Painful Intercourse is a Common Problem for Women

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Most causes of painful intercourse are not “in your head” or psychological.

Painful intercourse is a common problem that OBGYNs diagnose and treat every day, but it is often a very upsetting problem that women don’t like to talk about with their doctor, so they often live with it, silently.  I want to encourage those of you who are experiencing this problem to talk to your doctor about it so you can receive treatment.  It is important for women to ask their doctor about their pain with intercourse so they can have a fulfilling sex life.

Most causes of painful intercourse are not “in your head” or psychological. I want to concentrate on the physical causes of painful intercourse and not psychological or couple issues, because frankly the psychological causes are not my area of expertise and I always ask my patients to see a counselor or psychiatrist to manage those causes.  There are many physical reasons a woman may experience painful intercourse that prevents them from enjoying the benefits of a good sexual relationship, and today I will discuss the causes and treatments for physical causes of painful intercourse.

At BioBalance Health® I concentrate on the hormonal deficiencies that can cause painful intercourse.   For women before and after menopause, having enough testosterone and estrogen is key to lubrication and skin that is thick enough to have comfortable intercourse. Without these hormones the vagina cannot lubricate, the skin “shrinks around the vagina and clitoris and the vagina is no longer stretchy and pliable enough to dilate to accommodate a penis.  The outcome of intercourse without enough estrogen and testosterone (called vaginal atrophy) is lack of orgasm, tearing of the vaginal opening, accompanied by pain and bleeding, and the feeling of being rubbed with “sandpaper” when having intercourse.  Within 3 weeks of replacing testosterone and estradiol with bio-identical pellets brings women back to health in many ways and relieving the pain and agony of sex from low hormone levels brings the joy of sex back to my patients.

Because of testosterone and estradiol deficiencies many of my patients have stopped having sex because it is too painful. We will talk about menopausal women who have hormone deficiencies first and then we will discuss painful intercourse in pre-menopausal women, what causes this problem and how to remedy this common problem.

A wonderful example of vaginal dryness that caused painful intercourse was embodied in one of my recent patients who looked at the floor while she told me that she just “could not” have sex because her vagina was too small.  This woman was 59 and she had been divorced for over 10 years by the time she came to my office for the first time.  She had many other symptoms of estrogen and testosterone deficiency, and she had seen her gynecologist to ask for help.  She had given her lubricant first and that did nothing for the size or stretchiness of my patient’s vagina.  She was still unable to have sex.  I don’t know why OBGYNs are afraid of using estrogen cream, estradiol in patch or pellet form or testosterone is any form, but they are!  When she got to me the simplest answer was estrogen cream to put on and in her vagina.  From experience I know that this doesn’t fully bring a woman back to sexual wholeness, so I also gave her estradiol and testosterone pellets, and she was able to stop the cream after one month.  Voila!!  She was healed and her new relationship blossomed into marriage!  With testosterone and estradiol her vagina was once again back to normal premenopausal shape and her sex life was not only possible, but wonderful!

To summarize the effects one by one of replacing both testosterone and estradiol in women with painful intercourse I will list the post-menopausal effects of testosterone and estradiol attributed to each hormone deficiency.

What Testosterone does for sex:

  • Improves Libido
  • Brings blood flow to the pelvis
  • Makes orgasm possible
  • Improves the wetness and stretchy ness of the vagina
  • Lengthens the vagina
  • Increases the size of the clitoris so it can be stimulated
  • Allows the vagina to stretch to accommodate a penis of any size
  • Labia around the vaginal opening enlarge and the skin of the whole vulva thickens
  • Improves the sensitivity of the vagina, clitoris and G spot


Estradiol’s function in sexual health:

  • Increases wetness in the vagina
  • Increases the thickness of the vaginal wall and vaginal opening
  • Improves the sensitivity of the vulva
  • Helps prevent recurrent bladder infections from having sex


The quality of vaginal wetness and elasticity is vital to a satisfying sex life. The necessary hormones must be replaced to achieve the same level of sexual satisfaction as you had before your hormone loss, menopause In this area of concern, most women are not willing to settle for second best!

There are other causes of painful intercourse that are not from a lack of hormones, but the previous causes and treatments for painful sex treat over 95% of my patients. Vaginal dryness can also be caused by dermatologic and medical disorders such as autoimmune diseases, vaginal infections and dehydration usually from diuretics like Lasix®.

The other causes of a dry vagina, vaginal infections, are listed below. The one cause that will require antibiotic or yeast treatment is vaginal infection.  Let me expand on that.  Usually, bacteria from the rectum is pushed into the vagina from wiping the wrong way (the right way is front to back), sex, or underwear.  This is hard to avoid and is from yeast, the bacteria called Gardnerella, Strep, Staph, or Ecoli. These are NOT necessarily a sexually transmitted disease; however any bacteria can be transmitted through intercourse.  The sexually transmitted disease such as Chlamydia and Gonorrhea generally cause a vaginal discharge but create pelvic scarring and infertility and have delayed pain and pain when the infection is active in the pelvis causing adhesions and scarring of the tubes.  Both of these sexually transmitted diseases can leave scars and cause pain during and after the infection.

If you want to do a simple and crude test at home to determine whether your vaginal pain is from a yeast or a bacteria, you can use litmus paper and it if turns blue, it is usually Gardnerella and needs an antibiotic cream or oral prescription.  If it turns yellow, it is generally yeast and requires over the counter yeast medicine.  The discharge for Gardnerella usually smells like “fish” and the discharge for yeast may or may not smell like bread baking. The sexually transmitted disease is not generally those that change the pH so don’t be fooled by a negative litmus test.

To be completely safe you should have a vaginal exam by a gynecologist or family physician or their nurse practitioner who can culture your vagina to find out exactly which bacteria or yeast is the cause, and she will prescribe the right kind of antibiotics for you.  Remember if it is rectal bacteria, it will turn the litmus paper blue, but you still need a doctor to prescribe your antibiotic and they will want to see you before writing the script!

In the world of post-menopausal women, pelvic pain can rarely be caused by Pelvic abnormalities.  This pain is usually not from the area around and in the vagina itself but deep in the pelvis when the penis thrusts against the vagina or cervix.  This is usually cause by one of the following problems, most of which can be seen on ultrasound, with the exception being adhesions.

Pelvic abnormalities causing painful intercourse after menopause

  • Pelvic masses: fibroids, ovarian cysts, retroflexed uterus,
  • Old Endometriosis
  • Adhesions
  • Colon mass or masses
  • Cervical scarring from a difficult childbirth
  • Uterine Prolapse

The anatomy requirements for intercourse are that the vagina must be stretchy and elastic, it must be able to lengthen which means it requires hormones and cannot be tethered by adhesions in the pelvis, and the uterus if you have not had a hysterectomy must also be freely moving and not folded on itself in the front or back which is called anterior flexion or retroflexion. Sometimes the uterus “falls down” (uterine prolapse) into the vagina and the act of intercourse pushing it out of the pelvis is painful.

The diagnosis of these problems must be made by a physician or nurse practitioner who specializes in women’s health.  First a physical and vaginal exam can find ovarian, colon and uterine masses like fibroids or ovarian cysts, and uterine prolapse.  The vaginal exam can rule out vaginal atrophy and infection.  Lastly, a vaginal or abdominal ultrasound or both can be ordered to “see” what is in the pelvis.  We require these on every menopausal woman to make sure they don’t get too much estradiol to stimulate their pre-existing problem (like fibroids).

Some problems can only be diagnosed surgically.  Uterine and pelvic adhesions can only be seen by doing a laparoscope under anesthesia.  Fortunately, they can also be treated by cutting the adhesions and placing an anti adhesion fabric around the uterus or ovaries.  Sometimes the adhesions are to the bowel and the treatment requires a hysterectomy only or with the removal of the ovaries.

Fibroids can grow under the influence of estrogen, and endometriosis can be active pre-menopause and make long lasting adhesions, however if the ovaries are removed or a woman has been in menopause it rarely reawakens to cause trouble. The adhesions it made before menopause still remain unless they are surgically removed.

It is important that a GYN or FP Doctor rule out the presence of ovarian, uterine and colon masses because rarely they can be precancer or cancer.  Your doctor will usually order the for no other reason than to rule these problems out, but they can see many other things that a patient has in the same test.

We have talked about several causative issues that result in painful intercourse, the diagnosis method and the treatments for them. There are many possible causes and many appropriate treatments. Sexual Pain is a very serious issue which is often under recognized and under treated by gynecologists. In order to be an informed consumer and participate in good medical decision making, a woman must know about their body and the malfunction thereof enough to ask (or even challenge) her physician to help her treat these very fixable problems. It is not “destiny” for a woman to be dry and have painful intercourse. The goal is to have pleasurable sex, it is good medicine and good treatment you can enjoy privately which can restore a happy satisfied mood, and the natural sexual abilities and climaxes you had in your youth!

Join us next time for Sexual Pain in Pre-menopausal Women.

This Health cast was written and presented by Dr. Kathy Maupin, M.D., Bio-identical Hormone Replacement Expert and Author.  (314) 993-0963

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