Ouch! All of a sudden, sex is a pain

Welcome to the updated Health section of Today.MSNBC.com, the "Today" show’s Web site! I’m Judith Reichman, M.D., the program’s medical contributor on women's health. I hope to address your questions and concerns in my weekly column, so please e-mail me. Meanwhile, you will find many answers to your questions in my latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," published this month by William Morrow, a division of HarperCollins.

Q: Why, all of a sudden, does sex hurt?

A: I assume you mean that you have more than a headache — that you have actual vaginal or pelvic pain with intercourse.

As we tend to in medicine, we’ve given this pain a complicated-sounding name — dyspareunia. It occurs to approximately 15 percent of women of reproductive age.

Obviously, pain will greatly affect your sexual function, which is both unfortunate and disconcerting. Not only does it disrupt one of life’s pleasures, but it can also be disruptive to a relationship.

Fortunately, though, the pain often responds to appropriate therapy.

The most common causes of pain during sex are:

Vaginal infection: This pain may be accompanied by burning, stinging, itching, a fishy odor and discharge. The likely cause is an overgrowth of anaerobes — bacteria that don’t like oxygen. This infection, called non-specific bacterial vaginosis, may occur after you take antibiotics that wipe out normal oxygen-liking bacteria, after sex that changes the vaginal PH (although this is not a sexually transmitted disease) or for reasons unknown. It can be treated with a local antibiotic vaginal cream containing metronidazole or ovules of clindomycin.

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Yeast infection: Most women experience this at least once in their liftetime, and as a result suffer from itching and/or an irritating cottage-cheesy discharge. It’s often caused by antibiotics that wipe out normal flora and leave the yeast. Pregnancy, birth control pills and estrogen hormones can also increase the chance of yeast infection. The treatment is an anti-yeast medication, either a prescription pill or vaginal cream or over-the-counter vaginal creams or suppositories.

Lichen Sclerosis: This disorder, in which the skin around the genitals tends to get thin and white, causes burning and discomfort during sexual intercourse. A doctor can diagnose it with a biopsy and treat it with a potent steroid cream called Clobetasol.

Estrogen deprivation: Lack of estrogen can result in inadequate lubrication and thinning of the tissue so that there is a “sandpaper” feeling when you try to have intercourse. This can occur just after delivery of a baby or while breastfeeding (or with certain very low-dose birth control pills) It commonly occurs in menopausal women who are not on hormone therapy. It is treated by replenishing estrogen; this can be done vaginally in the form of a cream, a tablet or a ring inserted into the vagina that releases estrogen over time. (Or hormone replacement therapy will also obviously replenish the missing hormone and restore vaginal health.)

Muscle spasm: Muscle contractions that makes penetration difficult is called vaginismus. This is an involuntary spasm of the outer muscles of the vagina. It can be primary, starting from the time you become sexually active, or secondary, occurring later in life. Vaginismus may be associated with psychological issues, such as strong anti-sexual feelings, fear of sex or a history of abuse. Treatment consists of desensitizing both your fears and the vaginal area, usually by a combination of sexual counseling and by use of special dilators.

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Vulvodynia: This refers to an extraordinary sensitivity anywhere in the vulva, but most often in the vestibulum, or lower part of the vagina. Pressure and penetration cause severe burning or stinging pain.  The cause is unknown, but vulvodynia has been linked with yeast infections, use of antibiotics, laser treatments or cryosurgery (freezing of the tissue). Vulvodynia has been found to occur more frequently in women with irritable bowel or bladder problems. Initially, therapy should start with soothing ointments such as A and D or hydrocortisone. I often advise patients to use a lidocaine gel before intercourse. Taking 1000 to 2000 mg of calcium twice a day may also be helpful.  If all this fails, I prescribe tricyclic antidepressants, which diminish the pain impulses in the nerves. As a last resort, surgery can be done to remove the sensitive tissue of the vestibulum; this is effective about 80 percent of the time.

Other causes of pain during sex include bladder infections, pelvic inflammatory disease, pelvic scar tissue, endometriosis, fibroids and ovarian cysts.

Dr. Reichman’s Bottom Line: Sex shouldn’t hurt — quite the contrary. Try to be as exact as possible in describing your discomfort so that your doctor can help you with the right diagnosis and treatment.

Dr. Judith Reichman, a regular “Today” show contributor, has practiced obstetrics and gynecology for more than 20 years. Her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," is published this month by William Morrow, a division of HarperCollins.

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