbating the problem further.

Please do not use Vaseline or petroleum based products, these are not designed for vaginal use.

Lack of arousal

Most women need to be warmed up before penetrative sex, but some men rush into sex before their partner is ready. This is why using lubricant can help.

Spending time enjoying foreplay can significantly improve your sexual pleasure. There may be times when penetrative sex is not possible, but you can still have great sex without intercourse.

Our brains often work overtime making it hard to switch the chatter off that can invade our throughts during sex. The constant chatter in our head can stops us from enjoying pleasurable sex.

Some medication can have sexual side effects which may impact upon your ability to become aroused so check with your GP and ask if there is an alternative with fewer side effects. Please do not stop taking your medication before seeking medical advice.

Fast or deep penetration

Even if a woman is well lubricated and fully aroused, she may experience pain if a man inserts his penis too quickly or deeply. The vagina relaxes as a woman warms up to having sex and opens more comfortably if the penis enters slowly. Guiding your partner in at your own pace can really help avoid any pain.

Deep insertion can also be painful, especially if your partner has a large penis. Often, having sex doggy style can be painful, so try backing onto the penis at your own pace. The same can be said when going on top. Do not allow your partner to pull you down onto their penis, but slowly lower yourself, controlling the speed and depth of insertion that is comfortable.

Allergic conditions

Many women experience that familiar itching or burning sensation when they try new products, from changing their washing powder, scented sanitary products to using a new shampoo/shower gel. Some commercially vaginal lubricants can cause allergic reactions, so be aware of what you are putting on the delicate skin of your genitals. Latex products, such as condoms or sex toys, can produce an allergic reaction too – as well as some spermicidal creams.

Time of the Month sell organic sanitary products which are gentler on the delicate tissues of the vulva and vagina.

The shelves in our supermarkets and chemists are laden with feminine hygiene products, mentrual products and even scented condoms. These are not good for vagina health. If in doubt, check the label but steet clear of such products, your vagina is self cleaning.

Vaginal Infections

Vaginal thrush, bacterial vaginosis or sexually transmitted diseases such as chlamydia, gonorrhoea and genital herpes can all cause genital pain, so seek medical advice if you think you may have one of these conditions. They can all be easily treated with medication. Your partner may have to be treated too to prevent them passing it back to you.

Be aware that your sexual lubricant may exacerbate thrush symptoms so choose a glycerin/glycol free product.

Vaginal Atrophy

Reported prevalance rates of Vaginal Atrophy or Genitourinary Syndrome of Menopause vary but it is estimated that around 15% of premenopausal and around 57% of post menopausal women experience this condition. However many healthcare professionals believe the figure could be much higher as many women do not seek advice due to embarrassment, believing it is a normal part of the menopause they have to live with or think there is no treatment.

Symptoms include: vaginal dryness, feeling too wet, painful sex, bleeding after sex, burning, irritation and itching in your vagina and around your vulval area, recurrent urinary tract infections (UTIs), can’t sit down comfortable, can’t wear your favourite jeans, your vulva area, labia, clitoral hood are shrinking / disappearing or your perineum is splitting from old episiotomy scars.

Treatment includes: getting the right diagnosis as many women are misdiagnosed with thrush, local oestrogen and systemic hormone replacement therapy (HRT), pH balanced vaginal moisturisers and sexual lubricants, dilation therapy or using slim sex toys to keep the vagina viable, CO2 laser therapy, pain relief, antidepressants and going commando.

Lichen Sclerosus

Lichen Sclerosus is a common condition, generally affecting postmenopausal women. It is generally thought to be linked to an overactive immune system, however the cause is not completely known. It is not an STI and cannot be contracted during sex.

It generally affects the vulva and around the clitoris and symptoms include itchy white patches of skin that start forming together to create a larger patch, red blood blisters caused by thinning of the skin and difficulty in having sex.

The main treatment for Lichen Sclerosus, also known as LS, is a steroid or cortisone cream or ointment to control symptoms. Avoiding fragranced products and wearing loose fitting clothing can ease symptoms.
Yes oil based lubricant can ease discomfort and pain too.

Endometriosis

Pain during or after sexual intercourse is a common symptom for women with endometriosis, making many women avoid sex which can impact upon their relationships. Your partner may avoid sex because they worry they may be hurting you and it does not feel pleasurable for you. However, by exploring positions and ways in which to enjoy sexual pleasure, communicating your concerns to your partner and speaking to healthcare professionals who understand, you can enjoy pain free sex.

Up to 50% of women with endometriosis complain of painful intercourse, ranging from sharp, stabbing, needle-like to a deep ache. It can feel mild to intense and felt during sexual intercourse and up to 24-48 hours post coitally, or both.

Some women experience pain with any form of sexual intercourse, whereas other women only experience when sex involves deep penetration.

As the symptoms of endometriosis are unpredicatable, there is no knowing when it may occur. Some women experience pain throughout the month whereas others only experience it at certain times of the month, probably related to their menstrual cycle but not always.

Exploring ways to be intimate beyond penetration is important, there are many ways you can both enjoy sexual pleasure together.

Vaginismus

This is a condition whereby the muscles in or around the vagina tighten, making sex painful or impossible. It can be caused by a combination of physical and psychological issues. Physical causes can include urinary tract infections, sexually transmitted diseases, vulvodynia, a tight pelvic floor, skin conditions such as psoriasis or eczema, menopause, and birth trauma.

Psychological problems can be caused by disgust towards the act of sex related to a strong moral or religious upbringing or emotional or sexual trauma. With the appropriate medical intervention and counselling, this problem can be alleviated to enable penetrative sex. Treatment usually involves pelvic floor exercises, biofeedback training with a womens health physiotherapist and use of dilators or a vibrator/dildo to slowly encourage the vagina to relax and open.

Pain felt inside the vagina may be caused by pelvic inflammatory disease, endometriosis (when the lining of the uterus grows outside the uterus or is thicker than normal), fibroids (growths of muscle and tissue inside the uterus) growing close to your vagina or cervix, irritable bowel syndrome and constipation.

Some women experience shooting or burning pain through their clitoris, the reason for this is often uknown so seeking medical advice from a gynaecologist, psychosexula therapist and womens health physiotherapist is important.

Dietary irritants

Foods containing high levels of oxalates can cause urethral irritation in women who are sensitive to them. When too much oxalate is absorbed into the blood stream via the gut, it combines with calcium to form sharp calcium-oxalate crystals which embed themselves into the delicate tissues anywhere in the body, causing damage and pain. Women who have irritable bowel syndrome (IBS) absorb too much oxalate due to the poor condition of their bowel. Sticking to a low oxalate diet for 3-6 months has been found to improve symptoms. A list of high oxalate food can be found on the Vulval Pain Society website and includes celery, coffee, rhubarb, spinach and strawberries.

Vestibulodynia (provoked pain)

This condition is characterised by burning pain felt on the vestibule or entrance of the vagina when touched and is thought to affect 12-15% of women of childbearing age. It often occurs through light touch such as inserting a tampon or sexual intercourse and generally no other symptoms at other times.

Research by Reed et al (2012) found that women who have this condition are 2-3 times more likely to have more than one chronic pain condition, including IBS, fibromyalgia (musculoskeletal pain) and interstitial cystitis (bladder pain). Treatment for this condition includes pelvic floor exercises, biofeedback, low oxalate diet, counselling and sometimes surgery to remove the glands at the entrance of the vagina.

Many women completely avoid any sexual interaction with their partner, but research by Rosen at al (2010) discovered that couples enjoyed greater sexual satisfaction when the partner had a more concerned attitude toward their partner’s condition. By focusing on pleasurable sexual activities that do not involve penetration, couples can still enjoy the benefits of being intimate together. Communication is essential too.

Vulvodynia (unprovoked pain)

This is different to vestibulodynia in that it occurs spontaneously, the pain felt is often burning and sore in nature, there is no itching sensation and again it can be focused around the vulva or generalised.

The intensity of pain can vary from mild discomfort to a severe constant pain, making even sitting down uncomfortable. Usually continuous, the pain can affect sleep patterns and general day to day activities. Often the pain isn’t localised to the vulval area but can be experienced in the anus when having a bowel movement and in the bladder when you pee. Unprovoked vulvodynia can impact upon sexual activity during foreplay and penetration.

For a small minority of women, the course can be related to back pain as a result of nerve compression or a slipped disc causing referred pain to the vulval area. However, for the majority of women, the cause is idiopathic meaning there is no known reason for the condition.

Treatment consists of taking tricyclic antidepressant tabletsfor a period of 3-6 months. Taken in tablet form, staring with a low dose, then increasing every few days until the pain decreases or subsides. Using natural lubricants such as YES organic lubricants during sex play can help, as can applying aqueous cream to soothe the area.

When penetrative sex isn’t possible, couples can still enjoy sexual intimacy and pleasure through exploring other ways to enjoy sex.

Pudendal Neuralgia

Pudendal neuralgia, sometimes called pudendal nerve entrapment or Alcock canal syndrome, is long-term pelvic pain that originates from damage or irritation of the pudendal nerve – a main nerve in the pelvis. Your pudendal nerve runs from your lower back, along your pelvic floor muscles, out to your perineum (the skin between your pubic bone and your tailbone). It leads to pain in the clitoris/penis, vulva/scrotum, perineum, and rectum, especially when sitting. Other symptoms include numbness and pins and needles in the pelvic area, increased sensitivity to pain, even a light touch or wearing clothes, a feeling as if there is a swelling in your perineum, needing to urinate more often or urgency, pain during sex, difficulty reaching orgasm and erectile dysfunction in men ( NHS.UK 2019)

The prevalence of pudendal neuralgia is unknown, although some have estimated a prevalence of 1/100,000 people. Spinosa et al ( Rev Medical Suisse 2006) documented an incidence of 1% in the general population, affecting women more than men.

It can be caused prolonged sitting, cycling, horse riding or constipation (usually for months or years), having a smear test, abroken bone in the pelvis, damage to the pudendal nerve during childbirth – this may improve after a few months, sexual abuse, vaginal hysterectomy, rectocele & anterior prolapse, repair of the perineum, trauma from surgery, car accident, a fall and sometimes no reason can be found.

Treatment includes:

avoiding things that make the pain worse, such as cycling, constipation or prolonged sitting – it may help to use a special cushion with a gap down the middle when sitting and try constipation treatments
medicines to alter the pain – these will normally be special medicines for nerve pain, rather than ordinary painkillers like paracetamol
physiotherapy – a pelvic health physiotherapist can teach you exercises to relax your pelvic floor muscles and other muscles that can irritate the pudendal nerve
painkilling injections – injections of local anaesthetic and steroid medication may relieve the pain for a few months at a time
decompression surgery – if something is pressing on the pudendal nerve, such as a piece of tissue, surgery to move it away from the nerve may help improve your pain nerve stimulation – a small device is surgically implanted under the skin to deliver mild electrical impulses to the nerve and interrupt pain signals sent to the brain
You can also be referred to a specialist NHS pain management team or pain management programme for support and advice about treatment. ( NHS.UK 2019)

Conflict within a relationship

If a woman is experiencing emotional pain as a result of conflict within her relationship, pain may occur during sex. Many women experience hostility from their partner if they are unable to have sex which in turn increases their pain levels, thus creating a vicious circle. Consulting a couples’ counsellor or sex therapist can help.

If you experience pain during or after sex, seek medical advice. You can still enjoy pleasurable sexual activity without intercourse by incorporating the use of lubricant, such as YES, and slim vibrators.

Womens health physiotherapists are experts in treating pelvic health issues. They are trained to help women overcome gynaecological issues of the pelvic floor and restore pelvic health. Many WH physios are based in NHS hospitals so ask to be referred by your GP.

Psychosexual therapy can be useful, especially when the cause of the pain is unknown. You can be referred by your GP or find a private therapist. Many NHS therapists also work in private practice too.

Here at Jo Divine, we work with medical professionals who recommend a variety of products to patients who experience sexual pain. So do not suffer in silence, seek help and start to enjoy sex again.

Useful websites

Vulval Pain Society : www.vulvalpainsociety.org
Royal College of Obstetricians and Gynaecologists : www.rcog.org.uk
Pelvic, Obstetric and Gynaecology Physiotherapy
The Institute of Psychosexual Medicine : https://www.ipm.org.uk/
Comtempory Institute of Sexology : https://www.theinstituteofsexology.org/
Pink Therapy :http://www.pinktherapy.com/
Aoife Drury :https://drurytherapy.com/
Cystitis and Overactive Bladder Foundation: www.cobfoundation.org
College of Sexual and Relationship Therapists : www.cosrt.org.uk
SHETrust : shetrust.org.uk-endometriosis
Endometriosis UK : www.endometriosis-uk.org
Women4Real : www.women4real.com
Time of the Month : www.totm.com- organic sanitary products which are gentler on the delicate tissues of the vulva and vagina
Relate : www.relate.org.uk