What are the causes and treatments of dyspareunia (painful sexual intercourse)?

Causes and Treatments of Dyspareunia (Painful Sexual Intercourse)

Dyspareunia affects approximately 10-20% of women and requires a targeted approach based on identifying the specific underlying cause. 1 Treatment should focus on addressing the identified cause while considering both physical and psychological factors that may perpetuate the pain cycle.

Common Causes of Dyspareunia

Dyspareunia can be categorized as either superficial (entry) or deep pain:

Superficial Dyspareunia (Pain with Vaginal Entry)

• Vulvodynia/Vulvar Vestibulitis: Characterized by focal erythema and pain at the vaginal entrance that can be reproduced during examination with a cotton swab 1, 2
• Vaginal Dryness/Inadequate Lubrication: Common cause that may be related to insufficient arousal, hormonal changes, or medication side effects 2
• Vaginal Atrophy: Often associated with estrogen deficiency, particularly in postmenopausal women or those on certain cancer treatments 3
• Vaginismus: Involuntary spasm of pelvic floor muscles that causes pain with attempted penetration 2
• Postpartum Causes: Including perineal trauma, episiotomy scars, and breastfeeding-related hormonal changes 3

Deep Dyspareunia (Pain with Deep Penetration)

• Endometriosis: A common cause of deep dyspareunia, especially with positions involving deep penetration 2, 4
• Pelvic Floor Dysfunction: Overactive or tight pelvic floor muscles can cause pain during intercourse 1, 5
• Pelvic Inflammatory Disease (PID): Can cause deep pelvic pain during intercourse 3
• Adnexal Pathology: Including ovarian cysts or masses 2
• Uterine Retroversion: Can cause pain with certain positions 1
• Pelvic Adhesions: From previous surgery, infection, or inflammation 2

Diagnostic Approach

A thorough evaluation should include:

• Pain Assessment: Location (entry vs. deep), intensity, timing, and factors that worsen or improve symptoms 1
• Physical Examination:
  • Visual inspection of external genitalia for signs of inflammation, lesions, or atrophy 1
  • Cotton swab test to identify focal areas of pain, particularly for vulvodynia 1
  • Single-digit vaginal examination to assess pelvic floor muscle tenderness 1
  • Bimanual examination to evaluate for uterine position, masses, or adnexal tenderness 1

Treatment Approaches

For Vulvodynia/Vulvar Vestibulitis

• Topical Treatments: Lidocaine for pain relief before intercourse 3
• Pelvic Floor Physical Therapy: To address muscle tension and spasm 1
• Modified Vestibulectomy: Surgical option for severe cases not responding to conservative measures 1
• OnabotulinumtoxinA Injections: For refractory cases 1

For Vaginal Dryness/Atrophy

• Hormone-Free Lubricants and Moisturizers: First-line treatment, especially for cancer survivors or those with hormone-sensitive conditions 3
  • Water-based gels or hyaluronic acid gels for regular use 3
  • Lubricants specifically for sexual activity 3
• Low-Dose Vaginal Estrogen: For those who don't respond to non-hormonal options and don't have contraindications 3
  • For breast cancer survivors on aromatase inhibitors, careful risk-benefit discussion is needed 3
• Vaginal DHEA (Prasterone): May improve sexual function in postmenopausal women, though safety data in hormone-sensitive cancer survivors is limited 3
• Ospemifene: FDA-approved for moderate to severe dyspareunia in postmenopausal women without history of breast cancer 3

For Vaginismus and Pelvic Floor Dysfunction

• Pelvic Floor Physical Therapy: To address muscle tension, spasm, and coordination 1, 5
• Vaginal Dilators: Progressive use to desensitize and stretch tissues 3, 1
• Cognitive Behavioral Therapy: To address anxiety and pain anticipation 3

For Endometriosis-Related Pain

• Hormonal Treatments: Including combined hormonal contraceptives, progestins, or GnRH agonists 4
• Surgical Management: Laparoscopic excision of endometriosis lesions for severe cases 4

For PID-Related Pain

• Antimicrobial Therapy: Broad-spectrum coverage for likely pathogens including N. gonorrhoeae, C. trachomatis, anaerobes, and gram-negative bacteria 3
• Pain Management: NSAIDs for associated discomfort 3

Special Considerations

Cancer Survivors

• Radiation-Induced Changes: Women who received pelvic radiation may benefit from early intervention with vaginal dilators to prevent stenosis 3
• Hormone-Sensitive Cancers: Non-hormonal options should be prioritized, though low-dose vaginal estrogen may be considered after thorough risk-benefit discussion 3

Postpartum Women

• Perineal Care: Proper healing of episiotomy or tears is important 3
• Breastfeeding-Related Dryness: May require additional lubrication 3

Important Pitfalls to Avoid

• Focusing Only on Physical Causes: Psychological factors often contribute to and perpetuate sexual pain, requiring integrated treatment approaches 2, 6
• Inadequate Assessment: Failing to perform a thorough examination may miss important diagnoses 1
• Dismissing Symptoms: Dyspareunia significantly impacts quality of life and relationships and should be taken seriously 3, 1
• Delayed Treatment: Early intervention may prevent chronic pain cycles from developing 3
• Overlooking Partner Involvement: Including partners in education and treatment can improve outcomes 6

Dyspareunia is a complex condition that requires a comprehensive approach to diagnosis and treatment. With proper identification of the underlying cause and appropriate interventions, most women can experience significant improvement in symptoms and sexual function.