Gynaecologist Dr Gabrielle Downey breaks down the reasons sex hurts and what you – and your doctor – can do about it
Painful sex is distressing for both the woman and her partner, and so many women think nothing can be done about it. The good news is the vast majority of the time, there is a simple explanation such as lack of lubrication or a thrush infection. Both of these can be easily remedied with more attention to foreplay and over-the-counter medication such as lubricants from the pharmacy.
The main thing to remember is pain during sex can be treated, and it must be reported
If the pain does not settle, then an assessment and examination by your GP will help. It is important to be clear with him/her about whether the pain is at the vaginal entrance, just inside, deep inside or all of the above as the potential causes and treatments vary depending on this. The main thing to remember is pain during sex can be treated, and it must be reported.
The main thing to remember is it can be treated, and it must be reported.
Pain at the vaginal entrance
Vaginal entrance pain is usually caused by an infection, and swabs should be taken. Other less common causes are skin disorders such as lichen sclerosus, a skin disorder a bit like eczema, which is treated by steroid creams, and vestibulitis, which is inflamed tissue at the vaginal entrance. These latter two require referral to a gynaecologist. Vestibulitis is often missed. It is characterized by extreme pain at penetration, burning and soreness after sex and possibly even split skin at times. If left untreated, then vaginal spasm can occur and eventually lead to sex and tampon avoidance. Don’t panic – there are treatments, but the condition has to be recognised first. Often women (and their doctors) think it is just thrush, and some are even told it is all in their heads.
Pain just inside the vagina
Pain just inside the vagina may be caused by a problem with your bladder and urethra (the tube from the bladder to the outside) or a rigid hymen (that’s a hymen that is not thin enough to open at intercourse). It could also result from vaginal bands, which are a bridge of tissue just inside the vagina, or fluid build-up or another problem in the Bartholins gland, which is the gland that makes the mucous for lubrication during sex. At examination your doctor should be able to determine which of these are most likely and advise management. Tablets usually manage bladder and urethral problems. A rigid hymen or vaginal band can be fixed by simple surgical removal (and it’s available on the NHS) and the Bartholins gland by antibiotic or surgery to open the entrance and allow the fluid to drain.
Pain deep inside the vagina
Pain deep inside usually means there is a problem in the pelvic organs such as the cervix, womb, tubes, ovaries and the surrounding tissue. Once again the most common cause is infection, and your GP should take ‘triple swabs’ looking for all the common organisms that could be causing an infection. If any of these are positive, they will often treat you with antibiotics if they suspect infection before getting the results, but always follow them up with another check up to ensure it’s clear. Pelvic infection left untreated can cause infertility, so it’s important to get this sorted out.
Pelvic infection left untreated can cause infertility, so it’s important to get this sorted out.
The next most common cause is a condition called endometriosis, a common condition estimated to affect two million people in the UK, according to the NHS. It classically causes pain from mid-cycle up to your period. It can only be diagnosed by a procedure called a laparoscopy (where a specialist looks inside your tummy with a telescope). The surgeon often offers to treat the condition at the same time either by removing it or burning it away. It is caused by period blood coming out of the tubes and sticking to the tissue. Each month it bleeds inside the womb and causes damage. You should be offered a treatment that reduces your periods such as a progesterone coil/injection/implant or combined pill if you do not want to get pregnant.
Fibroids can also cause pain during sex
You doctor could suspect an ovarian cyst, in which case he/she will arrange a scan. Most cysts are simple and less than five centimetres, are benign and resolve on their own so should be left alone. But ‘complex cysts’ and those over five centimetres will require referral. Unfortunately these usually come with no other symptoms. Polycystic ovaries (about 10 – 12 small cysts < 1 cm) do not cause pain and do not need referral and can usually be treated by medications such as metformin (a diabetes medication) and the contraceptive pill to regulate periods – though losing weight is the best way to reduce the symptoms.
each episode of tubal infection reduce fertility by around 20 per cent
Fibroids (these are benign lumps of gristle on the muscle of the womb) can also cause pain during sex. They can be left alone and advice given about positions to try to avoid pain, depending on where the fibroid is. The same is true if the womb is bent backwards, which is usual for 20 per cent of women. It rarely requires surgery, but if it is undertaken it is called a ventrosuspension and is performed through the telescope.
Pain along the whole genital tract can be due to infection (pelvic inflammatory disease). It is important this is managed properly to prevent tubal damage as each episode of tubal infection reduce fertility by around 20 per cent.
After the menopause
In the post-menopausal woman, pain can be caused by lack of oestrogen and easily treated with oestrogen cream or pessary.
Very rarely it can be caused by inflammation of the vagina such as lichen planus, a rare inflammatory disorder, and if this is suspected, you should see a specialist.
Non-gynaecological conditions can cause pelvic pain such as irritable or inflammatory bowel disease, bladder infections and appendicitis. All require appropriate treatment and referral, and your GP should be able to treat these.
Of the conditions mentioned above, your GP should be able to treat everything except lichen planus, endometriosis and cysts that are complex or over a certain size. For any of these, ask to see a specialist.
Dr. Gabrielle Downey is a Birmingham-based consultant gynaecologist. She has been a consultant gynaecologist at the Birmingham City Hospital for over 15 years. Dr. Downey publishes regularly in renowned journals and writes for medical textbooks, was a co-author to the current NHS cervical smear program, and has specialist expertise in problems such as abnormal smears among many other conditions.
Click here to read more about Downey.