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.



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.

Consider Participating in an Elagolix Study

Uterine fibroids (UF) are very common in women of reproductive age, affecting approximately 70% and 80% in white and black women, respectively, across the lifecycle. If you have been diagnosed with uterine fibroids and the doctor recommends surgery, you should know there are non-surgical methods to treat this condition. Before making an important health decision of any kind, it’s good to have all the facts, so that you can make an informed decision. Get a second opinion. Concerned that you might offend the physician by wanting a second opinion? Don’t be! Doctors want to ensure that patients get the best care based on the most accurate diagnosis. A recent study from the Mayo Clinic says that not only are diagnoses fine-tuned with a second opinion, they help cut down on unnecessary procedures which can have unintended consequences such as hampered sexual function.

A Monthly Hindrance
Are you someone who, during your monthly period, need to change pads, tampons, and also clothes so frequently you don’t want to leave the house? This puts a serious damper on work and lifestyle. The pain and heavy bleeding associated with conditions such as fibroids are the leading reasons why women undergo hysterectomy in the United States, which affects  fertility and puts women at risk for early bone loss. So, keeping your ovaries, if you can, offers the benefit of maintaining bone density that otherwise begins to decline with a hysterectomy or naturally-occurring menopause.

Menorrhagia is the medical term for menstrual periods with abnormally heavy or prolonged bleeding. Although heavy menstrual bleeding is a common concern among premenopausal women, most women don’t experience blood loss severe enough to be defined as menorrhagia. But for others, it is a show-stopper every month. With menorrhagia, every period you have causes enough blood loss and cramping that you can’t maintain your usual activities. Does this sound familiar?

Reducing Symptoms with Elagolix
If you have menstrual bleeding so heavy that you dread your period, a new and effective treatment for the disease’s most common symptoms, including pain related to menstruation and chronic pelvic pain throughout the menstrual cycle, is being tested in clinical trials and I was a part of a trial for Elagolix. Elagolix, is an oral medication that treats symptoms of uterine fibroids.  Elagolix has been shown to work well to reduce severe menstrual pain (dysmenorrhea, DYS) and non-menstrual pelvic pain (NMPP) by suppressing the hormones that feed the fibroid growth according to Abbvie’s new study. This hormone suppression is reversible when the medication is stopped.

• Women were premenopausal, 18‐51 years of age
• Women had HMB of >80mL menstrual blood loss
• Women were diagnosed with uterine fibroids with a total uterine volume of ≥200 cm 3 to ≤2,500 cm 3
• Women had no evidence of or recent history of cervical malignancy or endometrial pathology
• Women agreed to use two forms of non‐hormonal contraceptives
• Women were required to take 400 IU vitamin D and 500 to 1000 mg of calcium supplements during treatment and follow‐up periods, and if their hemoglobin concentration

The women were separated into two groups:
Elagolix alone
300mg twice daily (BID) in cohort 1
600mg once daily (QD) in cohort 2
Elagolix with low dose add‐back (LDA) therapy of estradiol (E2)/norethindrone acetate (NETA), 0.5mg
E2/0.1mg NETA
Elagolix with standard dose add‐back (SDA) therapy of 1.0mg E2/0.5mg NETA

Women treated with elagolix with or without additional hormonal therapy (e.g,estradiol or norethindrone acetate)  had significant reductions in menstrual blood loss, compared to placebo. Trial results presented during the annual scientific meeting of The American Congress of Obstetricians and Gynecologists (ACOG) show that after six months of continuous treatment, Elagolix therapy was able to mitigate the painful symptoms and heavy bleeding and offer relief.  Some patients experienced nausea, headaches, and hot flashes, but these side effects were tolerable. We concluded that Elagolix treatment with and without add‐back therapy was superior to placebo in significantly reducing menstrual blood loss.

Weight and Race Influence Health
Risk of uterine fibroids is three times higher in black women, who tend to have an earlier age of onset, larger (number and size), more rapidly growing fibroids, and greater symptom severity than white women. Obesity is also a well-established risk factor for fibroids, with studies suggesting higher disease burden. I conducted a   phase 3 study of a new therapy that is available for these patient populations. The medication, ulipristal acetate (UPA) is an oral selective progesterone-receptor modulator (SPRM) that acts on endometrial and fibroid tissue progesterone receptors to reduce bleeding and fibroid size.
Women, 18-50 years of age
Premenopausal (follicle stimulating hormone ≤20 mIU/mL)
Excessive/prolonged uterine bleeding in ≥4 of last 6 menstrual cycles
Cyclic bleeding ≥22 days but ≤35 days
Menstrual blood loss ≥80 mL
Discrete uterine fibroid of any size and location, by transvaginal ultrasound
Uterine size ≤20 weeks by clinical exam

Of 157 women randomly selected, 148 completed treatment and 133 completed treatment-free follow-up. Patients, regardless of race or weight, who participated in the UPA trial had a significant decrease in fibroid-related bleeding, reporting an improvement to their quality of life. This is a very promising therapy that can help women who experience these health issues.

We are continuing studies on these two therapeutic options and are actively recruiting new patients to try these and related therapies.

Our Clinical Studies
If you have been diagnosed with uterine fibroids, an oral medication for the disease’s most common symptoms, including pain related to menstruation and chronic pelvic pain throughout the menstrual cycle, is available through our research study.

Eligible participants are women who are:
between 18 and 49 years of age
in good general health
experiencing heavy menstrual bleeding (menorrhagia) from uterine fibroids
be willing to discontinue current hormonal treatments for the course of screening and up to six months of treatment. Our goal, as part of a compassionate medical practice, is to maintain or regain optimal health and, shrinking, if not, eliminating, painful fibroids.

Medical insurance is not required for study participation and compensation for time and travel is provided. To learn more about the study or if you’re interested in enrolling, please contact Alisha Lutat, Vanessa Lukas, or Carol Mack, PA-C at 202-293-1000 or email us at info@jamesasimondmd.com

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