Nothing ruins a good time in bed like pain and discomfort. Pelvic pain during sex, athough unwanted and disruptive, is more common than you might think. In fact, the American College of Obstetricians and Gynecologists estimates as many as 75 percent of those of us with vaginas experience pelvic pain during sex at some point.
However, as common as the issue is, it's also hard to draw a direct line between cause and effect: Many ob-gyns agree you could fill multiple books (and many have) on the multiple causes of sex-related pelvic discomfort. Allure spoke to some top ob-gyns to discover some of the most common causes of intercourse-related pelvic discomfort.
Issues With the Physical Act of Sex
For some, pain can be avoided by switching up how we approach sex. For example, according to our experts, many people need more foreplay than we may be getting. Adequate lubrication and sufficient foreplay are critical to preventing all sorts of pelvic pain as well as potential tearing or tissue damage.
Sexual position is another common cause for discomfort, especially for those with a retroverted uterus. "If you're in a position where insertion is really deep, sometimes it's manipulation of the cervix or the uterus itself," explains Jennifer Lincoln, a Portland, Oregon-based, board-certified ob-gyn hospitalist. She also says that past surgeries in that area might be the cause of the problem, as an issue called adhesive disease can be an after-effect of some procedures. "With the thrusting motions and movements, that scar is being stretched, which means the movement kind of forced upon it with sex can be really uncomfortable," she explains. Try shifting to different positions until you find one that feels good, or have your doctor address the post-surgical problem.
Potential Inflammation and/or Infections
Itching, burning, and pain might be a sign of potential infection and/or inflammation of the vaginal tissues. Take, for example, use of feminine hygiene products. Even though our ob-gyns agree the vagina is a self-cleaning wonder, perceptions to the contrary could lead one to use these items, sometimes with unwanted side effects. "Products such as douches and vulvar hygiene products can lead to both vaginal infections and vulvar dermatitis reactions," explains Staci Tanouye, a board-certified ob-gyn practicing in Jacksonville, Florida, who goes on to explain that both conditions, if they become chronic or recurrent, can reflexively lead to complications such as vulvodynia, dyspareunia (pain with sex), or pelvic pain.
Then there are also complications due to dermatologic conditions and potential infections like pelvic inflammatory disorder and various STIs to consider. "Yeast infections, desquamative inflammatory vaginitis; all [of these] can make the tissues extremely sensitive, irritative and painful," cautions Tanouye. She explains untreated STIs can cause painful inflammation in the vagina, cervix, and uterus.
Tanouye also says not to discount UTIs and other uterine diseases as probable causes. Prescribed meds can help, as does thoroughly cleaning toys or other sexual aids while the condition clears.
Other Medical Conditions
Other common, painful causes can disrupt your sex life. For example, Lincoln states that physical issues such as fibroids and cysts can be truly life-altering. Additionally, Tanouye says conditions like endometriosis and adenomyosis, as well as issues with the pelvic floor, could also be the cause, including the involuntary spasms of vaginismus. Lincoln says other organs in that area, including the bladder and the bowel, might be to blame: "Bad constipation or interstitial cystitis: all those nerves are connected so they can all cause pain." All that is to say: If you're in pain, talk to your doctor. Ob-gyns have a host of remedies at their disposal, up to and including surgery when needed.
Lack of Access to Affirming and Literate Care
Danielle Jones, a board-certified ob-gyn hospitalist working in Texas, tells Allure that because of the lack of LGBTQIA+ affirming health care, many transgender and nonbinary people often avoid seeking treatment for pain, and even when they do, they often receive incorrect diagnoses or inadequate care. For example, though individuals who've elected to have bottom surgery may not be at risk for endometriosis, pelvic pain may be caused by other issues. "Neovaginas, in general, can lead to somewhat unique causes of pelvic pain, including vaginal stenosis — or narrowing of the vagina — which can be painful with intercourse or just in general." Additionally, according to Jones, common vaginitis infections may occur slightly more frequently for those who have had bottom surgery, though Jones says these important issues can be diagnosed fairly easily by trans-inclusive providers.
Jones explains that a lot of trans men and nonbinary people with vaginas fall through the cracks of the medical system as well. While not every trans person decides to undergo hormone replacement therapy, fluctuations in hormones can play a role in pelvic pain, regardless of gender identity. A decrease in estrogen, for example, can be associated with a decrease in lubrication and less vaginal elasticity, which can be at least partially relieved by adequate lubrication and topical estrogen, according to Jones, if a person is willing and able to use it. "[Topical estrogen] doesn't increase blood estrogen levels enough to counteract the testosterone they're [taking], but it can make intercourse a lot less painful," she says.
While the first impulse when looking for the cause of physical discomfort may be to look for a physical cause, the cause may actually be emotional. In fact, past or current trauma, including domestic violence and sexual trauma, can often have a direct impact on sexual comfort. "Oftentimes, the way domestic abuse presents in our office is people complaining of recurrent problems," explains Jones. "Sometimes that could be pain with intercourse, infections we are not finding — all kinds of things bring people in when they would like to outcry about domestic abuse, but don't know how. The onus is on the health-care team to be taking a good history and asking the right questions to assess for that."
Indeed, the emotional cannot be separated from the physical. Kate Balestrieri, a licensed clinical and forensic psychologist, certified sex and sex addiction therapist, and PACT-trained couples' therapist based in Los Angeles says the mind and the body are entirely connected when it comes to sexual activity. Balestrieri works with clientele who struggle with sexual dysfunction issues as well as relational betrayal, sexual trauma, and/or different kinds of dysfunctional relationships, and explains that while the list of causes can sometimes be extensive, there often tends to be a common thread. "Certainly a lot of what I see comes down to anxiety, fear about the safety of the sexual activity or the partner, i.e. risk narratives around safety or exploitation because of previous sexual trauma," she tells Allure.
Her list goes on to include depression and anxiety, eating disorders, substance abuse, repressing gender or sexual identity due to factors such as safety concerns, pregnancy or miscarriage, and perception of infidelity. Discussing relationship issues, as well as any mental health issues you may be struggling with as an individual, with a licensed therapist can open a world of therapies that exist to alleviate discomfort.
Essentially, don't be afraid to ask for help. "If you're having recurrent pain that is prohibitive to a normal, happy sex life, you need to see someone for it," offers Tanouye. Also, know that these discussions are nothing to be embarrassed about. "This is what we do, day in, day out," she says. "I talk about vaginas, sex — all kinds of sex — every single day, all day. I've heard everything; it's all normal to me." Finally, if you don't feel heard, go see someone else. "If you bring it up and your practitioner blows it off or says [something like], 'Well, you just need to drink a glass of wine,' that's a cop-out," says Lincoln.
That said, our experts recognize changing providers is complicated: Access to medical care is a challenge for many people for a multitude of reasons, and online reviews are often not reliable. Tanouye suggests trying a new doctor within the same clinic, asking close friends and family, and looking on social media for people who have a point of view around care that aligns with your needs.
In addition, says Lincoln, if you have children, it can be helpful to ask your pediatrician for recommendations. Both Tanouye and Lincoln also highly recommend a widely untapped resource: nurses. Tanouye suggests asking nurses who work with ob-gyns ("They always have the best inside info," she says) and Lincoln suggests querying local labor and delivery nurses about which ob-gyns they use personally. "They see doctors in the thick of it and definitely will have strong opinions about who's a good listener, respectful, and/or excellent in the operating room," advises Lincoln.
Jones agrees. "Certainly any time you've been in and talked about pain with intercourse and it's not getting better, keep coming back until we find the problem, because pain with sex is not normal and we should figure out what's causing it," she says.
"Please don't give up," pleads Lincoln. "I promise you there's better health out there."
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