Dyspareunia is pain when women try to begin sexual intercourse or pain during intercourse.

• The pain may be superficial or deep.
• It may result from vaginal dryness or disorders of the genital organs.
• The diagnosis is based on symptoms and a pelvic examination.
• Anesthetic ointments, lubricants, exercises to relax pelvic muscles, or a change in the position for intercourse may help.
• The cause, if identified, is treated.

The pain may be superficial, felt in the area around the opening of the vagina (genital area or vulva). Or the pain may be deep, felt within the pelvis when the penis or a dildo is thrust further inside. The pain may be burning, sharp, or cramping. Pelvic muscles tend to become tight, which increases the pain, whether it is superficial or deep.

Causes

Causes vary depending on whether the pain is superficial or deep.

Superficial Pain: Intercourse can be painful because the vagina does not secrete enough fluids. Then the vagina feels dry, and lubrication for intercourse is inadequate. Inadequate lubrication often results from insufficient foreplay. Also, as women age, the lining of the vagina thins and can become dry because estrogen levels decrease. This condition is called atrophic vaginitis. During breastfeeding, the vagina may become dry because estrogen levels are low. Taking antihistamines can cause slight, temporary dryness of the vagina.

Superficial pain may also result from the following:

• Increased sensitivity of the genital area to pain (provoked vestibulodynia—see Sexual Dysfunction in Women: Provoked Vestibulodynia (Vulvar vestibulitis)), which is the most common cause
• Inflammation or infection in the genital area (including genital herpes), the vagina, or Bartholin's glands (the small glands on either side of the vaginal opening)
• Inflammation or infection of the urinary tract
• Injuries in the genital area
• An allergic reaction to contraceptive foams or jellies or to latex condoms
• Involuntary contraction of the vaginal muscles (vaginismus)
• Rarely, a congenital abnormality (such as an abnormal partition within the vagina)
• Surgery that narrows the vagina (for example, to repair tissues torn during childbirth or to correct a pelvic floor disorder—see Pelvic Floor Disorders)
• A hymen that interferes with entry of the penis

The hymen is a membrane that encircles or, in a very few women, covers the opening of the vagina. When women have sexual intercourse the first time, the hymen, if not previously stretched (for example, from tampon use or sexual stimulation with a finger inside the vagina), may tear, causing some pain and bleeding. A few women are born with an abnormally tight hymen.

Deep Pain: Deep pain during or after sexual intercourse may result from the following:

• Infection of the cervix, uterus, or fallopian tubes (pelvic inflammatory disease), which may cause collections of pus (abscesses) to form in the pelvis
• Endometriosis
• Growths in the pelvis (such as tumors and ovarian cysts)
• Bands of scar tissue (adhesions) between organs in the pelvis, which may form after an infection, surgery, or radiation therapy for cancer

Radiation therapy can cause both superficial and deep pain. The vagina can be less stretchable, and scarring around it can make it smaller and shorter.

Sometimes one of these disorders causes the uterus to get stuck in a bent-backward direction (retroversion). The ligaments, muscles, and other tissues that hold the uterus in place may weaken, resulting in the uterus dropping down toward the vagina (prolapse—see Pelvic Floor Disorders: When the Bottom Falls Out: Prolapse in the Pelvis). Such changes can also cause deep pain.

Pain is greatly affected by emotions. For example, minor discomfort may feel like severe pain after a traumatic sexual experience, such as rape. Anger toward a sex partner, fear of intimacy or pregnancy, a negative self-image, or a belief that the pain will never go away may amplify pain.

Diagnosis

The diagnosis is based on the woman's description of the problem, including when and where the pain is felt, and on the results of a physical examination. The genital area is gently but thoroughly examined for possible causes, such as signs of inflammation or abnormalities. A doctor may touch the area gently with a cotton swab to determine where the pain occurs. The doctor checks the tightness of the pelvic muscles around the vagina by inserting one or two gloved fingers into the vagina. To check the uterus and ovaries, the doctor then places the other hand on the lower abdomen. A rectal examination may also be done.

Treatment

Couples are encouraged to find ways to attain mutual pleasure (including having orgasms and ejaculation) that do not involve penetration. Such means can include stimulation involving the mouth, hands, or a vibrator.

Pelvic muscle relaxation exercises may help relieve symptoms, regardless of the cause.

For superficial pain, applying an anesthetic ointment and taking sitz baths may help, as may liberally applying a lubricant before intercourse. Water-based lubricants rather than petroleum jelly or other oil-based lubricants are preferable. Oil-based lubricants tend to dry the vagina and can damage latex contraceptive devices such as condoms and diaphragms. Spending more time in foreplay may increase vaginal lubrication.

For deep pain, using a different position for intercourse may help. For example, being on top can give women more control of penetration, or another position may limit how deeply the penis can be thrust.

More specific treatment depends on the cause, as in the following:

• Thinning and drying of the vagina after menopause: Estrogen applied as cream, inserted into the vagina as a pill or in a ring, or taken by mouth (as part of hormone therapy)
• Infections: Antibiotics, antifungal drugs, or other drugs as appropriate (see Some Vaginal Infections)
• Cysts or abscesses: Surgical removal
• A rigid hymen or another congenital abnormality: Surgery to correct it
• Prolapse of the uterus: Insertion of a pessary, which resembles a diaphragm, into the vagina to support and reposition the uterus or sometimes surgery

Provoked Vestibulodynia (Vulvar vestibulitis)

Provoked vestibulodynia (vulvar vestibulitis) is increased sensitivity to pain in the area around the opening of the vagina (vestibule), making even gentle touch or stimulation painful.

Provoked vestibulodynia is the most common cause of dyspareunia that occurs when the penis enters the vagina or moves. The pain starts immediately, lessens when the penis stops moving, and resumes when the penis moves again.

Doctors are not sure why it happens, but the nerve pathways that conduct pain signals from the vulva and the parts of the brain that process those signals are physically changed (remodeled) and become more sensitive. As a result, touch that normally would seem mild is perceived as very painful. Muscles in the pelvis may also be tight, increasing pain. After intercourse, women may have a burning sensation in the genital area or burning after urination.

This disorder involves chronic pain and often occurs with other types of chronic pain, such as jaw pain or pain due to irritable bowel syndrome.

Treatment

Treatment may include anti-inflammatory creams or anesthetics applied to the area and drugs taken by mouth, such as certain antidepressants and anticonvulsants, given in low doses. These drugs may help reverse changes in the nerve pathways that increase sensitivity to pain. Which treatments are most effective is not clear.

Avoiding possible irritants, such as soap, bubble bath, panty liners, and tight jeans, may help. Pelvic muscle relaxation exercises, yoga, and general relaxation exercises can help relax pelvic (and other) muscles. Women may benefit from cognitive-behavioral therapy (which is used to treat chronic pain), particularly when they are also taught the skill of mindfulness (concentration of awareness in the moment). Psychotherapy and sex therapy can help some women.

Surgery to remove part of the area around the vaginal opening is sometimes advised. This procedure removes the hypersensitive nerve endings, but the nerves can regrow, and pain can recur.

Botulinum toxinSome Trade Names
BOTOX
(a bacterial toxin used to paralyze muscles or to treat wrinkles) may be given to deaden the pain nerves but is currently considered experimental.

Because this disorder involves chronic pain, treatments are becoming more comprehensive, including management of stress and emotional reactions to the pain.

Last full review/revision November 2008 by Rosemary Basson, MD, FRCP(UK)