Painful Intercourse (Dyspareunia)

Overview

Dyspareunia is the medical term for pain during penetrative sexual activity (such as intercourse). It is a condition that generally affects women, and a number of women experience pain with penetration at some point in their lives. The results of a 2003 study showed that approximately 17-19% of women in the United States experience dyspareunia.

The pain can be moderate to severe, affecting the vagina, clitoris, pelvis, and/or labia (the lips of the vulva). It may be persistent pain that is further aggravated by sexual activity, or it may be pain that only occurs during penetration.

There are many reasons why a woman might have pain during sex, spanning from physical conditions to psychological factors to changes in her body brought on by menopause or after childbirth. Fortunately, most causes of dyspareunia can be treated.

Symptoms

While the main symptom of dyspareunia is pain during penetrative sexual activity, the location, severity, and type of pain can vary greatly depending on the underlying cause of it. Those with dyspareunia may have:

  • Pain in the vagina, vulva, clitoris, pelvic floor muscles, or upper pelvis
  • Pain during initial entry only
  • Pain with any vaginal penetration, including putting in a tampon
  • Localized or generalized pain
  • Pain during deep thrusting
  • Pain following pain-free sex
  • Burning, itching, aching, or throbbing
  • A painful sensation deep in the pelvis similar to menstrual cramps

Causes

Dyspareunia can be associated with physical or psychological factors, and sometimes a combination of both. Here are some of the conditions and situations that may result in painful penetration:

Vaginal dryness and hormonal factors:

  • Vaginal dryness (or not enough lubrication) is a common cause of dyspareunia. Often, this can be the result of not enough foreplay, but other things may cause vaginal dryness as well. A woman’s estrogen levels affect vaginal lubrication, so she may notice pain during sexual activity when her estrogen drops after childbirth, while breastfeeding, or during menopause. Certain medications like antidepressants, high blood pressure drugs, antihistamines, sedatives, and some birth control pills can also negatively impact vaginal lubrication.
  • Vulvo-vaginal atrophy (VVA)/genitourinary syndrome of menopause (GSM) occurs in 50% (or more) of postmenopausal women and can cause dyspareunia. When a woman enters menopause, her estrogen and testosterone levels decrease which can lead to the thinning of her vulvar and vaginal tissues, vaginal dryness, less vaginal elasticity, and burning, tearing, bleeding, or pain during or after sex.

Pelvic floor muscle dysfunction:

  • Pelvic organ prolapse occurs when the pelvic floor muscles become weak or damaged, and one of the pelvic organs like the bladder, uterus, rectum, or small bowel descends from its normal position and into the vagina.
  • Vaginismus, or hypertonic pelvic floor muscle dysfunction, is a condition in which the pelvic floor muscles are very tight and spasm involuntarily. This condition makes vaginal penetration painful and can be associated with constipation, pressure in the bladder, and difficulty with tampon insertion and gynecological examination.

Vulvodynia:

Vulvodynia is persistent pain of the vulva that lasts for at least three months and has no easily identifiable cause. The pain can be generalized (affecting the entire vulvar region) or localized to a specific area of the vulva. In addition to feeling pain during sexual activity, women with vulvodynia may experience pain or discomfort with tight clothing and prolonged sitting.

  • Clitorodynia is a form of vulvodynia in which vulvar pain is localized in the clitoris.
  • Vestibulodynia is a type of vulvodynia in which the pain is localized in the vestibule, or the entrance to the vagina. Provoked vestibulodynia is the most common form of vulvodynia and causes a woman to feel pain in her vestibule whenever it is touched.

Infections and skin conditions:

  • Acute cystitis, commonly referred to as a urinary tract infection (UTI), is inflammation of the bladder. Often, it is brought on by a bacterial infection and can cause painful sex.
  • Infections such as bacterial infections, vaginal yeast infections, and sexually transmitted infections (STIs) like trichomonas, genital herpes, chlamydia, and gonorrhea may be the source of pain.
  • Inflammatory skin conditions like lichen planus, lichen sclerosus, or eczema of the vaginal skin could be the issue. An allergic reaction to hygiene products, soaps, laundry detergents, spermicides, or even clothing can also affect the sensitive area.
  • Pelvic inflammatory disease affects a woman’s reproductive organs. It is often the result of an infection that spreads from the vagina to the uterus, fallopian tubes, and/or ovaries.

Gynecological, urological, and gastrointestinal factors:

  • Endometriosis is a condition in which endometrial tissue (tissue from the uterus) begins to grow outside of the uterus, often causing chronic pelvic pain.
  • Irritable bowel syndrome, whether causing diarrhea, constipation, or both, and other gastrointestinal issues may be associated with dyspareunia.
  • Ovarian cysts are fluid-filled sacs that develop in or on the ovaries. These cysts can contribute to dyspareunia in specific cases.
  • Painful bladder syndrome/interstitial cystitis, unlike common cystitis, is not caused by an infection. It is a chronic bladder pain condition that causes frequent urination, pelvic pain, and dyspareunia. Women with interstitial cystitis may experience pain during penetration due to the bladder’s close proximity to the vagina, or pain with deep thrusting when other urinary structures are impacted.
  • Uterine fibroids are non-cancerous growths in or on the uterus that often do not show symptoms but can sometimes cause dyspareunia.

Other anatomical and medical factors:

  • Congenital abnormalities, meaning abnormalities that are present at birth, may cause problems, such as imperforate hymen in which the hymen covers and blocks the vaginal opening.
  • Medical treatments such as pelvic surgery, hysterectomy, and cancer treatments including radiation and chemotherapy may result in pain during penetrative sexual activity.
  • Vaginal injury or trauma due to an accident, surgery, female genital mutilation (female circumcision), or childbirth can cause painful penetration.

Psychological factors:

  • Past sexual abuse or violence can greatly influence how one experiences sex, sometimes causing it to be painful even later in healthy, consensual circumstances.
  • Psychological stress ranging from anxiety, depression, lack of self-esteem, worries or doubts about one’s physical appearance or sexual performance, and lack of intimacy in a relationship can have a big impact on one’s comfort level during sex.

Diagnosis

A knowledgeable health care provider can diagnose the most likely cause(s) of dyspareunia through a comprehensive patient history (with a focus on the patient’s reproductive and sexual history), a gynecological examination, and any additional tests that may be required.

Beginning with the medical history, the provider may ask the patient a series of questions about the type, severity, duration, and location of the pain. It is helpful for a provider to know if the pain gets better or worse in specific situations, for example, during a woman’s period, while urinating, or in certain sexual positions.

For the physical examination, the provider will look at the outside of the genitals for any signs of skin irritation, infection, or abnormalities that may be causing the problem. Then, he or she might use a cotton-tipped swab to apply light pressure to different parts of the vulva and vestibule to help determine exactly where the pain is occurring. The health care professional may also press on the upper pelvic floor structures like the uterus, ovaries, and bladder with their hands, or perform an internal exam of the pelvic floor muscles by inserting one gloved finger (with lubrication) into the vagina to assess the muscles’ strength and control. An internal digital examination may also be done to assess areas of tenderness deeper in the vagina. Finally, the provider will use a device called a speculum to separate the walls of the vagina to be able to see inside. Often, this part of the exam can be painful for those suffering from dyspareunia, so the patient should speak up if the pain ever becomes too intense.

If necessary, the provider may recommend a pelvic ultrasound for a better view of what is happening internally or additional measures like hormone testing to figure out if the pain might be related to hormone levels.

Treatment

Treatment options for dyspareunia will be aimed at addressing the underlying cause. Personal lubricants, increased foreplay, changing medications, and/or topical estrogen creams may be recommended to treat dyspareunia caused by vaginal dryness.

Bacterial infections in the bladder or vagina can usually be treated effectively with antibiotics, but the patient should be aware that vaginal yeast infections may be more likely to occur after taking antibiotics. Vaginal yeast infections can be treated with oral or topical antifungal medications.

Pelvic floor physical therapy, vaginal dilators, and breathing techniques might be helpful for those who suffer from vaginismus or overly tight pelvic floor muscles.

Endometriosis and painful bladder syndrome/interstitial cystitis have their own specific treatments, which can be discussed with a health care provider with experience treating these conditions.

If psychological factors are at play, counselling or sex therapy may be a good treatment option. A counselor may be able to help a patient address past trauma or sexual abuse that is preventing her from having pain-free, enjoyable sex. A professional sex therapist or counsellor may be able to help her and her partner improve their communication, foster intimacy, address body image and performance concerns, and tackle any negative emotional responses to sex brought on by past painful experiences.

Resources:

Giorgi, A. Medically reviewed by Debra Sullivan, Ph.D, MSN, R.N., CNE, COI. (2020, February 3). What You Need to Know About Dyspareunia (Painful Intercourse). https://www.healthline.com/health/dyspareunia.

Goldstein, I., Clayton, A.H., Goldstein, A.T., Kim, N.N., & Kingsberg, S.A. (2018). The International Society for the Study of Women’s Sexual Health Textbook of Female Sexual Function and Dysfunction Diagnosis and Treatment. Wiley Blackwell.

Harvard Health Publishing. (2019, March 22). Painful Sexual Intercourse (Dyspareunia). https://www.health.harvard.edu/a_to_z/painful-sexual-intercourse-dyspareunia-a-to-z.

Leonard, Jayne. Medically reviewed by University of Illinois. (2017, December 22). What causes dyspareunia, or painful intercourse? https://www.medicalnewstoday.com/articles/192590.

Mayo Clinic. (2019, September 14). Interstitial cystitis. https://www.mayoclinic.org/diseases-conditions/interstitial-cystitis/symptoms-causes/syc-20354357.

Mayo Clinic. (2020, August 26). Ovarian cysts. https://www.mayoclinic.org/diseases-conditions/ovarian-cysts/symptoms-causes/syc-20353405.

Mayo Clinic. (2020, February 7). Painful intercourse (dyspareunia). https://www.mayoclinic.org/diseases-conditions/painful-intercourse/symptoms-causes/syc-20375967.

Nappi, R.E., Graziottin, A., Mollaioli, D., Limoncin, E., Ciocca, G., Sansone, A., Meriggiola, M.C., Becorpi, A.M., Maffei, S., Russo, N., & Jannini, E.A. (2021). The Gynogram: A Multicentric Validation of a New Psychometric Tool to Assess Coital Pain Associated With VVA and Its Impact on Sexual Quality of Life in Menopausal Women. The Journal of Sexual Medicine, 18(5), 955-965. https://www.jsm.jsexmed.org/article/S1743-6095(21)00260-5/fulltext.

Rosen, N.O., Dawson, S.J., Brooks, M., & Kellogg-Spadt, S. (2019). Treatment of Vulvodynia: Pharmacological and Non-Pharmacological Approaches. Drugs, 79(5), 483-493. https://doi.org/10.1007/s40265-019-01085-1.

Seehusen, D.A., Baird, D.C., & Bode, D.V. (2014). Dyspareunia in Women. American Family Physician, 90(7), 465-470. https://www.aafp.org/afp/2014/1001/p465-s1.html.

SX21: Sex in the 21st Century. (2010, February 24). Dyspareunia. https://sexualmed.org/known-issues/dyspareunia/.


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