Introduction: The first three letters I post are a sampling of experiences of women who suffer from painful intercourse, and my answer covers all three of their situations. The fourth letter posted describes a woman who has overcome the pain, but has not made a good sexual adjustment after the symptoms ended. My answer to that letter explains how to overcome the effect of having tried to have sex under conditions of extreme pain.

Dear Dr. Harley:

In reading your August 26th Q&A, Preparing for Marriage, you tell E.C. that failing to meet your spouses needs opens the door for an affair. I hate to hear you say that! I have been having problems for several months now and my doctor believes I may have endometriosis. One of the problems I have been having is very, very painful intercourse. Therefore, my husband's needs are very hard for me to meet. We have tried other outlets other than intercourse, but it doesn't seem to be enough for him. How can I get him to understand that intercourse really does hurt a lot!!! He thinks I am faking or that I am having an affair because I don't want sex with him. It just plain hurts and I don't want to do it very often. Our marriage is deteriorating fast because of this and also a few other factors. He's making it very hard for me to love him! Any suggestions?

R.D.

Dear Dr. Harley,

My husband and I have been married for almost two years. We are very much in love, we enjoy each other's company, and we have a solid commitment to our marriage. The problem has been our sex life. Both of us were virgins when we got married. Although my husband has been an extremely patient lover, from the very first night of our honeymoon, sex has been an ordeal for us. Sometimes it works and other times it doesn't. Almost every time we attempt to make love, I get very nervous and it is painful for me. A few times in the last two years, we have had wonderful, spontaneous sex. I have switched birth-control pills and tried relaxing before sex, but it seems that arousal is difficult because I anticipate the pain. I have no history of abuse (of any kind), and I very much want to have sex that will drive my husband wild! What can I do?

A.P.

Dear Dr. Harley,

I have a problem. Whenever I have sex, it hurts. Sometimes, after we are finished, blood shows up in my underwear. Do you have any idea what could be causing the problem. I am going to get to a doctor, but I would like to prepare myself before I get there.

C.D.

Dear R.D., A.P. and C.D.,

A good sexual rule of thumb is, Don't have intercourse if it's painful. If you ever experience pain during intercourse, stop. Then see a doctor to help you determine the cause of the pain and help you overcome the problem. When the physical cause of the pain is eliminated, go back to having intercourse painlessly and enjoyably. To do otherwise invites disaster.

It's true that when important emotional needs, such as sexual fulfillment, are unmet, there is a risk for an affair. But having sex at all costs is not the solution. In fact, if you follow my Policy of Joint Agreement (never do anything without an enthusiastic agreement between you and your spouse) you would never have sex in a way that's painful to you. Instead, you would pursue painless sexual options until you have resolved the problem.

Most women throughout most of their lives experience no pain whatsoever when they have intercourse. The vagina is designed for intercourse, and works very well for that purpose under most conditions. But, once in a while, most women do experience pain during intercourse. When they do, they should identify and treat the problem before having intercourse again.

There are primary and secondary causes of vaginal pain during intercourse. The primary causes are those that are responsible for the initial pain or discomfort. Secondary causes are those that are created by the pain itself if intercourse continues. These can trigger vaginal pain long after the primary causes have been overcome.

Primary Causes of Vaginal Pain

One of the most common primary causes of vaginal pain during intercourse is a dry vagina. Usually, when a woman is sexually aroused, fluids are secreted in the vagina that keep the lining well lubricated. But if a woman is not sexually aroused, or if fluids are not secreted for some other reason, intercourse can cause very painful damage to the vaginal lining. And in some cases, the lining of the vagina can actually tear, resulting in post-intercourse bleeding.

There are two ways to avoid a dry vagina during intercourse. The first is to avoid intercourse until you are sexually aroused. The second way is to use an artificial water-based vaginal lubricant, such as K-Y jelly, Vagisil Intimate Moisturizer, or Replens Vaginal Mosturizer, as a substitute or backup for natural lubricant.

Since vaginal secretion is usually an indication of a woman's sexual interest, I usually recommend that intercourse wait until she experiences sexual arousal and natural lubrication. I want couples to avoid getting into the habit of sex that's passionless for her. But if natural secretion is an unreliable indicator of your sexual arousal, I would certainly recommend an artificial lubricant.

If you're not sure if a dry vagina is the cause of your pain, use an artificial lubricant once. If there is no pain under those conditions, then you have proof that it's the cause of your distress.

Another common cause of vaginal discomfort during intercourse is bacterial infection. This occurs frequently in women, and an antibiotic will generally cure the problem within a week or so. A related problem is bladder infections. While the problem may be in the bladder or urethra, not in the vagina, it often causes discomfort during intercourse.

A visit to your doctor will identify and treat a bacterial infection so that you will have minimal interruption in your sexual fulfillment. But be sure to make the appointment as soon as intercourse is uncomfortable. Otherwise it can develop into a secondary cause of vaginal pain that I will explain later.

There are other diseases that can cause pain or discomfort during intercourse. Vaginal endometriosis is one of them. When your doctor examines you for possible bacterial infection, be sure to ask him or her about endometriosis, because it is often overlooked during an examination. Your doctor examination will also be able to check for any vaginal tumors or venereal diseases that may be causing your discomfort. These problems may take longer to treat than bacterial infections, but whatever the problem turns out to be, don't have intercourse until it has been overcome.

If you have experienced vaginal bleeding after intercourse, your doctor should also be able to identify its source, and treat it for you. Sometimes a scratch or tear in the lining caused by something other than intercourse can be the cause of your problem.

It is very important for you to be comfortable with regular pelvic examinations. Otherwise you may let a medical problem become so far advanced that it causes you permanent injury. If you are embarrassed to see a male doctor, find a female doctor. But whatever you do, don't let your inhibitions prevent you from experiencing painless intercourse.

If your doctor can identify the source of your vaginal discomfort, don't have intercourse until the problem is treated and overcome to his or her satisfaction. Some problems can be treated in a week or less, while others, like endometriosis may take months to overcome.

If you are unable to have intercourse during treatment for a vaginal disease, that doesn't mean you'll be forcing your husband to rush off to have sex with someone else. I suggest that your husband be informed by your doctor of what it is you are going through, and how you will be treated. A major problem you may face is your husband's failure to see your sexual reluctance for what it is: vaginal pain brought on by a physical cause. If he doesn't believe you when you explain that it's the pain that makes you reluctant, his ignorance puts your sexual relationship, and probably your marriage, at risk. But once he understands the nature of the problem, and knows that it isn't an affair or some other emotional cause, he will be happier with alternatives to intercourse while you wait for your treatment to take effect.

In some cases, a husband's thoughtlessness is remembered long after the painful symptoms are gone. If your husband tries to force you to have painful intercourse with him and threatens you if you do not cooperate, your memories of his insensitivity will be a far greater barrier to your future sexual relationship than your disease ever could have been. Don't let him create those barriers to your future together. Insist that there be no sex unless you enjoy the experience with him. It's not only in your best interest, but in his best interest too. If you go ahead and try to make love when it's painful to you, you may have a very difficult time making love to him in the future.

A Secondary Cause of Vaginal Pain

What should you do if you eliminate the primary causes, and you still experience vaginal pain? What if your doctor finds no physical cause for your discomfort during intercourse? That can be very discouraging to most women, who begin to think that it's all in their heads. If the pain is not physically caused, then it must be psychological, right?

Not necessarily. In fact, most cases of persistent vaginal discomfort are not due to primary causes at all, but rather to a reflex called vaginismus. It's not psychological or emotional, it's very physical. Vaginismus is a painful reflex that is created in association with a primary cause of vaginal pain. In other words, if you experience vaginal pain from any one of the primary causes I've mentioned, vaginismus can develop secondarily. Long after the primary cause is ended, the vaginismus can persist.

This reflex responds to stimulation of the vaginal opening. If you suffer from vaginismus, you will notice it most when you first try to insert something into your vagina. The opening involuntarily contracts and pain is immediately felt. In extreme cases, the contraction is so tight that nothing can penetrate it.

From this description, you can see how it would interfere with intercourse. Regardless of how sexually aroused you might be, or how lubricated your vagina might be, as soon as you try to insert your husband's penis, you would experience excruciating pain. It may be difficult to insert his penis, because the vaginal opening becomes constricted. In some cases, it is impossible to insert a penis.

Naive couples often don't know what to make of vaginismus. Some of my clients believed it was God's punishment for their having sex before marriage. Others have blamed it on the sins of their parents. But whatever its cause, it certainly feels like punishment for something. Only after I am able to explain the cause of the reflex and help them eliminate it, do they realize that sin has nothing to do with it.

There is a tried and proven way to overcome the vaginismus reflex. If you follow this procedure, I guarantee your success. I recommend that you follow the exercises I recommend in the privacy of your bathroom, or when you are alone in the house. Your husband should not be included until the later sessions.

First determine how strong the reflex is and what triggers it. The way to determine its strength is to insert your finger into the vaginal opening to see what happens. If there is no reaction to your finger, insert something increasingly wider, like candles, until you can trigger the reflex. It will be an involuntary contraction of the opening as you try to insert the object, and it will be painful.

Notice how large the object must be before the reflex is triggered, and how tight the opening gets. The smaller the triggering object, and the tighter the opening, the more difficult it will be to extinguish the reflex. If you can't get your finger into the opening without extreme pain, you have a very well developed case of vaginismus. But regardless of its intensity, it can be eliminated.

The way to eliminate this reflex is to set aside a few minutes each day, preferably several times a day, to expose the opening of your vagina to penetration without triggering the reflex. If you can associate vaginal penetration with no pain or discomfort, the reflex will be extinguished. But remember, even an occasional triggering of the reflex can strengthen it.

Begin each session by covering your finger with water-based lubrication (such as K-Y jelly, Vagisil Intimate Moisturizer, or Replens Vaginal Mosturizer). Very slowly, lubricate the opening of the vagina with your finger, then slowly insert your finger about an inch. Even in the worst cases of vaginismus, a finger can be inserted so slowly into a lubricated vaginal opening that the reflex is not triggered. In a slow circular motion, gently rub the vaginal opening with your finger in ever-increasing circles. Remember to go slowly enough not to trigger the reflex or experience any discomfort. After you have rubbed the opening for about a minute without any pain or discomfort, slowly insert your finger into the vagina, and in a circular motion gently rub the inside of the vagina as far as your finger will go. Then remove your finger, and do the same thing all over again. Do it about five times before you end the session.

You will notice that after the first insertion of your finger, the opening is much less sensitive, and you will be able to penetrate much more quickly without triggering a reflex. Move your finger slowly enough so that you avoid any discomfort. But after a while, you will find that you can move it very freely without pain.

You may end the first session thinking that you have overcome the reflex, only to discover at the beginning of the next session that it is back. So start the next session very slowly and carefully, doing again what you did during the first session. When you think you are ready, use a larger object than your finger, such as a candle, and increase the diameter of the object until it is about the size of a penis. Be sure to re-lubricate whatever you choose to insert, and go slowly to avoid the reflex.

The number of sessions to completely eliminate the reflex will depend on the severity of the vaginismus. But when it is eliminated, you should be able to insert an object the size of a penis, with lubrication, fairly rapidly without any pain or discomfort.

There are some women who are not comfortable touching themselves, and would prefer having their husbands carry out these exercises. While it can work, the problem with anyone else doing it is that no one but you knows precisely how much pressure to use, and your husband would inadvertently trigger the reflex far more often than you would. That means that it would take much longer for you to overcome vaginismus with his help.

His turn should come after you are convinced that the reflex is extinguished. Up to this point, obviously, you should have avoided intercourse, because it would have brought the reflex back. But when you think the reflex is gone, it's time to start having intercourse again. Unfortunately, you will find that after you have learned to insert a penis-sized object into your vagina without incident, the reflex may suddenly reappear the first time your husband tries to insert his penis.

To prepare for that common outcome, the first time you have intercourse you should insert his penis yourself. Use plenty of lubricating fluid, and lay on top of him when you do it so you can control the penetration. He should lay motionless so that the penetration and thrusting is done only by you so you can stop whenever you experience the least amount of discomfort. Eventually, you will be able to insert his penis without any pain, thrust as fast and deep as you want, and experience no discomfort whatsoever. The vaginismus reflex will have been eliminated.

If it ever comes back, it will be in a much milder form, and you will be able to eliminate it in a day or so by going back to inserting his penis yourself and controlling the thrusting motion during intercourse.

To repeat what I have already said numerous times, whenever you experience any pain during intercourse, stop immediately. Then solve the problem before resuming intercourse.