Dyspareunia (Painful Sex) Is Not Normal and Requires Medical Evaluation
Painful sex (dyspareunia) is not normal and should be considered a symptom requiring medical evaluation and treatment. Dyspareunia affects approximately 10-20% of women in the United States and can significantly impact quality of life, relationships, and mental health 1, 2.
Understanding Dyspareunia
Dyspareunia can be categorized as:
- Superficial pain: Occurs during vaginal penetration or attempted insertion
- Deep pain: Occurs with deeper penetration, felt in the lower abdomen or deeper vagina
The prevalence of dyspareunia ranges from 10-28% of women during their lifetime 2, making it a common but not normal condition.
Common Causes of Dyspareunia
Potential Organic Causes:
- Infections: Including pelvic inflammatory disease (PID), which may present with dyspareunia as one of its symptoms 3
- Vaginal atrophy: Common in postmenopausal women due to decreased estrogen levels 4
- Inadequate lubrication: Can cause friction and pain during intercourse 1
- Vulvodynia/vestibulodynia: Chronic pain or discomfort of the vulva 1, 5
- Pelvic floor dysfunction: Including overactive pelvic floor muscles 1, 5
- Endometriosis: Can cause deep dyspareunia 1, 6
- Lichen sclerosus: Can cause painful fissures and dyspareunia 3
Other Contributing Factors:
- Psychological factors: Anxiety, depression, relationship issues 7
- Past trauma: Including sexual trauma 7
- Neurogenic inflammation: Can lead to chronic pain syndromes 7
Evaluation Approach
When a patient reports painful sex, a thorough evaluation should include:
Detailed pain assessment:
- Location (entry vs. deep)
- Timing (primary vs. acquired)
- Quality and severity
- Aggravating and alleviating factors
Physical examination:
- External genital inspection for visible abnormalities
- Cotton swab test to identify focal areas of pain
- Single-digit vaginal examination to assess pelvic floor muscle tenderness
- Bimanual examination to evaluate for uterine position, masses, or tenderness 1
Laboratory testing as indicated:
- Testing for sexually transmitted infections
- Vaginal pH and microscopy
- Hormone levels if atrophy is suspected
Treatment Approaches
Treatment should target the underlying cause:
For Vaginal Atrophy:
- Local estrogen therapy: Available as creams, tablets, or rings 4
- Non-hormonal moisturizers and lubricants: Used 2-3 times weekly (moisturizers) or during sexual activity (lubricants) 4
For Vulvodynia/Vestibulodynia:
- Topical analgesics: To reduce pain during intercourse 1
- Pelvic floor physical therapy: To address muscle dysfunction 1, 5
For Inadequate Lubrication:
- Water-based or silicone lubricants: Applied before sexual activity 1
For Pelvic Inflammatory Disease:
- Antibiotic therapy: Broad-spectrum coverage for likely pathogens 3
- Treatment of sexual partners: To prevent reinfection 3
For Persistent Cases:
- Cognitive behavioral therapy: To address psychological components 1
- Vaginal dilators: For gradual desensitization 1
- Surgical options: Such as modified vestibulectomy for specific conditions 1
Important Considerations
Low threshold for diagnosis: Healthcare providers should maintain a low threshold for diagnosing conditions like PID that may present with dyspareunia, as delayed diagnosis can lead to reproductive health damage 3
Impact on quality of life: Dyspareunia can significantly affect relationships, mental health, and overall quality of life 2
Multidisciplinary approach: Complex cases may benefit from collaboration between gynecologists, physical therapists, and psychologists 2
Cultural sensitivity: Approach discussions about sexual health with cultural humility and trauma-informed practices 3
Regular follow-up: Conditions like vaginal atrophy tend to worsen if left untreated 4
Remember that dyspareunia is a symptom, not a diagnosis, and finding the underlying cause is essential for effective treatment. Patients should be encouraged to seek medical attention rather than accepting painful sex as normal.