Ask the Doctor: Why Sex Can Be Painful—and How to Manage
by Dr. Mary Jane Minkin M.D. updated 3/2020
According to the National Survey of Sexual Health and Behavior, research into the sexual experiences of 5,865 adolescents and adults ages 14 to 94 revealed that 30 percent of women report pain during vaginal intercourse. Read on to learn what causes this common health concern and some strategies to care for your sexual health. (1)
Q: What are the most common causes of pain during vaginal intercourse?
A: There are many causes, including vaginitis (vaginal infections); PID (pelvic inflammatory disease), in which case the pain would usually be abdominal or pelvic, not vaginal in this case; vaginal dryness (especially as a result of breastfeeding or in women who are postmenopausal); and endometriosis (more pelvic than vaginal).
Q: What should women know about how best to describe pain to their healthcare provider to get an accurate diagnosis and effective treatment?
A: Describing the location as accurately as possible is crucial, for instance, “in the vagina,” “deep into the pelvic or abdomen,” or “more superficial” (i.e., toward the outside of the vulva).
Q: What are the most effective methods of treating the pain women experience during vaginal intercourse?
A: The most effective approach is to treat the cause of the pain. If the woman has vaginitis, we treat the infection, which will generally take care of the pain.
Another step we consider is to work to normalize the pH in the vagina. Studies show that vaginal issues often occur and odor-causing microorganisms can flourish when pH is unbalanced. High vaginal pH is often related to an imbalance of bacteria that can lead to odor, itch, discomfort, or pain. Triggers associated with a high pH are semen, blood, soaps, detergents, oils, and infections.
When a woman is dealing with vaginitis, she will often have a high vaginal pH. Vaginitis causes inflammation of the vaginal tissues, which is a precursor to other infections or irritations, and can cause pH to become out of balance; the normal range is 3.8 to 4.5. It is imperative to introduce acidity to rebalance pH and restore vaginal health.
Lowering the pH with a product such a RepHresh® Vaginal Gel (polycarbophil/carbomer) can be very helpful. RepHresh is clinically shown to maintain a healthy vaginal pH, which can help reduce the risk of such issues as odor and discomfort. RepHresh is best used when unbalanced vaginal pH is most likely to occur: after your period, before or after sex, and after douching.
If a woman is experiencing vaginal dryness—which can be caused by many factors, the most common of which is menopause—moistening the tissue with a moisturizing cream, vaginal estrogens, or other agents that provide moisture is helpful. The most commonly recommended over-the-counter, long-acting vaginal moisturizer is Replens™, which can be used every three days. Replens is different from other lotions or lubricants because it contains a bioadhesive that attaches to dry, compacted cells and delivers continuous moisture until those cells are naturally regenerated.
If a woman has pelvic pain, she needs to see a healthcare provider, who can treat her for PID (if that’s what is causing the pain) or treat the endometriosis with specific hormonal therapy, or even surgery, which can help.
Q: When might painful intercourse be a symptom of a significant or potentially life-threatening condition like cancer or a sexually transmitted disease (STD)?
A: Pain is actually not the leading symptom of most gynecologic cancers. If a woman has abnormal bleeding, that’s the red flag to get to the doctor; bleeding with intercourse or spotting between periods needs investigation. As for ovarian cancer, the leading symptom I ask my patients to pay attention to is a sense of bloating in the pelvis—a “full feeling” even if she eats only three spoonfuls of food. I want my patients to let me know about that right away.
STDs can cause pain and should be treated by a physician. A woman should also see a doctor if she has a fever or abnormal vaginal discharge that is occasionally blood streaked.
Q: How does pain that accompanies intercourse affect women emotionally?
A: If the pain is chronic and resistant to treatment, it can be very debilitating. In this situation, women will often shy away from intercourse, which can have a negative impact on the relationship; the significant other becomes anxious about causing the pain with intercourse and can become distant.
Q: What are some of the reasons why women aren’t reporting pain or seeking treatment?
A: Many times women think there is nothing that can be done for the pain, which is typically not the story. We can usually help most women. Antibiotics can really help with STDs. Hormone therapy is usually quite effective for endometriosis. RepHresh usually helps with vaginitis. And for postmenopausal women, there are many options for dryness. I encourage any woman who is experiencing pain with intercourse to see her provider and seek help.
- National Survey of Sexual Health and Behavior. Indiana University website. Available at: . Accessed January 11, 2017.
Mary Jane Minkin, MD*, is clinical professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the Yale School of Medicine and has been in private practice in New Haven, Connecticut, for more than 35 years. Dr. Minkin is board certified in obstetrics and gynecology, and she practices at Yale–New Haven Hospital. Additionally, she is the founder of the women’s health resource Madameovary.com, a guide to up-to-date women’s health information.*