Dyspareunia is the term used for persistent pain in the genital area or inside the pelvis region during sexual intercourse. The pain is characterised as sharp or intense and can occur during or after sexual intercourse. Women are more likely than men to get the illness. It has many possible causes, however, it can be treated. In this write-up, we will go through the possible causes, symptoms, diagnosis and treatment of this condition.
- What Is Dyspareunia?
- Understanding Dyspareunia
- Dyspareunia At A Glance
- Prevalence Of Dyspareunia
- Types Of Dyspareunia
- Causes Of Dyspareunia
- Symptoms Of Dyspareunia
- Risk Factors For Dyspareunia
- Complications Of Dyspareunia
- Diagnosis Of Dyspareunia
- Treatment Of Dyspareunia
- Coping And Supporting
- Preventing Dyspareunia
- Dyspareunia Is Manageable
What Is Dyspareunia?
Dyspareunia is a medical term, a condition that refers to painful sexual intercourse that occurs among women across all age groups. The pain mainly occurs during or after sexual intercourse. This pain is generally associated with or restricted to vaginal opening or may also be felt deep within the pelvis. Pelvic muscles may feel tense, thereby causing intense pain or cramps. It is also termed as a genital pain that can be caused owing to tons of factors such as biological, medical, interpersonal, and psychological. Additionally, the condition can cause tension in a couple’s sexual life, resulting in negative emotional effects. A 2014 study 1states “Dyspareunia is recurrent or persistent pain with sexual activity that causes marked distress or interpersonal conflict.”
Women who experience pain during sexual intercourse throws a challenging situation for the physician practicing obstetrics and gynecology. There are many sides to this condition that makes it difficult to diagnose the disorder followed by medical and surgical therapy, and interpersonal relationships. To evaluate this symptom, the physician practices an unusual process of self-examination. Positive feelings about sexual pleasure and coital function, as well as an understanding of one’s role, are the two most important aspects in defining one’s mental health and spousal well-being. relationship necessary to foster a comprehensive exploration of the symptom.
“Dyspareunia is recurrent or persistent pain with sexual activity that causes marked distress or interpersonal conflict. It affects approximately 10% to 20% of U.S. women. Dyspareunia can have a significant impact on a woman’s mental and physical health, body image, relationships with partners, and efforts to conceive,” says a study. For many gynaecologists, any record of pain indicates a persistent search for a surgically treatable cause of the symptom. However, the study of dyspareunia demands a more complex approach defined by a thorough knowledge of female sexual functioning, frankness toward the discussion of sexual matters, and other special skills.
The doctor should process a well-rounded understanding of sexual physiology to assess vaginal lubrication, pelvic vasocongestion, and the morphologic alterations of the vagina during sexual response. The physician must feel comfortable in asking explicit questions catering to the sexual activities of the patient to assess the legitimacy of the patient’s sexual concern and encourage self-disclosure. Since dyspareunia in women gives rise to negative attitude towards sex, resulting in relationship problems and behavorial pattern changes, a doctor must listen to the patient carefully to understand her problems form her perspective.
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Dyspareunia At A Glance
- Dyspareunia is a medical term, a condition that refers to painful sexual intercourse that occurs among women across all age groups.
- Dyspareunia is a common disorder in women and if diagnosed and treated in the right time, one can get relief from the symptoms to a large extent.
- This pain is generally associated with or restricted to vaginal opening or may also be felt deep within the pelvis.
- Dyspareunia is recurrent or persistent pain with sexual activity that causes marked distress or interpersonal conflict.
- Dyspareunia is more likely to cause distress or interpersonal disputes among the partners.
Prevalence Of Dyspareunia
Painful sex or dyspareunia is a common condition among women, even though it is a neglected health problem. According to a study 2 , the prevalence rate of dyspareunia on a global level varies from 3 to 18% and lifetime estimates range from 10 to 28%. As per the report, painful sex was strongly linked with other sexual function problems such as vaginal dryness, sexual anxiety and lack enjoyment in sex. The condition was also associated with sexual relationship factors as well as with opposing experiences such as non‐voluntary sex. Women were also found suffering from psychological and physical health, including depressive symptoms.
Another 2006 study 3 shows that the World Health Organization had reported a global prevalence rate of painful intercourse between 8% and 21.1% which varied by country. A 2016 systematic review in Brazil had revealed that the prevalence rate of dyspareunia ranged from 1.2% to 56.1%, a rate which was different from Puerto Rico’s prevalence rate of 17% to 21%. A longitudinal cohort study 4 found that nearly half of the surveyed women, approximately 46.3% reported a lack of sexual activity interest, 43% experienced a lack of vaginal lubrication and 37.5% of included women had dyspareunia 6 months after birth.
Types Of Dyspareunia
Based on the area of the pain, dyspareunia can be classified as:
1. Superficial Dyspareunia
This type of pain is felt during penetration, resulting in temporary contractions at the vaginal entrance. It can also cause pain in the pelvic floor muscles due to the contraction of the vagina. Such pain can also happen due to severe allergic reaction from contraceptive foams or latex condoms.
2. Deep Dyspareunia
Deep dyspareunia is defined by symptoms such as burning, aching, or tearing. The key factor behind the cause of deep dyspareunia is pelvic diseases such as endometriosis, PID (pelvic inflammatory disease) or ovarian cysts. The condition can develop due to the growth of ovarian cysts and tumours inside the uterus.
Causes Of Dyspareunia
According to a recent systematic review 5 , “The etiology of dyspareunia encompasses structural, inflammatory, infectious, neoplastic, traumatic, hormonal, and psychosocial conditions.” Physical causes of dyspareunia or painful intercourse vary and this variation depends on the location of the pain, i.e., whether it is occurring during penetration or with deep thrusting. Emotional factors may also be associated with a certain type of painful intercourse. Here are the causes of the dyspareunia classified under three main subheadings.
1. Entry Pain
Pain during penetration can occur due to various factors such as:
A. Vaginal Dryness
Vaginal dryness is a common condition among women and this generally happens when there is not enough foreplay. Low estrogen levels after menopause, childbirth or during breastfeeding can also lead to vaginal dryness.
Certain medicines leave a negative impact on sexual desire or arousal, thereby resulting in low lubrication that further makes sex a painful experience. Such medicines include antidepressants, sedatives, high blood pressure medications, antihistamines and birth control pills. Moreover, the use of opioids 6 can also increase sexual dysfunction in some people.
C. Injury, Shock or Irritation
Any injury or irritation caused by an accident, pelvic surgery, female circumcision, or a birth canal incision made during childbirth (episiotomy).
D. Skin Disorder
An infection in one’s genital area or urinary tract can also result in painful intercourse. Eczema or other skin diseases in the genital area can also be the problem.
The uncontrolled spasms or contractions of the muscles in the vaginal wall can make penetration painful.
D. Congenital Abnormality
A problem that is present by birth, such as incomplete development of the vagina (vaginal agenesis) or growth of a membrane obstructing the vaginal opening (imperforate hymen) can also be the cause of dyspareunia.
2. Deep Pain
Deep pain usually signifies that pain that occurs with deep penetration of the penis. The pain can be in certain positions. Causes include:
A. Certain Illnesses or Conditions
Dyspareunia can also develop if a woman is inflicted with certain diseases such as pelvic inflammatory, endometriosis disease, retroverted uterus, uterine prolapse, uterine fibroids, cystitis, irritable bowel syndrome, adenomyosis, haemorrhoids, pelvic floor dysfunction and ovarian cysts.
B. Surgeries or Medical Treatments
The cutting for pelvic surgery, including hysterectomy can cause painful intercourse. Medical treatments for cancer, such as radiation and chemotherapy, can also lead to painful sex later.
3. Emotional or Psychological Factors
Emotions run deeply with sexual activities which is why they might play a role in sexual pain. Emotional factors include:
A. Psychological Issues
Excessive nervousness, depression, anxieties about your physical appearance, worrying about intimacy or relationship problems can add to a low level of arousal, leading to discomfort or pain.
A woman’s pelvic floor muscles tend to stiffen in response to stress in life which can result in painful intercourse.
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C. Past Sexual Abuse
It is not necessary that everyone with dyspareunia will have a history of sexual abuse, however, if someone has been abused, it may play a role.
There are other conditions that may also lead to painful sex experience. These are:
- Vaginal Infections: This is a common condition and includes yeast infections.
- Cervical Problems (opening to the uterus): With this condition in a woman, the penis can reach the cervix with maximum penetration. So cervical problems can cause pain during deep penetration.
- Uterus Problems: These problems may comprise of fibroids that may cause deep intercourse pain.
- Endometriosis: It is a condition where the tissue that lines the uterus grows outside the uterus.
- Problems With the Ovaries: Thi condition may include cyst on the ovaries.
- Pelvic Inflammatory Disease (PID): With PID, the tissues deep inside the pelvic become severely infected and the pressure of sex causes deep pain.
- Ectopic Pregnancy: A condition where during pregnancy, the fertilized egg develops outside the uterus.
- Menopause. With menopause, there natural moisture level of the vaginal lining may decrease, resulting in the dry vagina.
- Post Surgery Intercourse: Having sex too soon after surgery or childbirth.
- Sexually Transmitted Diseases: This condition may include genital warts, herpes sores, or other STDs.
- Vulvodynia: This condition refers to persistent pain that affects a woman’s external sexual organs or the vulva, including the labia, clitoris, and vaginal opening. This pain may occur in one place, or affect different regions from time to time. There is no concrete cause or cure for this condition. However, self-care and medication together can help bring relief.
Symptoms Of Dyspareunia
The pain associated with dyspareunia can vary depending on the severity of the symptom. The symptoms of this condition are:
- Experiencing pain only during penetration
- Pain with every penetration, including the insertion of a tampon
- Deep pain with every thrust
- Burning, itching or aching pain
- Throbbing pain, lasting hours after intercourse
- Pain in the vagina, bladder or urethra
- Pain during or after intercourse
- Severe pain deep in the pelvis during intercourse
- Pain occurring after a pain-free intercourse
- Pain restricted to specific partners, positions or circumstances
- Pain similar to that of menstrual cramps
Risk Factors For Dyspareunia
The factors that increase the risk of dyspareunia are:
- Lactating mother at six months postpartum holds the chance to encounter the problem of dyspareunia
- Abnormalities, such as the development of fibroids or uterus prolapses, can double the risk of dyspareunia
- Women with any sexual abuse in the past or any psychological trauma can experience dyspareunia
- Individuals with weakened immunity or overall poor health status are more likely to experience painful intercourse (dyspareunia)
- People with a history of constant pelvic pain experience painful sex
- A history of trauma or injury to the vagina
- Women with infections in the ovaries would experience painful intercourse
- The growth of scar tissue outside the uterus
- Skin infections around the genitals
- Congenital abnormalities within the vagina with penetration and raise the risk of dyspareunia
- At times, haemorrhoids can heighten the risk of dyspareunia
Complications Of Dyspareunia
While this condition is not known to cause any major complications, painful sexual intercourse may result in the loss of sexual interest and cause relationship problems. Dyspareunia is more likely to cause distress or interpersonal disputes among the partners. In rare cases, fear of sexual intimacy due to dyspareunia may lead to female infertility.
Diagnosis Of Dyspareunia
The diagnosis of dyspareunia typically depends on the symptoms. A patient’s medical and sexual history along with physical examination will enable the doctor to understand the cause of the symptoms.
The occurrence of distinctive pain upon touching the genitals or the pain occurring with early penetration and deeper penetration is a hint to the cause of the symptoms. Thus, the doctor will ask a few questions about the exact location of the pain, the length and timing of the pain. The doctor will also ask the patient questions such as:
- Was there a time when you had painless sex or is it that you always had dyspareunia?
- Do you have enough natural lubrication or does the symptom improve with the use of commercially available lubricants?
- Narrate your sexual history
- Were you sexually abused in the past or do you have any traumatic injury involving your genitals?
Additionally, if the patient is a middle-aged woman, the doctor will ask whether she is experiencing irregular periods, hot flashes or vaginal dryness, symptoms suggesting that she may have atrophic vaginitis. Also, if the woman is a new mother, the doctor will question her whether she is breastfeeding her baby because breastfeeding can also lead to vaginal dryness and dyspareunia.
A pelvic examination is also a common part of the diagnosis. During this examination, the doctor will look at the external and internal pelvic area for the signs of:
- Anatomical problems
- Inflammation or infection
- Genital warts
- Abnormal masses
The internal examination is done using a speculum, a device used to view the vagina during a Pap Test. The doctor also may use a cotton swab and apply slight pressure to different regions of the vagina in order to determine the pain location. With the initial examinations, the doctor may suggest other tests, such as:
- Pelvic ultrasound
- Counselling to determine the presence of emotional causes
- Urine test
- Culture test to check for bacteria or yeast infection
- Allergy test
Treatment Of Dyspareunia
Treatment options differ depending on the cause of the pain. Here are the various ways of treating this condition.
If an infection or medical condition leads to painful sexual intercourse, treating the condition might resolve your problem. A patient can change the medications that cause low lubrication problems, thereby increasing the chances of eliminating the symptom. Many postmenopausal women have dyspareunia as a result of insufficient lubrication caused by low estrogen levels. Topical estrogen applied directly to the vagina can be used to treat this condition.
The drug ospemifene 7 (Osphena) is the first and only non-estrogen compound approved by the Food and Drug Administration (FDA) to treat moderate to severe levels of dyspareunia in women with low vaginal lubrication. Ospemifene acts like estrogen on the vaginal lining. One 2014 study states “Ospemifene 60 mg once a day was approved by the U.S. Food and Drug Administration in February 2013 for women with moderate to severe dyspareunia.”
According to 2013 study 8 , this drug is a new selective estrogen receptor modulator that is used “in the treatment of vulvar and vaginal atrophy in postmenopausal women with moderate to severe dyspareunia and physiological vaginal changes.” Drawbacks of the drug are it might cause hot flashes along with the risk of stroke, blood clots and cancer in the lining of the uterus (endometrium). Another drug to relieve painful intercourse is prasterone (Intrarosa). It’s a capsule that women can place inside their vagina daily.
2. Therapy Treatments
Certain non-medication therapies are also available that might help with dyspareunia. These are:
- Desensitization Therapy: This therapy will teach a woman vaginal relaxation exercises that may help to decrease the pain.
- Counseling or Sex Therapy: If sex has been a painful business for a woman for some time, she may grow a negative emotional response to sexual stimulation even after treatment. If a woman and her partner have avoided sex for the pain, communicating with the sex therapist or a counsellor may resolve this issue.
- Cognitive-Behavioural Therapy: CBT also can be helpful in changing negative thought patterns and behaviors towards sexual intercourse due to the pain.
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3. Lifestyle & Home Remedies
Apart from visiting doctors and therapists, one can take the initiative to communicate with her partner and take steps to minimize pain with a few changes to her sexual routine.
- Change Positions: If a woman is suffering from a sharp pain during thrusting, trying a different position with less thrusting action may help. Trying out the position of sitting on the top of her partner will regulate the penetration to a depth that will feel good.
- Communicate: A woman must talk to her partner about the likes and dislikes during sexual intimacy. If she needs her partner to go slow, it must be communicated clearly.
- Do Not Rush: It is essential to indulge in longer sessions of foreplay to stimulate natural lubrication. A woman might reduce pain by delaying penetration until she feels fully aroused.
- Use Lubricants: Couples should try using personal lubricants to make sex a comfortable and pleasurable experience. They must try different brands until they find the right one.
Coping And Supporting
Until the pain associated with vaginal penetration decreases, couples should look for other alternatives to get intimate. Kissing, sensual massage, and mutual masturbation are some of the alternatives to intercourse that are comfortable, fulfilling and fun than the regular sex routine.
As a patient, you must talk to your doctor to resolve painful intercourse problems. The doctor might diagnose and treat the problem or connect you to a specialist. You can also prepare for this discussion with your doctor by making a list of the following:
Your sexual problems, the onset of the problems, frequency and the circumstances under which they occur
Essential medical information including the conditions for which you are receiving treatment
All medications, vitamins or other supplements and the dosage
Additionally, you can also ask a few questions to your doctor such as:
- What could be the cause of my problem?
- What lifestyle changes can I make?
- What are the available treatments?
- What reading materials and websites do you recommend?
There’s no particular prevention strategy for dyspareunia. However, you can do the following to lessen the risk of pain during sex. These are:
- After childbirth, wait for at least six weeks before resuming your sex routine
- Use a water-soluble lubricant for vaginal dryness
- Maintain proper hygiene to avoid infections
- Get a proper routine medical check-up
- Use condoms or other barriers to prevent sexually transmitted diseases (STDs)
- Boost natural vaginal lubrication with enough foreplay for a longer duration
Dyspareunia Is Manageable
Dyspareunia is a common disorder in women and if diagnosed and treated in the right time, one can get relief from the symptoms to a large extent. It is essential to remember that for such a disorder, communication without any hesitation with one’s partner and the doctor is the key to solving the problem. Additionally, a few lifestyle changes along with therapies can alleviate one from this condition, if not completely, then majorly.References:
- Seehusen, D. A., Baird, D. C., & Bode, D. V. (2014). Dyspareunia in women. American family physician, 90(7), 465–470.
- Mitchell, K. R., Geary, R., Graham, C. A., Datta, J., Wellings, K., Sonnenberg, P., Field, N., Nunns, D., Bancroft, J., Jones, K. G., Johnson, A. M., & Mercer, C. H. (2017). Painful sex (dyspareunia) in women: prevalence and associated factors in a British population probability survey. BJOG : an international journal of obstetrics and gynaecology, 124(11), 1689–1697. https://doi.org/10.1111/1471-0528.14518
- Sorensen, J., Bautista, K. E., Lamvu, G., & Feranec, J. (2018). Evaluation and Treatment of Female Sexual Pain: A Clinical Review. Cureus, 10(3), e2379. https://doi.org/10.7759/cureus.2379
- O’Malley, D., Higgins, A., Begley, C. et al. Prevalence of and risk factors associated with sexual health issues in primiparous women at 6 and 12 months postpartum; a longitudinal prospective cohort study (the MAMMI study). BMC Pregnancy Childbirth 18, 196 (2018). https://doi.org/10.1186/s12884-018-1838-6
- Tayyeb M, Gupta V. Dyspareunia. [Updated 2021 Jun 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562159/
- Ajo, R., Segura, A., Inda, M. M., Planelles, B., Martínez, L., Ferrández, G., Sánchez, A., César Margarit, & Peiró, A. M. (2016). Opioids Increase Sexual Dysfunction in Patients With Non-Cancer Pain. The journal of sexual medicine, 13(9), 1377–1386. https://doi.org/10.1016/j.jsxm.2016.07.003
- Soe, L. H., Wurz, G. T., Kao, C. J., & Degregorio, M. W. (2013). Ospemifene for the treatment of dyspareunia associated with vulvar and vaginal atrophy: potential benefits in bone and breast. International journal of women’s health, 5, 605–611. https://doi.org/10.2147/IJWH.S39146
- Portman, D. J., Bachmann, G. A., Simon, J. A., & Ospemifene Study Group (2013). Ospemifene, a novel selective estrogen receptor modulator for treating dyspareunia associated with postmenopausal vulvar and vaginal atrophy. Menopause (New York, N.Y.), 20(6), 623–630. https://doi.org/10.1097/gme.0b013e318279ba64