Painful sexual intercourse (dyspareunia)

What is it?

Pain during or after sexual intercourse is known as dyspareunia. Although this problem can affect men, it is more common in women. Women with dyspareunia may have pain in the vagina, clitoris or labia. There are numerous causes of dyspareunia, many of which are treatable. Common causes include the following:

• vaginal dryness
• atrophic vaginitis, a common condition causing thinning of the vaginal lining in postmenopausal women
• side effects of drugs such as antihistamines and tamoxifen (Nolvadex and other brands)
• an allergic reaction to clothing, spermicides or douches
• endometriosis, an often painful condition in which tissue from the uterine lining migrates and grows abnormally inside the pelvis
• inflammation of the area surrounding the vaginal opening, called vulvar vestibulitis
• skin diseases, such as lichen planus and lichen sclerosus, affecting the vaginal area
• urinary tract infections, vaginal yeast infections, or sexually transmitted diseases
• psychological trauma, often stemming from a past history of sexual abuse or trauma.

Symptoms

Women with dyspareunia may feel superficial pain at the entrance of the vagina, or deeper pain during penetration or thrusting of the penis. Some women also may experience severe tightening of the vaginal muscles during penetration, a condition called vaginismus.

Diagnosis

Dyspareunia typically is diagnosed based on your symptoms. Your medical and sexual history and your physical examination will help your doctor to determine the cause of your symptoms.

Distinguishing pain that occurs with touching the genitals or early penetration from pain that occurs with deeper penetration is a clue to the cause of your symptoms. Therefore, your doctor will ask you questions about the exact location, length and timing of your pain. He or she also will ask you:

• if there was ever a time you had painless intercourse, or if you have always had dyspareunia
• if you have enough natural lubrication, and if your symptoms improve if you use commercially available lubricants
• about your sexual history (to help assess your risk for sexually transmitted infections)
• if you have ever been sexually abused, or had a traumatic injury involving your genitals.

In addition:

• If you are middle-aged, your doctor will ask whether you are experiencing irregular periods, hot flashes or vaginal dryness, or symptoms suggesting that you may have atrophic vaginitis.
• If you are a new mother, your doctor will ask whether you are breastfeeding your baby, because breastfeeding also can lead to vaginal dryness and dyspareunia.

During the physical examination, your doctor will check your vaginal wall for signs of dryness, inflammation, infection (especially yeast or herpes infection), genital warts and scarring. Your doctor also will do an internal pelvic examination to look for abnormal pelvic masses, tenderness or signs of endometriosis. He or she also may suggest that you speak with a counselor to determine whether a history of sexual abuse, trauma or anxiety may be contributing to your symptoms.

Expected duration

How long your symptoms last depends on the cause. If you have vaginal dryness from inadequate lubrication, the symptoms will improve rapidly if you use a commercially available lubricant or if you are more aroused before intercourse. If you have vaginal dryness from atrophic vaginitis, your symptoms will improve with an estrogen cream placed in the vagina. You should discuss this with your physician.

Oral estrogen therapy can increase the risk of breast cancer and heart disease, but vaginal formulas are considered safe for most people. If you have a urinary tract or vaginal yeast infection, the dyspareunia typically goes away within one week of antibiotic or antifungal therapy. If you have a sexually transmitted disease, you may need longer, more intensive treatments with antibiotics to clear the condition. Skin diseases usually will improve with the use of steroid creams, but often require long-term treatment. If you have had symptoms of dyspareunia for months or years, and psychological factors play a role, you may need prolonged counseling before your symptoms are relieved.

Prevention

Although some causes of dyspareunia, such as a history of sexual abuse or trauma, can't be avoided, other causes can be prevented:

• To decrease your risk of yeast infection, avoid tight clothing, wear cotton underpants, and practice good hygiene. Change your underclothes after prolonged sweating. Bathe or shower daily, and change into dry clothing promptly after swimming.
• To avoid bladder infections, wipe from front to back after using the toilet, and urinate after sexual intercourse.
• To avoid sexually transmitted diseases, avoid sex or practice safe sex by maintaining a relationship with just one person, or using condoms to protect against sexually transmitted diseases.
• To prevent vaginal dryness, use a lubricant, or seek treatment if the dryness is due to atrophic vaginitis.
• If you have endometriosis, avoid very deep penetration, or have sex during the week or two after menstruation (before ovulation), when the condition tends to be less painful.

Treatment

Treatment depends on the cause of dyspareunia:

• If vaginal dryness is the problem, you can ease penetration and sexual intercourse with increased clitoral stimulation before intercourse, or lubrication with an over-the-counter lubricant such as K-Y jelly, Replens, or Astroglide.
• For vaginal yeast infections, you will be given antifungal medication.
• Antibiotics will be prescribed for urinary tract infections or sexually transmitted diseases.
• To relieve painful inflammation, try sitz baths, which are warm-water baths in a sitting position.
• For skin diseases affecting the vaginal area, the treatment will vary depending on the disease. For example, lichen sclerosus and lichen planus often improve with steroid creams.
• For vulvar vestibulitis, typical therapies include topical estrogen cream, low-dose pain medications, and physical therapy with biofeedback to lower the muscle tension in the pelvic floor.
• For atrophic vaginitis, estrogen therapy will be prescribed, usually as a vaginal formulation.
• If endometriosis is causing your dyspareunia, you will likely be prescribed medication, or you may need surgical procedures to control or remove abnormal growths of uterine tissue.
• For dyspareunia that persists despite above therapies, addressing issues related to stress or anxiety regarding sexual intercourse can help.

When to call a professional

Although sexual intercourse may be uncomfortable the very first time, it should never be painful. If you suddenly begin having pain before, during or after intercourse, see your doctor. It is important to seek care early, before you begin to avoid sexual intercourse or feel anxious in anticipation of your partner.

Prognosis

Many causes of dyspareunia are rooted in a physical condition that can be cured or controlled with proper medical care. However, women with longstanding dyspareunia or a history of sexual abuse or trauma may need counseling to help manage the symptoms.

Additional info

American College of Obstetricians and Gynecologists
https://www.acog.org/

Urology Care Foundation
https://www.urologyhealth.org/