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Pain in the Vulva or Pelvis

The vagina is not the only site of discomfort that can put a damper on sex. Pain in the vulva (the external part of the genitals, including the labia and clitoris) or in the pelvic region can do the same. Although vulvar and pelvic pain can and do occur in women at midlife and beyond, pain in these areas is also common before menopause.

Vulvar pain. The main causes of vulvar discomfort are:

  • Vulvodynia, a chronic condition involving pain (stinging, burning, irritation, or rawness) in the vulva. The pain may come and go and may occur with or without touching or pressure. All or only a portion of the vulva may be affected. There are usually no visible signs. Vulvodynia almost always involves pain with intercourse, which may last from minutes to days. Studies suggest that about 3% to 15% of women suffer from vulvodynia. Treatments include self-care measures (such as wearing all-cotton underwear or washing the vulva with water only), medication, relaxation exercises, and (in severe cases) surgery.
  • Vulvar vestibulitis (focal vulvodynia), or extreme sensitivity in a narrow band of tissue just outside the opening of the vagina. It can be identified by touching the hypersensitive area with a moist cotton swab, which will cause pain in a woman with this condition.
  • Reactions to perfumed soaps or other hygiene products, such as douches, lubricants, or vaginal sprays. These reactions, which are referred to as "contact dermatitis," typically cause itching, burning, and pain and may involve a rash and swelling. They usually resolve after use of the irritating product is stopped, although topical or oral medications can be used if needed. Menstrual pads and other absorbent pads can also be a source of irritation, but so can chronic dampness.
  • Vulvar masses such as genital warts or benign cysts, which are not usually painful but can cause discomfort if large.
  • Skin conditions such as eczema, psoriasis, lichen sclerosus, or ulcers.

Pelvic pain. Chronic pelvic pain is mainly a condition of reproductive-age women, affecting about 15% to 20% of women ages 18 to 50, but peri- and postmenopausal women are not immune to it.

Although chronic pelvic pain is not well understood, it is defined as pain in the pelvis, the front of the abdomen, the lower back, or the buttocks that lasts more than 6 months, has no clear anatomic cause, and is severe enough to cause disability or lead to medical care. It is believed to have many contributing factors and is often hard to distinguish from other medical conditions. The best way to treat it is an area of controversy. Chronic pelvic pain is of interest here because it often results in pain or pressure during sex.

In some cases, pelvic pain can be clearly traced to bands of internal scar tissue (adhesions) that form after injury or infection in the pelvic or abdominal region. This scar tissue can make sex painful and make it harder to achieve orgasm. 

Any pain felt deep inside the body during intercourse may be a red flag for an underlying medical problem and should be evaluated by a healthcare provider. Possible underlying conditions that could cause pelvic pain during sex include pelvic inflammatory disease (usually caused by a sexually transmitted infection), endometriosis (a condition that is normally diagnosed before menopause), pelvic adhesions (described above), bowel or bladder disease, and ovarian cysts. 

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