Painful sex in women (dyspareunia)

Dyspareunia (painful sex) is defined as persistent or recurrent genital pain that occurs just before, during or after intercourse. There are two types:

• entry (superficial) dyspareunia, where pain is felt at the entrance to, or within the vagina
• deep (abdominal) dyspareunia, where pain is felt in the abdomen.

Dyspareunia is common and may cause considerable distress to women and their sexual partners. It may be caused by structural, infective and inflammatory diseases of the vulva, vagina and internal organs. Psychosocial factors inevitably contribute to, and result from, dyspareunia.

• Dyspareunia may be primary, i.e. occurred with the first attempt at intercourse and ever since; or secondary, i.e. occurring later, having previously had no pain with intercourse.
• Pain can occur on every attempt at intercourse or only on certain occasions or in certain situations.

Entry dyspareunia

The most common vulval skin diseases resulting in superficial or entry dyspareunia include:

• Dryness or eczema/dermatitis especially when due to contact irritant or, less often, contact allergic factors (e.g. latex allergy), or chronic rubbing/scratching leading to lichen simplex
• Primary fissuring of posterior fourchette
• Medications that dry the skin, particularly isotretinoin
• Genital herpes or other sexually transmitted infections
• Lichen sclerosus
• Lichen planus.
• Plasma cell vulvitis.

Dyspareunia associated with dry vagina or vaginal inflammation (vaginitis) may be due to:

• Insufficient lubrication due to lack of sexual arousal or inability to reach orgasm
• Hormonal changes such as birth control medication, lactation, cancer treatment or menopause (atrophic vaginitis)
• Irritation from vaginal lubricants, creams, foams, douches, pessaries, condoms or devices
• Medications that dry mucosal surfaces, such as antihistamines or antidepressant medications such as amitriptyline
• Dry mucosae due to Sjogren syndrome
• Vulvovaginal candidiasis
• Bacterial vaginosis
• Chlamydia infection
• Trichomoniasis
• Erosive vaginal lichen planus
• Desquamative inflammatory vaginitis
• Radiation induced vaginitis following treatment for uterine or cervical cancer.

Dyspareunia may also result from:

• Malformation of the genitalia, e.g., narrowed vagina, labial adhesion, vaginal septa, imperforate hymen
• Injury, e.g., during childbirth, genital mutilation or surgery
• Urinary tract infection
• Interstitial cystitis (painful bladder syndrome)
• Any pain affecting the vestibule (if cause is unknown, this is called vestibulodynia)
• Any pain affecting the vulva (if cause is unknown, this is called vulvodynia)
• Tense pelvic floor muscles and/or vaginismus (involuntary pelvic muscle contractions during attempted intercourse)
• Low libido related to fear, anxiety and relationship problems including sexual abuse.

Deep dyspareunia

Deep dyspareunia means sexual pain that is felt in the abdomen, rather than in the vagina. Causes may include:

• Recent pregnancy / childbirth
• Retroverted uterus (this refers to the position of the womb)
• Uterine prolapse
• Pelvic inflammatory disease or infection
• Endometriosis
• Ovarian cysts
• Uterine fibroids
• Bowel disease especially irritable bowel syndrome (IBS)
• Lumbosacral arthritis
• Adhesions following previous surgery or radiation
• Genital tract cancer.

Diagnosis of dyspareunia

Correct diagnosis requires careful history and clinical examination of the whole body including external genitalia, and pelvic examination by a medical expert (e.g., gynaecologist, sexual health physician or general practitioner). Colposcopy (pelvic examination using magnification and a bright light) may be performed. The site of pain should be carefully identified. Examination under anaesthetic may be required if discomfort is too great to allow a normal internal examination.

Investigations may include:

• Bacterial and viral swabs
• Skin biopsy
• Ultrasound examination
• Radiographic examination

In many cases, no physical reason is found for dyspareunia and it is considered a pain syndrome.

Treatment of dyspareunia

Intercourse should not be painful. It's important to feel relaxed before attempting intercourse. Foreplay leading to sexual excitement relaxes the pelvic muscles, widens the vagina and releases vaginal fluids. Use liberal amounts of water-based lubricants and apply these to the penis and vaginal opening. Penetration from behind or woman-on-top may be better tolerated.

If a cause for the dyspareunia has been found, then appropriate treatment should help. General measures may also assist:

• Don't use scented bath oils or shower gels, soaps or douches.
• Emollients help vulval dryness and water-based lubricants or moisturisers are used for vaginal dryness.
• Oestrogen cream, pessaries or rings reduce hormone-associated vaginal dryness, and are often prescribed to post-menopausal women.
• Local anaesthetic cream or gel may allow pain-free penetration.
• Tricyclic medicines such as amitriptyline can reduce pain.
• Botulinum toxin has been used to relax hypertonic pelvic floor muscles (experimental).

An experienced pelvic floor physiotherapist can help in retraining the pelvic floor to relax using special exercises. Counselling or behavioural therapy is appropriate for some women or couples.

If vaginal intercourse remains painful, consider other sexual options including massage and mutual masturbation.