Causes of Dyspareunia
Dyspareunia has multiple organic causes that must be systematically identified by location (superficial vs. deep) and patient context, with postpartum trauma, pelvic floor dysfunction, hormonal deficiency, and vulvodynia being the most common etiologies in clinical practice. 1, 2
Classification by Pain Location
Superficial (Entry) Dyspareunia
Vulvodynia and vulvar vestibulitis are primary causes of superficial pain, identifiable by localized tenderness when touching the vulvar vestibule with a cotton swab during examination 3, 2. This condition causes pain specifically with attempted vaginal insertion 3.
Lichen sclerosus presents with characteristic porcelain-white papules and plaques, causing dyspareunia through erosions, fissures, or introital narrowing 1. This diagnosis is frequently missed in young patients because it has a bimodal distribution affecting both prepubertal girls and postmenopausal women—do not dismiss this diagnosis based on age alone 1.
Inadequate lubrication from insufficient arousal, medications, or hormonal factors causes superficial pain 3, 2.
Vaginismus manifests as involuntary spasm of the pelvic floor muscles, observable when attempting to insert an examining finger or speculum 3.
Deep Dyspareunia
Pelvic floor muscle dysfunction causes both superficial and deep pain, with tender pelvic floor muscles identifiable on single-digit vaginal examination 1, 2.
Endometriosis causes deep pain through inflammatory lesions and adhesions in the pelvis 3, 2.
Pelvic adhesions, pelvic congestion, and adnexal pathology produce deep pain on palpation of the uterus and adnexa during bimanual examination 3.
Urethral disorders, cystitis, and interstitial cystitis may cause painful intercourse, identifiable through palpation of urethral structures 3.
Context-Specific Causes
Postpartum Dyspareunia
Postpartum dyspareunia affects 35% of women after childbirth, with a critical pattern: 43% experience pain at 2-6 months postpartum, 22% at 6-12 months, and 40% at 12-24 months—do not dismiss this as normal or temporary since it persists beyond 12 months in 40% of cases 1, 4.
Specific postpartum causes include:
- Perineal trauma and episiotomy scars 1
- Vaginal dryness from breastfeeding-induced hypoestrogenism 1
- Pelvic floor dysfunction from childbirth 1
- Even women with intact perineum have 15-16% prevalence at 6-12 months 4
Hormonal Causes
Estrogen deprivation from multiple sources causes vaginal atrophy, dryness, and dyspareunia 1:
Young cancer survivors treated with chemotherapy, radiation, or endocrine therapy frequently experience dyspareunia from vaginal dryness, scarring, and hormonal changes 1.
Integrated Etiologic Factors
Hormonal, inflammatory, muscular, iatrogenic, neurologic, vascular, connective tissue, and immunologic factors all contribute to dyspareunia and require systematic evaluation 5.
Psychosexual factors including vaginismus, loss of libido, arousal disorders, and sexual pain-related disorders often overlap with organic causes—finding an organic basis does not rule out emotional or psychogenic contributions 5, 6.
Critical Diagnostic Pitfalls
Do not overlook lichen sclerosus in young patients, as it has a prepubertal peak and may be asymptomatic or mistaken for other conditions 1.
Screen for postpartum depression (14% prevalence) and anxiety (16% prevalence), as these commonly coexist with dyspareunia and impact sexual function 4.
Recognize that dyspareunia may be part of broader sexual dysfunction affecting up to 80-91% of women at 12 months postpartum, requiring comprehensive assessment beyond isolated pain 4.