A banana spooning an eggplant with a light pink background.

A banana spooning an eggplant with a light pink background.Is penetration ever painful for you? Whether it’s with fingers, toys, or penises, you’re not alone:  an estimated 50% of menopausal women with sexually active partners experience pain during vaginal penetration. And that’s just women in menopause. (Note: Here’s a Partner’s Guide to Menopause)

Dyspareunia is a very general term for pain with penetration during intimate sexual contact. Deep pelvic pain, or deep dyspareunia, usually emerges because of other existing disorders hidden in the pelvis—either adjacent to or touching the upper portions of the vagina.

There are a few different possible causes for this deep pelvic pain (or deep dyspareunia), which include:

  • fibroid tumors in the uterus
  • cysts in the ovaries
  • tumors on the ovaries
  • endometriosis
  • scarring from pelvic infections or prior surgery

While the disorders that we just listed above are relatively common, the deep pelvic pain that can result from them is not nearly as common. Most people with these disorders won’t have the correlating deep pelvic pain, but if you experience a new onset of deep pain during sex, which can be triggered by a new partner or experience, you should talk with a doctor or other health professional.

More common causes of both superficial and deep pelvic pain include:

  • Vaginal atrophy following menopause (AKA vulvovaginal atrophy, genitourinary syndrome of menopause, or GSM)
  • Vestibulodynia (vulvar vestibulitis)
  • Pelvic floor muscle dysfunction

Regardless of the cause, pain during penetration is not fun, and it certainly isn’t comfortable. To provide additional context, this typically happens when there’s any restriction of movement at the opening of, or at the top of the vagina.

The vagina is meant to slide on its neighboring organs (i.e., ovaries, tubes, uterus, intestines, rectum, etc.). When the top of the vagina (or the vaginal apex) is restricted or bumps up against a tender neighboring organ or disorder, like a fibroid or an ovarian cyst, during penetration, it can cause deep pain.

Other relevant factors include:

  • Depth of penetration
  • Sexual position

Let’s do some quick math—Depending on the length and girth of the fingers, penis, or toy that’s penetrating you + the length of your vaginal canal = deep pelvic pain may only occur intermittently, for example, only with sex in particular positions, with a particular partner, or with a particular partner in a particular position.

If you are experiencing deep pelvic pain from penetration, regular or otherwise, a diagnosis can usually be determined with a vaginal or abdominal ultrasound (sonogram). Vaginal ultrasounds are preferred since the probe that’s inserted into the vagina can be used to reproduce or simulate the pain that’s felt during penetrative sex—quickly demonstrating exactly where and how the pain is initiated.

If endometriosis is the cause, there are a couple of things to note:

  1. Endometriosis often goes undiagnosed for many years.
  2. Endometriosis can be difficult to diagnose.
  3. A complete evaluation may require a careful rectal exam; this is because endometriosis causing deep penetrative pain during sex may best be felt on a rectal exam.

Typically, treatment of deep pelvic pain is focused on any underlying disorder. It may be surgical (i.e., fibroids, ovarian cysts, endometriosis, or scarring) or responsive to medication (i.e., fibroids, ovarian cysts, endometriosis).

When surgery isn’t preferred or necessary, there are medical therapies to shrink the size of fibroid tumors and reduce the heavy menstrual bleeding associated with them, and other medical treatments have been developed to shrink endometriosis, and reduce the associated pain, including deep sexual pain. These treatments include oral contraceptives, and both the injectable GnRH agonists (i.e., Leuprolide, Triptorelin) and the oral GnRH antagonists (i.e., Elagolix, Relugolix, Linzagolix). These GnRH modulating drugs are used to temporarily create a menopausal hormone milieu, because menopause typically shrinks these pathologies and clears the way for unrestricted movement of the upper vagina.

Typically, medical approaches are favored initially, and surgery reserved as a last resort. However, exceptions to this rule are common. For example, if fibroid tumors are causing infertility or recurrent miscarriages and there is related deep pelvic pain during penetration, surgery may be the only choice that can address all three problems: the infertility, pregnancy loss, and deep pelvic pain.

Additional remedies include pelvic floor physical therapy, including treatments like trigger point injections and pelvic floor “Botox,” which can be helpful in reducing the reactive pain, and can help your pelvic muscles to unlearn the guarding they do related to these disorders.

A very simple and non-invasive at-home remedy for pain with deep penetration is reducing the depth of penetration. Testing various positions that shorten penetration can help to achieve this, as can the OhNut, a wearable device that allows you to customize the penetration depth of penises and/or toys.

What else have you found to help? Comment with any thoughts, questions, or concerns. Or you can always give us a call to setup a consult.

 

References:

Yong PJ. Deep Dyspareunia in Endometriosis: A Proposed Framework Based on Pain Mechanisms and Genito-Pelvic Pain Penetration Disorder. Sex Med Rev. 2017 Oct;5(4):495-507. doi: 10.1016/j.sxmr.2017.06.005. Epub 2017 Aug 1. PMID: 28778699.

Donnez J, Stratopoulou CA, Dolmans MM. Uterine Adenomyosis: From Disease Pathogenesis to a New Medical Approach Using GnRH Antagonists. Int J Environ Res Public Health. 2021 Sep 22;18(19):9941. doi: 10.3390/ijerph18199941. PMID: 34639243; PMCID: PMC8508387.

Orr N, Wahl K, Joannou A, Hartmann D, Valle L, Yong P; International Society for the Study of Women’s Sexual Health’s (ISSWSH) Special Interest Group on Sexual Pain. Deep Dyspareunia: Review of Pathophysiology and Proposed Future Research Priorities. Sex Med Rev. 2020 Jan;8(1):3-17. doi: 10.1016/j.sxmr.2018.12.007. Epub 2019 Mar 28. PMID: 30928249.

Eid S, Loukas M, Tubbs RS. Clinical anatomy of pelvic pain in women: A Gynecological Perspective. Clin Anat. 2019 Jan;32(1):151-155. doi: 10.1002/ca.23270. Epub 2018 Dec 3. PMID: 30390350.

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