Painful sex: common causes, vaginismus and vulvodynia

Sex should not be painful. Yet many people feel pain during sex at some point in their lives, and it is not always obvious why, writes Brook, a sexual health charity. Painful sex is common, it adds, and it is not your fault. This guide brings together what Brook and the NHS say about the usual causes, two conditions often behind it, vaginismus and vulvodynia, and what can help. It is general information, not medical advice. For your own situation, a doctor, a nurse or a sexual health service is the right place to ask.

Why sex can hurt

Pain is the body’s way of saying that something needs care and attention, Brook explains. It lists several reasons:

• Sensitivity. The genitals can be very sensitive, and touch that is rougher than you enjoy, sharp nails or a lack of lubrication can hurt.
• Not enough arousal. Without physical arousal, touch can be uncomfortable. Being wet, relaxed and well aroused helps, and touch is rarely pleasant when you are not in the mood.
• Penetration itself. Receiving penetration asks more of the body: the muscles need to relax, and the skin in these areas is easily hurt.
• A medical cause. Pain can be a sign of a sexually transmitted infection, thrush, a urinary infection such as cystitis or another problem, or of tearing or soreness from earlier sex.
• A painful past experience. It can make arousal harder and make the muscles around the vagina and anus clench, which makes penetration harder and more painful.

Dryness plays a part too. The NHS lists pain or discomfort during sex among its signs, with causes such as the menopause, pregnancy or breastfeeding, some medicines, or not being aroused enough. Vaginal health basics covers dryness, thrush and other infections, and cystitis and UTIs covers urinary infections.

Vaginismus

The NHS describes vaginismus as the vaginal muscles tightening up on their own when something is put into the vagina, which can cause a burning or stinging pain. Anyone with a vagina can have it. It can happen:

• When putting in a tampon.
• With penetration during sex, whether with a finger, a sex toy or a penis.
• During cervical screening.
• When something comes near the vagina, out of fear of penetration.

It is an automatic reaction, not something you control, the NHS insists. It can appear even after painless penetrative sex in the past, and it does not necessarily affect arousal or the enjoyment of other kinds of sexual contact.

The causes are not always clear. The NHS mentions anxiety or fear about sex, a painful sexual experience, sexual assault or abuse, an unpleasant medical examination or a difficult birth, the belief that sex is shameful or wrong, and a painful condition such as thrush.

Treatment usually works on two fronts, according to the NHS: the feelings around penetration, and gradually getting used to it. The options it describes:

Treatment	What it involves
Psychosexual therapy	A talking therapy about feelings towards the body and sex
Relaxation techniques	Mindfulness, breathing and gentle touching exercises
Pelvic floor exercises	Squeezing and releasing to gain control of the muscles
Sensate focus	Exercises to help relaxation during sex and increase desire
Vaginal trainers	Tampon shaped objects of different sizes, used gradually

Treatment starts with specialised therapists, then some exercises are practised at home, and a partner can be involved if you wish.

Vulvodynia

Vulvodynia is pain in the vulva that lasts at least 3 months and has no specific cause, the NHS explains. The vulva usually looks no different. The pain can burn, throb, stab or feel sore. It can cover all or part of the vulva, be constant or come and go, start on its own or with touch, for example a tampon or sex, and reach the inner thighs or the area around the anus or the urethra. It can affect sleep, concentration and sexual relationships.

The exact cause is not known. The NHS mentions damage, irritation or oversensitivity of the nerves in the vulva, earlier vaginal infections, changes in hormone levels and weak pelvic floor muscles.

Treatment aims mainly to manage the pain, often with several specialists: a gynaecologist, a physiotherapist, a psychologist or a pain specialist. It can include medicines, pelvic floor exercises, vaginal trainers, psychological therapies such as cognitive behavioural therapy or psychosexual therapy, and occasionally surgery when nothing else has worked. No single treatment works for everyone, the NHS notes.

It also lists everyday habits that can help:

• Loose cotton underwear, and pads rather than tampons during periods.
• Trying different positions during sex, with lubricant.
• Ways to ease stress, such as yoga or mindfulness.
• Avoiding long periods sitting in one position, hot baths, douching and scented products in or around the vagina.

What a consultation involves

Brook urges anyone with painful sex to get medical help: a professional can test for and treat infections, help soreness or tears to heal and point to further support. It suggests keeping a note of triggers to bring along. Health professionals are there to help, not to judge, it adds.

Both sources describe a similar visit. The doctor asks about your symptoms and may ask to examine the vulva and vagina. For vulvodynia, a cotton bud is often used to touch the vulva gently and find the painful areas, and a swab can rule out an infection. For vaginismus, the examination is usually very quick and is mainly there to rule out another cause. You can ask for a female doctor, bring someone with you, and talk beforehand about what would make the examination more comfortable. The doctor may then suggest a specialist, such as a sex therapist.

What can help, day to day

Alongside medical help, Brook suggests a few practical steps:

Practical tips from Brook and the NHS

• Talking with your partner about what hurts and what feels good.
• Taking your time, and paying attention to how your body responds.
• More lubricant, and a water based lubricant if dryness is part of it (NHS).
• Different kinds of foreplay, to find what helps arousal (NHS).
• Being kind to yourself.

On the first time, Brook is clear: it is not supposed to hurt either. Nerves can make it harder for body and mind to feel ready, and touch is usually easier when you feel aroused. Exploring at your own pace and talking about desire offer gentle ways to take things slowly.

When to get help

The NHS suggests seeing a doctor or a sexual health service in these situations:

• You think you may have vaginismus.
• Pain or discomfort in the vulva does not go away or keeps coming back.
• Putting in a tampon is difficult because of pain.
• Sex is difficult because of pain, such as burning or stinging.

Brook adds that if sex is often painful, it is important to get help, and that a health professional can help you find any further support you need, including when the pain is linked to a past experience.

Questions about painful sex

Is it normal for sex to hurt?

Painful sex is common, but sex is not supposed to hurt, Brook says. Pain is a sign that something needs attention, and it is worth getting help.

What is vaginismus?

According to the NHS, it is the vaginal muscles tightening on their own when something is put into the vagina. It is an automatic reaction, not something you control, and treatments exist.

What is vulvodynia?

The NHS describes it as pain in the vulva that lasts at least 3 months and has no specific cause. Treatment aims to manage the pain, often with several specialists.

Can I ask for a female doctor?

Yes. The NHS and Brook both say you can ask to see a female doctor and bring someone with you.

Does the first time have to hurt?

No, Brook says. Feeling nervous can make it harder to feel ready, and touch is usually easier when you feel aroused.