Dryness, tightness, menopause, endometriosis, prolapse, childbirth injury, hysterectomy pain, mesh problems, skin disease, size mismatch, and treatment options explained in plain English By Red M. Alinsod, MDAlinsod Institute | Revique Medical & AestheticsArlington, Texas Painful sex is common. But it is not something a woman should be expected to silently endure. Too many just live with it. The medical term is dyspareunia, which means pain before, during, or after intercourse. Some women feel burning at the opening. Some feel tearing. Some describe “sandpaper.” Others feel deep stabbing pain, pelvic pressure, a “wall,” a tight band, or soreness that lasts for hours or days afterward. The American College of OBGYN notes that nearly 3 out of 4 women have pain with intercourse at some time in their lives. Common does not mean normal. Pain is not normal. Painful sex can come from the vulva, the vaginal opening, the vaginal canal, the pelvic floor muscles, the uterus, the bladder, the rectum, prior childbirth injuries, prior surgeries, mesh exposure, endometriosis, menopause, cancer therapy, or skin disease. Often, there is more than one cause. Detective work has to be done. My goal with this article is simple: to help you understand what may be happening, give you language for your symptoms, and show you that there are thoughtful medical, hormonal, regenerative, pelvic floor, and surgical options when the cause is properly identified. It is a pretty intensive Newsletter this month. Pick and choose what interests you and click on the links that lead to detailed explanations. Start here: Where does it hurt? The first question is not “What treatment do you want?”The first question is where is the pain? Pain at the opening Pain at the vaginal opening often feels like burning, tearing, stretching, paper cuts, or “too tight.” This can happen with menopausal dryness, Genitourinary Syndrome of Menopause, lichen sclerosus, vestibulodynia, scar tissue, childbirth injury, prior labiaplasty, prior vaginoplasty, pelvic floor spasm, or a small/tight introitus. Take a look at these pictures for the many causes of Painful Sex at the opening: Pain inside the vaginal canal Vaginal canal pain may feel like friction, dryness, narrowing, rubbing, rawness, or inability to stretch. This can happen after menopause, breastfeeding, hysterectomy, chemotherapy, pelvic radiation, hormone-blocking cancer therapy, scarring, or vaginal stenosis. Here are some causes of Painful Sex that is beyond that you can see on your own: Deep pain Deep pain often feels like a collision. Patients say, “It feels like he is hitting something,” or “It only hurts in certain positions.” Deep pain can be related to endometriosis (lining of the uterus found outside the lining of the uterus), adenomyosis (endometriosis in the body of the uterus), fibroids (firm mass of muscle tissue found in the walls of the uterus), ovarian cysts, uterine prolapse, pelvic floor dysfunction, bladder pain, bowel pain, hysterectomy scarring, vaginal cuff tenderness, or cancer-treatment changes. Mayo Clinic lists deep thrusting pain as a dyspareunia pattern and includes endometriosis, uterine prolapse, adenomyosis, pelvic floor conditions, ovarian cysts, hysterectomy scarring, radiation, and chemotherapy among possible causes. Here are examples of pictures of the most common cause of Pelvic Pain: Endometriosis. . Pressure, bulging, or “uncontrollable” sex A bulge, pressure, heaviness, looseness, blocked feeling, bowel trapping, or bladder urgency during sex may point toward pelvic organ prolapse: cystocele, rectocele, uterine prolapse, vaginal vault prolapse, or enterocele. * Transvaginal Uterine Suspension with Dermal Allograft Surgery Partner pain Sometimes the partner feels hard “rocks” constipation stools. He can also feel poking, scratching, or sharpness. This can happen when mesh or permanent suture is exposed in the vagina. The FDA specifically advises patients with mesh to notify their provider if they have persistent vaginal bleeding or discharge, pelvic or groin pain, or pain with sex. Let’s systematically go over the main causes of Painful Sex once more in a bit more detail. This is not an exhaustive list but it does cover all the main culprits. I will organize and number them and also give you some of the therapies I use in my office to manage the problems: 1. Menopausal dryness, tightness, and Genitourinary Syndrome of Menopause One of the most common and most under-treated causes of painful sex is Genitourinary Syndrome of Menopause, or GSM. GSM is the modern term for what used to be called vaginal atrophy or atrophic vaginitis. It is broader and more accurate because the problem affects more than the vagina. GSM can involve the vulva, labia, clitoris, vaginal opening, vaginal canal, urethra, bladder, and pelvic tissues. GSM can happen with: natural menopausesurgical menopause after ovary removalhysterectomy with hormonal changeschemotherapypelvic radiationbreast cancer endocrine therapyanti-estrogen medicationsbreastfeedingperimenopausemedications that reduce arousal or lubrication ACOG explains that low estrogen can thin, dry, and inflame the vaginal walls, reducing lubrication, elasticity, and tissue comfort. Vaginal dryness can also happen after childbirth, breastfeeding, cancer treatment, or anti-estrogen medications. * The Aging Vagina and GSM What low estrogen does to the tissue Estrogen helps maintain vaginal and vulvar tissue thickness, moisture, blood flow, elasticity, pH balance, lubrication, and resistance to tearing. When estrogen stimulation drops, the tissue can become thin, dry, pale, tight, fragile, and inflamed. Women often describe: “sandpaper” sexburning at the openingtearing at the bottom of the vaginableeding after sexdryness that lubricant does not fixtightness that feels newpain with pelvic examsurinary urgency or recurrent UTIsloss of confidence and desire because sex now hurts This is not simply a lubrication problem. It is a tissue-health problem. 2. “I use lubricant and it still hurts” Lubricant is helpful, but lubricant does not rebuild estrogen-deprived tissue. Lubricants reduce friction during sex. Moisturizers improve day-to-day tissue hydration. Both can be valuable. The 2025 AUA/SUFU/AUGS GSM guideline recommends vaginal moisturizers and lubricants to improve dryness and painful sex. But if the underlying issue is GSM, many patients need more than lubricant. Pull out the vaginal estrogens and Carboxytherapy and think about radiofrequency treatments such as ThermiVa or even the vaginal lasers. They both work well. The same guideline recommends offering local low-dose vaginal estrogen for GSM-related vulvovaginal dryness, discomfort, irritation, and dyspareunia. It also recommends offering vaginal DHEA as an option for GSM-related dryness and painful sex. Vaginal Estrogen Options Vaginal estrogen can come as a cream, tablet, insert, or ring. ACOG explains that low-dose vaginal estrogen releases a small dose directly into the vaginal tissue to help restore thickness and elasticity and relieve dryness and irritation. Common forms include: Creams: flexible dosing and useful for vulvar and opening symptomsTablets or inserts: less messy and easy to useRings: steady release over time for patients who prefer less frequent dosing ACOG states that topical estrogen for vaginal or vulvar dryness and pain with intercourse usually improves symptoms within a few weeks and acts locally on tissues. For cancer survivors, treatment should be individualized with the oncology team. The American Cancer Society notes that cancer therapy can cause vaginal dryness, thinning, narrowing, shortening, and painful sex, and that vaginal estrogen is sometimes used for dryness, narrowing, and atrophy after discussion with the cancer care team. Carboxytherapy Options There is now a Carboxytherapy Gel treatment that gets results even faster than vaginal estrogens. It is made by Lumisque and called CO2LiftV or “The V.” In Latin America, Europe, Asia, carbon dioxide is injected under the skin to cause local tissue trauma and start the healing cascade to form new vessels, stimulate new collagen and elastin formation, and increase local moisture production. It hurts and is is not FDA approved in the USA. The Japanese came up with the same carbon dioxide treatment without the need for needles and with a mixture that created localized carbon dioxide that helped heal the skin. It was first used in the face as a mask then modified to work in feminine genital tissues. And it worked like Rocket Fuel in the speed of results obtained to create vaginal moisture and comfort. Not just for dry and thin skin but also for Lichen Sclerosus. The stuff works so well it is a CORE product for my Center of Excellence in Arlington, Texas. Go to www.lumisque.comfor info. Watch this Doctor Discussion on CO2LiftV: Doctor Discussion on The V How CO2LiftV is Helping Patients, From a Panel of Urogynecologists 3. Tightness is not always vaginismus Many women say, “I think I’m too tight.” That may be true, but the reason matters. Vaginismus is a type of sexual dysfunction. It happens when vaginal muscles cramp up or spasm involuntarily. We call them Levator Muscle Spasms. dYou can get aroused, get wet, but penetration is a No No and hurts too much. Even the touch of a QTip swab may incapacitate a patient! A woman may feel tight because of GSM dryness. She may have scar tissue from birth, episiotomy, perineal tearing, surgery, radiation, mesh, or a prior vaginal repair. She may have lichen sclerosus causing narrowing of the opening. She may have pelvic floor muscle guarding because sex has hurt for months or years. She may have vaginal stenosis after cancer therapy or surgery. An exam will help identify the problem. See a gynecologist and not a plastic surgeon or cosmetic surgeon or dermatologist. Family Practice specialists can be very helpful on the
