Hormonal birth control can cause the same kind of sexual pain due to lack of lubrication and vaginal atrophy that is normally seen in postmenopausal women, says Andrew Goldstein, MD, an associate professor at George Washington University and a specialist in vulvar pain. He says he's been seeing "a ton of it" in the newer birth-control-pill formulations that have very low estrogen and a type of progestin that can lower testosterone. "I'm seeing 25-year-old women who have low desire and need lubricants, which is ridiculous!" he says.
"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.
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 sclerosus, 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.
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.