Symptom of Endometriosis: Pain During Sex

Many women and some men will experience pain with intercourse at some point during their lifetime. The clinical term for pain during sex is dyspareunia, and its characteristics can vary greatly from person to person. For some, this pain may be intense, stabbing, or throbbing in nature, while for others, it may be mild and like a dull ache. In some instances, it may happen upon initial penetration and go away quickly, but in other cases, it may be experienced during thrusting or after penetrative sex is underway and last for days post-intercourse. Dyspareunia doesn't always occur every time an individual has sex. It may only occur every so often or only in certain positions. Pain during sex may have larger implications if not addressed, such as impacting an individual's intimate relationships, self-esteem, self-perception, or mental health. Women with endometriosis often experience dyspareunia, most commonly deep dyspareunia.^1-4

What causes pain during sex?

Pain during sex can be caused by a variety of factors, including both physical and mental. The type of pain felt, or time at which discomfort is experienced, may point toward its underlying cause. As an example, pain upon entry may be due to a lack of lubrication, injury, or trauma that affects the external portion of the vagina. Additionally, infection, inflammation, muscle spasms (also called vaginismus), or a deformity present since birth may also lead to pain upon penetration. Depending on the severity of this pain, a woman may experience this upon any type of penetration, including when inserting a tampon.^1,5

Deep dyspareunia during sex, the most common type of pain experienced by women with endometriosis, is discomfort or pain post-insertion and during thrusting. This pain may vary in how it feels or is described by women experiencing it, however, it is occasionally explained as a feeling of being bumped into during sex. It has been theorized that the incidence and severity of this type of pain may be associated with irritation or invasion of the pelvic floor nerves, or infiltration of the uterosacral ligaments. The uterosacral ligaments support the uterus and attach to the sacrum (the bone at the base of the spine right above the tailbone).^2,3 Other issues that may contribute to dyspareunia are internal scarring, especially from a surgical procedure like a hysterectomy or other pelvic surgery, as well as conditions like uterine prolapse, pelvic inflammatory disease, uterine fibroids, cystitis (inflammation in the bladder), hemorrhoids, ovarian cysts, irritable bowel syndrome, or retroverted uterus (uterus is tilted back toward the rectum).¹

It has also been theorized that mental or emotional factors may also play a role in the presence of dyspareunia. Some of these include experiencing anxiety, stress, depression, fear, or negative self-perception. A history of sexual trauma, such as a past sexual abuse, may also play a role in the development of dyspareunia.^1,5

How will your doctor evaluate you?

Evaluating dyspareunia can be challenging, as a main focus is to determine the underlying cause of the pain among many similarly presenting conditions. In order to do this, your doctor will take full medical history from you, including information on your current pain experience, sexual history, past sexual traumas, any medications you are currently taking, and more. By learning more about your pain, when it happens, and what events have led up to the pain starting (if it wasn't always present), your doctor may be able to start narrowing down the list of potential causes. Your doctor will also perform a pelvic exam to look for any obvious signs of an underlying issue. Subsequent exams and diagnostic tests such as blood tests, imaging, or minimally invasive surgery like laparoscopy may be performed based on what your doctor suspects the cause of your pain is.^1,5,6

How is pain during sex treated?

Dyspareunia can be treated in a variety of ways, each of which centers around the underlying cause of the pain. For example, if a woman's pain is because of vaginal dryness, her doctor may recommend a lubricant to use during sex. If a woman's pain is due to an infection such as a urinary tract infection or yeast infection, she will be given medications to treat these. When a psychological or emotional issue is thought to be causing the pain, counseling or therapy may be recommended. In the case of endometriosis, common endometriosis treatments may be used in effort to improve dyspareunia. These include hormonal treatments or pain medications. In some cases, surgery to remove endometriosis lesions that are thought to be impacting a woman's sexual experience may be removed to reduce pain during sex.^1,2,5

How can you manage pain during sex?

In addition to the treatment options outlined above, there are some additional lifestyle or behavioral changes that may help improve pain during sex. Some of these include, but are not limited to, trying new positions during sex, using lubricant, reducing stress and anxiety, taking warm baths to relax muscles, practicing relaxation techniques such as meditation, slowing down during sex and waiting until you're fully aroused before starting penetration, and communicating with your partner about your needs.¹ Keeping open, honest lines of communication with an intimate partner may help reduce your stress levels, as well as prevent strain on your relationship.