Dyspareunia: The Clinical Term for Painful Sex
Dyspareunia is the medical term for painful sexual intercourse, affecting approximately 10-20% of women in the United States. 1 This condition can significantly impact quality of life, relationships, and psychological wellbeing, often leading to sexual dysfunction, anxiety, and depression.
Types of Dyspareunia
Dyspareunia is typically classified based on the location of pain:
- Superficial dyspareunia: Pain occurs at the vaginal entrance or with attempted penetration 1, 2
- Deep dyspareunia: Pain is experienced deep in the vagina or lower abdomen during intercourse 2, 3
Prevalence and Impact
- Affects 10-28% of women during their lifetime 3
- 35% of postpartum women experience dyspareunia, with varying prevalence by time since birth 4:
- 43% from 2-6 months postpartum
- 22% from 6-12 months postpartum
- 40% from 12-24 months postpartum
Common Causes
Superficial Dyspareunia
- Vulvodynia (vulvar pain without identifiable cause)
- Inadequate lubrication
- Vaginal atrophy (especially in postmenopausal women)
- Vaginismus (involuntary spasm of vaginal muscles)
- Postpartum causes (episiotomy, tears)
- Vulvar vestibulitis (localized pain at vaginal entrance)
Deep Dyspareunia
- Endometriosis
- Pelvic inflammatory disease
- Pelvic adhesions
- Adnexal pathology (ovarian cysts)
- Uterine retroversion
- Pelvic floor dysfunction
Diagnostic Approach
A thorough assessment includes:
- Detailed pain history: Location, intensity, timing, and factors that worsen or improve symptoms
- Physical examination:
- Visual inspection of external genitalia
- Cotton swab test to identify focal areas of pain
- Single-digit vaginal examination to assess pelvic floor muscles
- Bimanual examination to evaluate for pelvic masses or uterine retroversion
Treatment Options
Treatment should follow a stepwise approach based on the underlying cause 4, 5:
First-Line Treatments
- Vaginal moisturizers and lubricants for daily comfort and sexual activity
- Topical lidocaine for persistent introital pain 4, 5
- Pelvic floor physiotherapy for pelvic floor dysfunction 4, 5
Second-Line Treatments
- Vaginal dilators for vaginismus and vaginal stenosis 4, 5
- Cognitive behavioral therapy to address anxiety and pain-related fear 4, 5
- Low-dose vaginal estrogen for vaginal atrophy (with careful consideration in breast cancer patients) 4
Advanced Options
- Vaginal dehydroepiandrosterone (DHEA) for women on aromatase inhibitors 4
- Ospemifene for postmenopausal women without breast cancer history 4
- Modified vestibulectomy for refractory vulvar vestibulitis 1
- OnabotulinumtoxinA injections for persistent pelvic floor spasm 1
Special Considerations
- Cancer survivors: Treatment should be guided by the specific type of problem, with consideration of cancer history and current treatments 4
- Postpartum women: Higher prevalence of dyspareunia requires proactive assessment and management 4
- Psychological factors: Even with organic causes, psychological aspects often contribute to ongoing pain 2, 6
Multidisciplinary Approach
For optimal outcomes, collaboration between healthcare providers is essential:
- Primary care physician
- Gynecologist
- Pelvic floor physical therapist
- Psychologist/sex therapist
By addressing both physical and psychological components of dyspareunia, most women can experience significant improvement in symptoms and quality of life.