Why sex hurts…and we don't mean heartbreak

Last week we talked about when sex hurts, and why so many women still don’t admit to having this problem. It’s something that we, as sex writers, hear about constantly — it’s a sad but true fact that many women are more open with sex advice columnists than their own gynecologists — so we thought that focusing on this topic for a few weeks would, at the very least, prove that there’s a certain comfort to knowing you’re not alone. And knowing you’re not alone may give you the courage to speak up — to your partner and to your doctor. This week, the authors of the new book When Sex Hurts: A Woman’s Guide to Banishing Sexual Pain, give a basic overview of the causes of painful sex. For more information about any of the below, you can check out their book or talk to your doctor. Actually, whether you buy the book or not, please, for the love of sex, do talk to your gynecologist if sex hurts. It’s their freakin’ job to fix it, okay? No matter what you may have been taught.


Even the following brief overview of these conditions will reveal a very important fact about sexual pain: Conditions frequently overlap, and women will often have several underlying causes. That’s one reason why you’re still suffering. A reminder: The term dyspareunia refers to sexual pain—no matter what the cause. Terms like vulvodynia, vestibulodynia, and vaginitis refer to specific conditions that cause dyspareunia.

Provoked vestibulodynia (PVD). This syndrome used to be called vulvar vestibulodynia syndrome (and, less commonly, vestibular adenitis). But PVD is not a single condition; rather, it constellates at least a dozen different conditions, resulting in pain originating from the entrance to the vagina, the vulvar vestibule. The most common cause of sexual pain in premenopausal women, it is also one of the most difficult for most doctors to diagnose and treat correctly. The most common causes of PVD are hormonal changes, tight pelvic floor muscles, and an increased number of nerve endings in the vestibule. In Chapter 6 we show how you and your doctor can figure out the cause of your PVD.

Hypertonic pelvic floor muscle dysfunction. This condition, also known as vaginismus, occurs when the muscles that surround the vagina, bladder, and anus spasm, causing pain at the vulvar ves­tibule and leading to pain upon penetration. Tight (hypertonic) pel­vic floor muscles can also cause constipation, fissures in your rectum, frequent urination, and problems urinating. In addition, if the muscles are in severe spasm, you may experience generalized vulvar burning, the major symptom of generalized vulvodynia (see below).

Vulvar and vaginal atrophy. One of the most common causes of sexual pain is hormonal changes (decreased estrogen and testosterone) that result in thinning (atrophy) of the vaginal and vulvar tissue. This, in turn, leads to dryness, irritation, tearing, and pain at the vestibule (provoked vestibulodynia). There are many causes of these hormonal changes, including hormonal contraceptives, infertility medications, endometriosis treatments, removal of the ovaries, medication for breast cancer, and menopause. In our experience, hormonal birth control methods (pills, patches, and rings) are the leading cause of atrophy in premenopausal women, thus a leading cause of their sexual pain.

Vulvar and vaginal skin disorders. The skin of the vulva and the mucosa of the vagina are susceptible to inflammatory skin diseases that can cause ulcers, erosions, and scarring. The most common of these disorders are lichen sclerosus and erosive lichen planus.

Interstitial cystitis (IC). IC, also know as painful bladder syndrome, is a condition in which the bladder lining becomes severely inflamed. This causes frequent urination (up to sixty times a day!), severe pelvic pain, and dyspareunia. Of women with IC, 75 percent say that sex makes their pain and need to urinate worse.

Endometriosis and chronic pelvic pain. Endometriosis, a condition in which uterine tissue grows outside the uterus, is one of the most complex and frustrating, yet common, conditions in gynecology. Women with endometriosis often experience severe pain, sometimes only at certain times during their menstrual cycle, sometimes always. In addition to chronic pelvic pain, these women may also suffer from deep dyspareunia.

Generalized vulvodynia. This condition results in pain in the vulvar area even when women aren’t trying to have sex. Most often, the pain is caused by a combination of tight pelvic floor muscles and injury to the pudendal nerve.

Gastrointestinal conditions. Conditions such as irritable bowel syndrome and ulcerative colitis can contribute to painful sex.

Infection. Numerous infections, including sexually transmitted infections, yeast infections, trichomoniasis, genital herpes, chlamydia, and gonorrhea, can cause sexual pain. However, while many women (and their doctors) may think an infection is behind their sexual pain, it rarely is.

Pudendal neuralgia. With this condition, the pudendal nerve—which carries sensation from the external genitals, the lower rectum, and the area between the genitals and the rectum (perineum) to the brain—has become damaged or trapped. Women with this condition feel severe burning and aching pain when they try to sit and often have problems with their bladder and bowels.

Excerpted from When Sex Hurts: A Woman’s Guide to Banishing Sexual Pain by Andrew Goldstein MD, Caroline Pukall PhD, and Irwin Goldstein MD. Read another excerpt from the book here, and check back in next week for a Q&A with the authors.


photo by Gabriel Delgado