What is Dyspareunia?
Painful sexual intercourse, also known in medical terms as dyspareunia, is a commonly neglected issue among women’s health. The condition, present in 3 to 18% of women across the globe, can affect 10 to 28% of women at some point in their lives. There are different types of dyspareunia: superficial dyspareunia, which causes pain at the entrance to the vagina, and deep dyspareunia, which causes pain further inside the vagina or lower pelvic area, often during deeper penetration.
Dyspareunia can also be primary or secondary. Primary dyspareunia means the pain starts at the beginning of sexual intercourse. In contrast, secondary dyspareunia means the pain starts after a period of pain-free sexual activity.
It’s important to note that dyspareunia can sometimes be confused with vulvodynia, a condition that causes genital pain for over three months irrespective of sexual intercourse. Dyspareunia can lead to various sexual problems, such as reduced sexual desire and arousal, and has the potential to cause issues in sexual relationships. It can significantly affect a woman’s physical and mental health, leading to conditions like depression, anxiety, over-awareness of pain, negative body image, and low self-esteem. Therefore, it’s crucial to promptly address and manage dyspareunia.
This review will focus on the cause, frequency, evaluation, management and outlook of dyspareunia.
What Causes Dyspareunia?
Dyspareunia, or painful intercourse, can be caused by a range of factors, such as structural issues, inflammation, infections, trauma, hormonal imbalances, or psychosocial conditions. Anatomic issues that could lead to dyspareunia include dysfunctional pelvic floor muscles, a backward-tilting uterus, remnants of hymen tissue, and pelvic organs dropping from their normal position.
In regard to hormonal factors, a lack of lubrication, common in reproductive years, can be due to an imbalance in hormones or problems related to sexual arousal. For younger women, contraceptives can sometimes cause an insufficient amount of lubrication. For post-menopausal women, lower estrogen levels can cause vaginal atrophy by making the lining of the vagina, which helps produce vaginal secretions, thinner.
Endometriosis, a condition where uterine lining grows outside the uterus, is another potential cause for dyspareunia. The pain from endometriosis-associated dyspareunia can be due directly to the endometriosis or indirectly due to bladder or pelvic floor issues. Regardless of the stage of endometriosis, severe deep dyspareunia is strongly linked with bladder and pelvic floor sensitivity and painful bladder syndrome. This implies that in some women with deep dyspareunia, pain mechanisms related to muscle tissue or sensitization might be at play.
Dermatological diseases like lichen planus, lichen sclerosis, and psoriasis can cause significant inflammation to the lining of the vagina. Infections in the area around and in the vagina, such as urethritis, vaginitis, and pelvic inflammatory disease, can result from sexually transmitted infections like gonorrhea and chlamydia, yeast infections, trichomoniasis, bacterial vaginosis, and viruses like herpes. Dyspareunia after giving birth is more common in women who have experienced perineal trauma during delivery, in comparison with women who had an uncomplicated vaginal delivery without perineal trauma or tearing.
Vaginismus, a condition more common in younger women where the pelvic floor muscles involuntarily contract during attempted vaginal penetration, can also cause dyspareunia. This could be due to a dysfunction in the pelvic floor muscles or linked to psychosocial issues such as a history of sexual abuse.
Risk Factors and Frequency for Dyspareunia
Dyspareunia, or pain during sexual intercourse, affects a range of people, though the exact number can vary depending on the definition used. In the United States, between 7% and 46% of people might experience this condition. While it can affect both males and females, it’s much more common among females. Despite this, only a small fraction of women seek medical help for severe symptoms, which makes it difficult to determine the true number of people affected.
Signs and Symptoms of Dyspareunia
When speaking to a patient about their pain, it’s important to ask non-judgmental questions. This includes getting a sense of things like how long the pain has lasted, its intensity, where it’s located, what makes it worse or better, and any related mental or emotional factors. The type of pain can help distinguish between surface-level and deeper issues. For example, a burning sensation is often linked to inflammation of the vagina, vulvodynia, thinning of vaginal walls, or a lack of adequate lubrication. On the other hand, a deep aching pain could suggest conditions like pelvic congestion syndrome, pelvic inflammatory disease, endometriosis, a backward-tilting uterus, uterine fibroids, and issues with the adnexa. Some details of the pain – such as whether it only occurs with certain partners or in every situation – can provide clues about psychological aspects.
The Initial Measurement of Patient-Reported Pelvic Floor Complaints Tool (IMPACT) form quizzes patients about various pelvic floor problems. This tool is useful for diagnosing and treating patients with dyspareunia, a condition characterized by painful intercourse.
In the first step of the physical exam, it’s important to educate the patient about the process and their own anatomy. Initially, the doctor will visually inspect the outer and inner labia, the vestibular area, the anus, and the urethral opening to look for any abnormalities such as lesions, enlarged labia, leukoplakia (white patches), or redness. Then, with a carefully-selected, warmed, and lubricated speculum (a pediatric speculum may be used for comfort), a speculum exam is conducted, during which the doctor will examine the cervix for any lesions, redness, and discharge. Appropriate cultures can be taken at this time. Lastly, a bimanual exam is performed to check for any masses, cysts or other anomalies in the uterus and adnexa.
Testing for Dyspareunia
Lab tests aren’t typically the main way to diagnose or treat dyspareunia, which is a term for painful sexual intercourse. Yet, it’s still good to cross out other possible problems to pinpoint the exact issue. For example, vulvodynia, which causes similar pain, can be checked for during a physical examination with a cotton swab test.
Other tests that may be required include cultures taken from the pelvic region to check for infections like gonorrhea, chlamydia, trichomoniasis, Candida, and Gardnerella. These are recommended when a woman has vaginal or cervical discharge. If genital ulcers are present, additional testing for herpes simplex or syphilis, or taking a culture might be necessary.
If a woman is experiencing symptoms like painful urination, urgency, frequent urination, or discomfort in the lower abdomen, a urine test should be done. Any visible skin changes or lesions found during the physical exam might require a tissue biopsy for further investigation.
A transvaginal ultrasound can be used to get more information about issues like pelvic masses, excessive growth of the endometrium (inner lining of the uterus), ovarian cysts, or abnormalities that a person may have been born with.
Treatment Options for Dyspareunia
Dyspareunia, or painful sexual intercourse, should be treated with a multifaceted approach that addresses physical, emotional, and behavioral aspects of the condition. This means incorporating a team of experts, including gynecologists, pain management specialists, physical therapists, sexual therapists, and mental health professionals who specialize in chronic pain.
First and foremost, it’s important for the physician to acknowledge the patient’s pain and explain that managing this pain may take time. It should also be communicated that despite best efforts, the pain may not entirely go away even after treatment. Patients should be aware of available treatment options and should participate in choosing the most suitable path for them. Generally, non-surgical approaches are explored first.
There are several medical treatment options for dyspareunia. These can include oral antidepressants, hormone replacement (either orally or topically applied), pain-relieving drugs (NSAIDs), botox injections, cognitive behavioral therapy, and other mind-focused therapies. The exact course of treatment depends on what’s causing the pain.
For instance, if pain during sex is caused by vaginal changes after menopause, hormone replacement treatment or specialized estrogen therapy might be useful. Infections causing pain are treated with the relevant antibiotics, antivirals, or antifungal medication based on test results. Pain following childbirth may be managed with vaginal lubricants, massage to break up scar tissue, or in persistent cases, surgery. Botox injections can be effective for pain caused by tense muscles in the pelvic floor.
In addition to these treatments, physical therapy focused on the pelvic floor can also be beneficial in most cases of dyspareunia. This type of therapy teaches the pelvic floor muscles to relax and helps train pain receptors. Cognitive-behavioral therapy can also help reduce anxiety and fear associated with sexual pain.
Surgery is considered a last option, used only when all other medical and behavioral treatments have been tried without success. It may be used to identify and treat pelvic inflammation, endometriosis, or a condition known as pelvic organ prolapse.
What else can Dyspareunia be?
Diagnosing dyspareunia, or painful sexual intercourse, isn’t always straightforward. Many other conditions can exhibit similar symptoms, so it’s important for doctors to exclude these first. They’ll usually do this through a combination of evaluating a patient’s medical history and carrying out a physical examination.
Here’s a list of some conditions that might be confused with dyspareunia:
- Vulvodynia (chronic pain around the opening of the vagina)
- Vaginismus (involuntary muscle spasm making sex painful)
- Atrophic vaginitis (vaginal inflammation due to thinning and shrinking tissues)
- Vulvar vestibulitis (pain and inflammation of the vestibule area of the vulva)
- Endometriosis and pelvic adhesions (painful condition where tissue similar to the lining of the uterus grows in other places)
- Uterine fibroids (non-cancerous growths in the uterus)
- Pelvic congestion (chronic pelvic pain caused by varicose veins in the lower abdomen)
- Pelvic inflammatory disease, endometritis (inflammation of the uterus and other reproductive organs)
- Other infections of the urinary and genital tract
It’s crucial for doctors to consider these possibilities, perform appropriate tests and assess patient history to ensure they arrive at the right diagnosis.
What to expect with Dyspareunia
The outcome of dyspareunia, or painful intercourse, largely depends on what’s causing the pain. If doctors can identify and treat the underlying issue, the chances of improvement are usually good. However, prognosis isn’t as positive when there seems to be no clear cause of the pain, a condition known as idiopathic dyspareunia.
Patients should be aware that treatment isn’t always a quick fix and could last for several months. It’s also important to understand that a complete cure isn’t guaranteed. Research indicates that patients typically start to see some improvement after about three months of treatment, experiencing a decrease in distress and an improvement in quality of life.
To achieve the best results, it is usually recommended that patients continue with their treatment plan for at least 24 months.
Possible Complications When Diagnosed with Dyspareunia
Dyspareunia, or pain during sexual intercourse, is typically a treatable condition that doesn’t lead to serious complications. However, despite it not being life-threatening, it’s important to seek timely treatment to avoid distressing consequences. Failing to address the issue promptly can lead to a loss of sexual interest and relationship problems. It can also cause significant emotional distress and conflicts between partners.
If dyspareunia goes untreated, it can sometimes lead to mental health problems. Issues such as major depression related to dyspareunia are more common in young women. In rare cases, the fear of pain during sex could even potentially contribute to infertility in women.
Preventing Dyspareunia
Many patients often find it difficult to talk about their sexual problems, which means these issues can go unnoticed for a long time. It’s important for doctors to encourage their patients to talk openly about their sexual health. Discussing sexual pain, known medically as dyspareunia, can be tough for patients and doctors alike, and this can sometimes lead to less-than-ideal treatment.
Doctors need the right education and training to properly assess and treat sexual pain. It’s crucial that doctors help their patients feel comfortable and reassured about discussing this issue. If a patient is able to talk about their condition with their family doctor, they can then be referred to a specialist for treatment, depending on the cause of their problem.
