Painful sex — It might not be the easiest topic for a lot of us, but pain during sex, also known as dyspareunia, needs to be talked about. 

Better yet, we need to talk about it loudly and often enough for every woman and  person assigned female at birth (AFAB) to sit up and take note: sex shouldn’t be painful (unless that’s what you’re specifically into — but that’s a whole other conversation…).

With the exception of mutually consenting adults exploring pain as part of sex (for example, trying biting or spanking, in which case, a little pain is good), sex should be comfortable and enjoyable.

However, for about 1 in 10 women, particularly those aged 18–24, sex can be an uncomfortable, burning, stinging, or wrenching experience. And what’s worse, instead of getting care and sympathy (and some extra hugs from our sexual partners) we often feel guilt or shame and avoid seeking the help we— and ourvaginas — need. . 

Painful sex disproportionately affects women and people assigned female at birth (no surprises there) – with only 3% of men experiencing painful intercourse, though these rates can be higher for men who engage in receptive anal intercourse. It’s for this reason that dyspareunia is considered a primarily female sexual dysfunction relating specifically to vaginal intercourse.

Let’s learn more about painful sex, what you can do about it, and shout it from the rooftops : pain during sex shouldn’t be a fact of life.   

What causes painful sex (aka dyspareunia)?

As mentioned above, dyspareunia is the medical term for pain that occurs before, during or after vaginal intercourse. To be very clear: dyspareunia sucks. Not only is it painful, but it can affect you physically and psychologically, shaking your confidence and lowering your quality of life.To understand what may be causing pain during sex, we need to understand the two types of dyspareunia.  They are classified according to where the pain is located. Let’s explore these now.

What is superficial dyspareunia?

Superficial dyspareunia (which, by the way, is hardly ‘superficial’ in how it makes us feel) is when pain occurs near the opening of the vagina during penetration. This kind of pain can be caused by a multitude of factors, including:

• Vaginal infections: Nope, they’re not shameful. Like any part of the body, vagina infections can happen. Yeast infections, bacterial vaginosis, or sexually transmitted infections (STIs) can lead to pain during intercourse. Fortunately, most vagina infections can be treated easily too.
  
• Vaginal dryness: If you’re not self-lubricating (aka. getting wet) before sex, then the insufficient lubrication within the vagina can cause discomfort or pain during penetration.
  
  Almost 1 in 5 women will experience vaginal dryness during sex. Lubrication can be influenced by factors such as hormonal changes, medications, breastfeeding, or psychological factors — or simply not having enough foreplay (note: foreplay is crucial when it comes to comfy sex) .
  
• Vulvovaginal atrophy: This is vaginal dryness caused by the vaginal tissues becoming thin, dry, and less elastic. Around 50% of women during menopause will experience this kind of vaginal dryness due to decreased oestrogen levels. Fortunately, vaginal moisturisers can help you feel lubricated both for sex and for daily comfort. ‍
• Skin conditions: Certain skin conditions affecting the vulva, such as lichen sclerosus or lichen planus, can cause inflammation, itching, and pain during sex.‍
• Vaginal trauma or scarring: Previous injuries, surgeries, or childbirth can lead to scar tissue formation or changes in the vaginal structure, resulting in pain during intercourse.‍
• Allergies or irritation: Vagina skin can be rather sensitive at times. Some individuals may experience discomfort or pain due to an allergic reaction or irritation caused by certain soaps, detergents, condoms, or personal care products.‍
• Pelvic floor muscle dysfunction: Tight or spasming pelvic floor muscles can contribute to pain during penetration. This can be caused by factors such as stress, trauma, previous surgeries, or chronic pelvic pain conditions.‍
• Certain medications: Some medications, including SSRI antidepressants, can affect sexual arousal and lubrication, leading to discomfort or pain during intercourse. If your medication might be causing painful sex, make sure you speak to your doctor about your options — there could be an alternative that helps your health condition and supports your sex life too.‍
• Penile/sex toy size: Don’t get us wrong, we applaud a sense of sexual adventure, but in some cases, a larger-than-average penis or sex toy may cause discomfort or pain during penetration. This doesn’t mean you can’t go big in the bedroom. To ensure a more comfortable experience ensure there is good communication between yourself and your partner, proper lubrication, and an openness to different positions.‍
• Vaginismus: Ever feel like your vagina has a mind of its own? With vaginismus, women have no control over when their vagina muscles tighten up. It’s often linked to an automatic fear response. These involuntary contractions of the pelvic floor muscles can make penetration very painful or impossible. 
  
  Vaginismus can be caused by physical or psychological factors and may require a combination of physical therapy, counselling, and gradual desensitisation as treatment.‍
• Vulvodynia: Vulvodynia is a chronic condition characterised by unexplained pain or discomfort in the vulva (that’s the outer area that is often mislabelled the vagina, learn more about vulvas and vaginas here). It can cause pain during intercourse, among other symptoms and it’s estimated to impact around 15% of vulva owners. The exact cause is unknown, but effective treatments may include topical medications, medicinal cannabis suppositories, nerve blocks, physical therapy, or counselling.
  

What is deep dyspareunia?

Like the name sounds, deep dyspareunia refers to pain during sex that is experienced deep within the pelvis (either deep inside your vagina or in your general pelvic region) during or after sexual intercourse.

Unlike superficial dyspareunia, which is localised pain near the entrance of the vagina or in the external genitalia (aka vulva), deep dyspareunia typically arises from issues involving the organs and structures located deep within the pelvic region.

Here are some potential causes of deep dyspareunia:

• Pelvic inflammatory disease (PID): PID is an infection of the reproductive organs, usually caused by sexually transmitted infections (STIs) like gonorrhoea or chlamydia. It can lead to inflammation, scarring, and pain during deep penetration. If you think your pain could be related to an STI, don’t be embarrassed. Doctors, like our stigma-free Hazel specialists, are there to help — not judge.
  
• Endometriosis: 1 in 9 women will experience this extremely painful condition that not only causes painful periods but also painful sex. Endometriosis is a condition where the tissue that normally lines the uterus grows outside of it. During intercourse, the deep penetration can cause pain due to the involvement of the endometrial tissue in areas such as the ovaries, fallopian tubes, or pelvic lining.

If you have endometriosis, and are experiencing painful sex, it can be a good idea to speak to a doctor who specialises in pelvic pain — after all, endometriosis is bad enough without it affecting your ability to orgasm.

• Fibroids: Uterine fibroids are non-cancerous growths that develop in or around the uterus. When fibroids are located in areas that are affected during deep penetration, they can cause pain or discomfort.
  
• Ovarian cysts: Ovarian cysts are fluid-filled sacs that can form on the ovaries. Larger cysts or cysts that rupture during intercourse may cause deep pelvic pain. If you’ve been unfortunately enough to have experience this kind of pain, it can be excruciating — we know, we’ve been there.
  
• Adenomyosis: With around 1 in 5 women having adenomyosis, we can honestly say it’s the evil twin of endometriosis. Adenomyosis occurs when the tissue that normally lines the uterus begins to grow into the muscular wall of the uterus. This condition can cause deep pelvic pain during intercourse.
  
• Pelvic adhesions: Feeling stiff internally can be a real pain during sex. Adhesions are bands of scar tissue that can form between pelvic organs, often as a result of previous surgeries, infections, or endometriosis. These adhesions can limit mobility and cause pain during deep penetration.
  
• Retroverted uterus: While ‘retroverted uterus’ might make a surprisingly great band name, it’s also a condition where the uterus is tilted backward instead of forward. Even though a retroverted uterus doesn’t cause serious health problems it can cause painful periods and/or painful sex.
  
• IBS-related symptoms: As if irritable bowel syndrome (IBS) wasn’t bad enough in the bathroom, it can also get in the way of your bedroom activities. Some individuals with IBS may experience deep pelvic pain or discomfort during intercourse due to the close proximity of the intestines to the reproductive organs.

There are many other factors that can contribute to deep dyspareunia (beyond the list we’ve shared above. So, if you're experiencing deep pain during sex, it's recommended to consult with a healthcare professional for a comprehensive evaluation and appropriate management. Deep pain might be deeply s**t — but there is lots of treatment options for you to explore

What else causes pain during sex?

How our mental health, mood and emotions impact dyspareunia

Painful sex isn’t all in your head, but sometimes the cause of the physical reaction can start there. For anyone who’s caught feelings with a fling or ‘dried-up’ after losing their desire for an ex knows, emotions are deeply intertwined with sex. How we feel psychologically can impact our sexual experience  — meaning that pain can rear its ugly head even when we think we’re feeling comfortable, aroused, and ready for intercourse.

Some emotional factors that can contribute to painful sex include :

• Psychological factors: Anxiety, depression, worrying about your physical appearance, having a fear of intimacy, or ruminating on relationship problems can all throw a wrench in the pursuit of sexual pleasure. Physiological issues can affect your arousal levels in a multitude of ways, leading to discomfort or pain during sex.
  
  It's important to tackle these concerns head-on or talk to your doctor or mental health professional about ways to cultivate a supportive sexual mindset
  
• Stress factors: Just like our shoulder or jaw muscles can tighten up when we’re stressed, so can our pelvic floor muscles. If you’re stressed out, your vagina may have difficulty lubricating and your internal muscles may struggle to relax, leading to pain and discomfort during sex. 
  
  Finding healthy ways to manage stress and making time for open communication with your partner can help you let go during intimate moments.‍
• A history of abuse or trauma: It’s not you or your body’s fault and it's not the case for everyone, but sometimes previous emotional, physical, or sexual abuse can trigger an involuntary pain response during sex. 
  
  Seeking support from professionals who specialise in trauma can be a vital step in addressing and healing from these experiences. If you have experienced abuse or trauma, you deserve support and understanding.‍
• History of dyspareunia: It’s not fair, but sometimes one session of painful sex can lead to more painful sex. Dyspareunia can create a lingering fear that becomes a vicious cycle where anxiety and stress amplify the discomfort. If you think that you might be experiencing this kind of repeated dyspareunia, it’s important to address both your mental well-being and your physical comfort to break the cycle.‍
• Lack of arousal: Foreplay. Forplay. And more foreplay — you should be getting it. If you’re experiencing pain during sex it can be due to a physical response that comes from not experiencing the right kind of touch or pre-sex stimulation.This doesn’t mean you have to jump into a variety of highly physical bedroom acrobatics — sometimes, foreplay can just mean setting the mood, making time for light touch, or engaging in activities like kissing that tell your body to relax and focus on the physical.

Take note (and while we’re here, if you have a male partner, get them to grab a pen too): Even though both vaginal lubrication and male erections are automatic sexual reflexes linked to body's neural and cardiovascular systems doesn’t mean they happen at the same time. Lubrication can take more time than an erection — so just because a man is ready, doesn’t always mean his female partner is too.

Occasionally a lack of arousal can also be caused by feelings of resentment towards your partner, being distracted, not feeling attracted to your partner, feeling afraid or uncomfortable with your partner or other factors. This doesn’t mean that you’ve done anything wrong — but if your gut (or vagina) is telling you not to have sex, then it’s worth sitting with these feelings and getting to the bottom of them. 

When it comes to a lack of arousal, It can be difficult to tell whether emotional or physical factors are at play.. Sometimes, we will just notice that we’re not lubricating, but won’t be able to pinpoint why (like, is my horrible meeting playing on my mind or am I subconsciously worried about my physical appearance? Either way, geesh.) 

Painful sex after menopause

As if hot flashes and mood swings weren't enough of a pain, some people  also experience painful sex during menopause. So, what's behind this new found discomfort?

During menopause, the body goes through many changes, including a significant drop in our oestrogen levels. As oestrogen plays a vital role in maintaining the health and elasticity of the vaginal tissues, lower oestrogen causes vaginal tissues to become thinner, drier, and less flexible, leading to discomfort or pain during intercourse.

What's more, menopause can also bring about a decrease in natural lubrication, making things even less smooth during penetration, which changes in pelvic floor muscles may affect the overall support and elasticity of the vaginal area.

But, before you decide to throw your whole menopausal pelvis out the window, there are ways to manage this situation. Vaginal moisturisers and personal lubricants can provide much-needed moisture and reduce friction during sex. If the symptoms are more severe, your healthcare provider might suggest low-dose oestrogen therapy to help restore vaginal health. 

Going through symptoms of menopause and peri-menopause? Join Hazel and access a team of care providers who can help.

Painful sex after birth

Along with the pain of pushing a watermelon-sized bundle of joy out your vagina (or through the ‘sun-roof’ in the case of a caesarean section), some people also experience painful sex after giving birth. It’s just another way women and people assigned female at birth get the s**t-end of the biological stick.

One reason why painful sex can happen after childbirth is because of the trauma to the vaginal tissues. Whether you had a vaginal delivery or a caesarean section, your body goes through a lot of changes during the process. Tears, episiotomies, or stitches can result in discomfort and sensitivity, making sex a bit challenging initially.

Hormonal changes also play a role. After giving birth, oestrogen levels take a nosedive, causing vaginal dryness and decreased elasticity. This can lead to friction and discomfort during intercourse. Additionally, breastfeeding, which suppresses oestrogen production, can further contribute to vaginal dryness.

Additionally, the pelvic floor muscles can also become weakened or stretched during childbirth, affecting their ability to support the pelvic organs properly. This can result in pain during penetration or a sensation of ‘looseness’ (don’t stress — it’s normal and doesn’t last).

In terms of managing painful sex after birth, time, healing, and self-care are your allies. Give your body the chance to recover and gradually regain its strength. Using lubricants can help with dryness, and pelvic floor exercises (hello, Kegels) can improve muscle tone. And most importantly, communicate with your partner, go at a pace that feels comfortable, and remember that this is all temporary. Our vaginas and hormones are pretty great at bouncing back. 

Painful Sex after trauma

Sexual and domestic violence can cause lasting impacts on our ability to feel safe within our own bodies, but it does not have to stay that way. The first, and most important, step in being able to explore sex after trauma is to know that you are not broken. Your body and mind just need a little time and support to find a new rhythm for sexual pleasure.

If you are currently in a situation where you’re experiencing violence of any kind, it’s important to know that it’s not your fault — and it’s never okay for someone to hurt you. Seeking support can be scary, but it’s the best way to get you, or anyone else being hurt, to safety.

A good place to start when looking for support is 1800 RESPECT (1800 737 732). The service is 24 hours, confidential and has trained professionals that can walk you through your next steps no matter where you are in your journey.

The team at Hazel is also here for you. If you’d like to know how we can help, reach out to our Care Team who can help you find the right care provider or point you in the right direction. All information provided in consultations are strictly confidential and our care providers will work with you at whatever pace you feel comfortable with.

How is dyspareunia diagnosed?

Experiencing sexual pain? Don’t keep it to yourself. Sometimes ‘diagnosing’ painful sex will be as simple as accepting that something isn’t feeling right in your sex life — but for an official diagnosis, we recommend speaking to a doctor you trust or booking a consultation with a clinic that specialises in female pain.

Typically a dyspareunia diagnosis involves a comprehensive evaluation by a healthcare professional. Some common steps and methods included in getting a dyspareunia diagnosis include:

• Getting your medical history: First things first, your provider will want to understand what you’ve been going through. They’ll most likely discuss your symptoms in detail and inquire about the nature, duration, and intensity of the pain during intercourse. They may ask questions about any underlying medical conditions, past surgeries, or trauma that could be contributing to the pain
  
• Performing a physical examination: While this is not always necessary (and you absolutely can say no) a physical examination may be conducted to assess the pelvic area for any visible abnormalities, signs of infection, or areas of tenderness. The healthcare provider may also perform a pelvic exam to evaluate the pelvic organs, such as the uterus, ovaries, and vaginal walls.
  
• Psychological assessment: Like we said earlier, good sex can start (and end) in the mind. Since psychological factors can play a role in dyspareunia, the healthcare provider may inquire about any emotional or psychological concerns that could be contributing to the pain. They may also assess your mental well-being and inquire about any history of trauma or abuse.
  
• Laboratory tests: Depending on your specific situation, the healthcare provider may recommend various laboratory tests. These can include tests for infections, hormone levels, or other relevant factors to identify potential underlying causes of dyspareunia.
  
• Imaging studies: If your doctor thinks that a particular condition might be causing your painful sex, then they might order imaging studies such as ultrasound, magnetic resonance imaging (MRI), or computed tomography (CT) scans to evaluate the pelvic organs and detect any structural abnormalities.
  
• Referral to specialists: If necessary, the healthcare provider may refer you to a specialist, such as a gynaecologist, urologist, or pelvic pain specialist, for further evaluation and management of your condition.

It's important to remember that the diagnostic process for painful sex will depend on your  individual circumstances, health background, and lifestyle factors. There is no  one-size-fits-all approach.

It’s important to have open and honest communication with your healthcare provider   (even when it feels a  bit weird or embarrassing. Trust us, they’ve heard it all.). That way you can receive an accurate diagnosis and appropriate treatment options tailored to your specific needs.

To get help and stigma-free support for pain during sex, join Hazel.

How can I manage pain during sex? 

Just because you’ve experienced painful sex doesn’t mean it has to stay that way. Pleasurable, comfortable sex can be just around the bedroom door so long as you find the treatment for your individual cause of the pain.

If your doctor is able to pinpoint  a physical cause for your pain, then dyspareunia management will focus on treating the underlying medical condition. In the absence of a physical cause, other techniques can be used to  help soothe painful sex.

Some common treatments for painful sex include: 

• Physical treatments: This is when the doctors can find a physical cause for the problem. These kinds of treatments aim to manage the underlying cause of the pain, such as surgery; physical therapy; hormonal, pharmacological, natural, antibiotics or other medications; infection treatment and more.‍
• Natural remedies: Some natural solutions, like medicinal cannabis, CBD suppositories or lubricants, herbal supplements, Chinese medicine, acupuncture and more may be useful as complementary or alternative therapies for managing the symptoms of dyspareunia in some people, especially those who are not responding to conventional treatment. ‍
• Psychological treatments: if your doctor thinks that your emotional or psychological health might be a contributing factor, then there are a range of treatments that could assist. These include individual therapy, couples or sexual therapy, or even certain medications to help treat underlying psychological causes of pain during sex Interested in exploring sexual therapy? Register your interest with us and we’ll let you know as soon as consultations with our Hazel Sexologist are available.‍
• New Sexual techniques: Sometimes a change is as good as a (medical) holiday. such as If you’re experiencing sexual pain, it can be helpful to try different positions, personal lubricants, and foreplay to help reduce pain. A focus on enhancing arousal to reduce discomfort and make sex more pleasurable may also help.‍
• Vaginal dilators: Yep. They look a bit like a dildo and they’re very good at getting vaginas to open up. These smart tube-shaped devices are sometimes used to help people with vaginas relax their pelvic muscles, enabling pain-free sex. These are available in small to large sizes which can be increased over time once you become comfortable.‍
• Relaxation techniques: Relaxation is key to enjoyable sex. Some relaxation techniques, including  meditation and mindfulness, may help your body relax so that sex can be more enjoyable. You may find recorded meditations aimed specifically at easing pain and discomfort during sex that you can listen to alone or with a partner.‍
• Sexual comfort products: There are a range of products designed to help make sex more comfortable, including the Ohnut that helps control the depth of penetration, or the hands-free clitoral vibrators like Eva II that help vulva and vagina owners maintain arousal and lubrication during penetration.  

We understand painful sex and how it can affect more than your sex life, but your confidence, relationships, and general well being too. At our digital clinic, our non-judgemental care providers work with you to find the best pain management solutions for your unique situation. Reach out to a member of our team to learn more about treatment options or book a consultation today to get started.

Exploring alternatives to vaginal intercourse

Sometimes,  there is no quick-fix when it comes to treating pain during sex, and it may take a bit of trial and error both with your sexual partner/s and your treatment provider before you reach a place where sex is consistently pleasurable, comfortable and pain-free. 

Does this mean that sex has to stop altogether? Hell no.

There are many ways to enjoy sexual pleasure with a partner (or by yourself) beyond penetration. Try finding ways to fulfil yours and your partner’s desires without vaginal intercourse. Some good places to start could be with extended foreplay, mutual masturbation, oral sex, massage, kissing or engaging in roleplay or fantasy ‚ but honestly, the list is as long as your consensual imagination

The Wrap Up

Forget polite dinner party conversations, we all need to talk about painful sex (dyspareunia).
Whether you’re experiencing superficial dyspareunia or deep dyspareunia, identifying the root cause is key to feeling better. Once you have a diagnosis, there are various treatment options, including physical treatments (like medications), psychological approaches (including therapy or relaxation techniques), or natural therapies like medicinal cannabis.

Remember, painful sex is not something you have to solve on your own. We provide a safe and supportive environment where you can discuss your concerns and find personalised solutions. So, let's break the silence surrounding dyspareunia — because if more conversations were taking place, every adult, but especially those assigned female at birth, would know that that sex doesn’t have to be painful (unless you're into that kind of thing, of course…). 

To stay in the know about what we’re doing, when our services are launching and how we can help you finally get the care you deserve, join Hazel.

To keep on learning, return to our The Lowdown.