Sex Pain: Millions of Women Have It

Find out what causes excruciating pain during sex and how to get treatment.

Aug. 6, 2009 — -- For many women sexual intercourse is an unbearable experience. The women profiled by "20/20" suffered in silence: They did not feel pleasure from sex. Instead, they said they felt excruciating pain.

The unbearable vaginal pain extended beyond sex to everyday activities like walking, and even light contact from wearing blue jeans could be too agonizing to bear. But all the women said what's almost harder than the physical pain is the emotional toll of suffering from such a mysterious condition without a clear diagnosis.

Dr. Andrew Goldstein, who runs the Center for Vulvovaginal Disorders in Washington, D.C., and is a pioneer in the new field of sexual pain disorders, said 20 million American women will suffer from sexual pain disorders at some point in their lives.

So what are the main causes of sex pain? Goldstein said the number one cause is birth control pills, followed by tight pelvic muscles and an overabundance of nerve endings at the opening of the vagina.

Understanding Sex Pain: Quiz for Treatment

1. Did your sexual pain begin while you were taking hormonal contraceptive (birth control pill/patch/vaginal ring) or when you were taking medication for infertility, endometriosis or breast cancer?

If so, it is possible that your pain is related to a deficiency of the hormones estrogen and/or testosterone. Your physician can perform a blood test to check the levels of these hormones. If the estradiol (estrogen) and free testosterone (the active form of testosterone) are low, a topical cream that combines estrogen and testosterone can be applied to the vulva. However, be aware that this cream may not work unless you stop your hormonal contraceptive. You should also consult your physician before stopping any medication.

2. In addition to your sexual pain, do you have low back pain or urinary symptoms such as frequency, hesitancy, and incomplete emptying, or do you have chronic constipation or rectal fissures?

If so, it's possible that your pain is caused by tight muscles of the pelvic floor, and exercises for that area may help. In addition, studies have shown that physical therapy, biofeedback and muscle relaxants may also be very useful. Current research is focusing on the use of Botox shots into the muscles of the pelvic floor to help loosen the muscle spasms

3. Did your pain begin after an allergic reaction to a topical medication such as a yeast cream?

If so, it's possible your pain is caused by an overgrowth of nerves at the opening of the vagina called the vestibule. When you have too many nerve endings, even very light touch causes the sensation of burning, cutting, and stabbing. This type of pain is usually treated with a combination of oral and topical medications that are used to numb nerves.

The topical medications include anesthetics such as lidocaine and capsaicin (which is made from the extract of chili-peppers.) Systemic medications include tricyclic antidepressants such as amitriptyline and anti-seizure medications such as gabapentin. It is also possible to get creams made of the amitriptyline and gabapentin if the side effects are too great when the medications are taken orally.

4. Do you have pain when there is deep thrusting or do you have severely painful menstrual cycles?

It's possible that your pain is caused by endometriosis, which is when the lining of the uterus, the endometrium, grows outside of the uterus -- such as in the pelvis, on the bladder or on the colon. As this extrauterine endometrial tissue is still under hormonal control, when the progesterone drops at the end of the menstrual cycle there is bleeding within the pelvis and this can cause severe pain and adhesions, which cause pain with deep thrusting. The only way to make definitive diagnosis of endometriosis is with a surgery called a laparoscopy. The laparoscopy can be used to diagnose and treat the endometriosis.

5. Do you have vulvar itching severe enough that you wake up at night scratching and you haven't gotten better with medications for a yeast infection?

It's possible that you have a vulvar skin disease such as lichen sclerosus or lichen planus. In addition to itching, these skin diseases cause chronic inflammation that can cause scarring of the vulva and vagina, which can then cause painful sex.

While some physicians make the diagnosis of these conditions just by their clinical appearance, most physicians, including Goldstein, suggest that a small skin biopsy be used to confirm the diagnosis. It is also importance to have this biopsy before treatment with any medications such as a topical steroid, because they can alter the results of the biopsy.

To find a doctor in your area who specializes in the treatment of pelvic pain, click here.

For more information on vulvodynia and sexual pain disorders, click here or here.

For information on physical therapy for sexual pain disorders, click here.