Last updated: Apr 05, 2008
Biological causes, psychological effects.
An estimated 6-14% of women suffer from sexual pain and many more postmenopausal women do. It may be menopause-related or it may be vulvodynia, but there are many other potential causes, from dermatological diseases to bladder conditions. Deep (abdominal) pain with penetration could be due to endometriosis, fibroids, or previous pelvic surgery.

Here are a few other causes you and your doctor may want to consider:

1. The Pill
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.

That doesn't mean the pills are bad—"for a large percentage of women, they're great," Dr. Goldstein says. But it does mean that women should be aware that there may be sexual side effects to hormonal birth control methods, which they can discuss with their doctor.

2. Cancer treatment
"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 estrogen 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 estrogen is relatively safe. Other treatments may include physical therapy and sex therapy.

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3. Skin problems
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.

4. Physical abnormalities
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.

5. Vaginismus
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 gonna flinch," says Christin Veasley, 32.

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.