- When did sex start to hurt (has it always hurt)?
- When does the pain begin (is it as you’re getting excited, only during penetration, related to orgasm)?
- Where do you feel the pain (is it in one specific area, or more general)?
- Are there still things you can do sexually that don’t cause pain?
- Explore on your own.
- If you don’t regularly masturbate, now’s the time to start.
Women's Sexual Pain, If It's Not Vulvodynia or Menopause
Here are a few other causes you and your doctor may want to consider:
"For women who have cervical or vaginal cancer and radiation, the whole vagina can become a rock-hard scar," says Irwin Goldstein, MD (no relation to Andrew), director of San Diego Sexual Medicine and the editor in chief of The Journal of Sexual Medicine. Also, "tamoxifen stops oestrogen from working," Dr. Goldstein adds, so breast cancer patients can have issues with vaginal dryness and atrophy, same as postmenopausal women and some birth control pill users. It's a tough situation, because systemic hormone replacement is not an option, as it may encourage the cancer. Some doctors, meanwhile, say local oestrogen is relatively safe. Other treatments may include physical therapy and sex therapy.
Problems with the skin in the genital area may be another reason for sexual pain. Common issues include childbirth lacerations or episiotomy scars, as well as dermatological diseases such as lichen sclerosis, or sexually transmitted infections such as herpes. One of Dr. Irwin Goldstein's patients came in with pain that ended up being traceable to a simple ingrown hair: "One of the pubic hairs grew into the skin and she had an infection of the clitoris," he says.
Dr. Andrew Goldstein says there are women who have imperforate hymens, but counsels a second opinion from a vulvar specialist before getting surgery. Many women who go in for hymenectomies actually have vulvar vestibulitis syndrome (VVS), which is often diagnosed by touching the area lightly with a Q-Tip. "If the hymen is too tight, the vestibule shouldn't hurt," he says. Women with VVS feel excruciating pain when specific areas are touched.
This is an involuntary tightening of the vaginal and pelvic floor muscles that makes penetration painful or even impossible. Some women experience pain with any sort of penetration, including medical; for others, only sexual penetration hurts. Vaginismus can be a result of rape or other sexual abuse, but it can also develop as an aversive reaction to physical pain. "If you keep trying to have sex or insert a tampon and it's painful every time, eventually you tense your muscles; you're going to flinch,"
The source of the pain must first be identified, and then the vaginismus can be treated with sex therapy, biofeedback (so the patient learns what her body is doing and can better control it), and dilator therapy. Is it in your head or your body? Doctors used to believe that women's complaints of sexual dysfunction were 90% psychological, 10% biological. "Now the thinking is 90% psychological, 75% organic," says Irwin Goldstein. What he means is that most sexual pain has a biological cause, but it usually also causes psychological issues. It makes sense: If sex hurts, you learn to fear it and avoid it. That's why the ideal is for sexual medicine doctors to work hand-in-hand with sex therapists.