What are the causes of dyspareunia (sex pain) in adults?

Causes of Dyspareunia (Sexual Pain)

Dyspareunia is recurrent or persistent genital pain during sexual intercourse that affects 10-20% of women, with causes ranging from hormonal deficiency and pelvic floor dysfunction to inflammatory conditions and postpartum trauma. 1, 2

Primary Physiologic Causes

Hormonal and Vaginal Atrophy

• Estrogen deprivation from hormonal contraceptives, breastfeeding, premature ovarian insufficiency, or menopause causes vaginal atrophy, dryness, and painful intercourse 3
• Vaginal dryness and atrophy represent the most common treatable cause in postmenopausal women and cancer survivors 4, 5
• Chemotherapy-induced menopause in breast cancer survivors significantly contributes to sexual dysfunction 4

Postpartum Causes

• Postpartum dyspareunia affects approximately 35% of women, with 43% experiencing pain at 2-6 months, 22% at 6-12 months, and 40% at 12-24 months postpartum 3
• Specific postpartum causes include perineal trauma, episiotomy scars, vaginal dryness from breastfeeding-induced hypoestrogenism, and pelvic floor dysfunction 3
• This pain persists beyond 12 months in 40% of affected women and should not be dismissed as normal or temporary 3

Pelvic Floor Dysfunction

• Pelvic floor muscle dysfunction causes both superficial and deep dyspareunia, with tender pelvic floor muscles identifiable on single-digit vaginal examination 3
• This represents a common and often overlooked cause that responds well to targeted physical therapy 4, 5

Dermatologic and Inflammatory Conditions

Vulvodynia and Lichen Sclerosus

• Vulvodynia (provoked vulvar pain) is a common diagnosis causing entry dyspareunia, identifiable by localized pain when the vulvar vestibule is touched with a cotton swab 1, 2
• Lichen sclerosus presents with porcelain-white papules and plaques, causing dyspareunia through erosions, fissures, or introital narrowing 3
• Lichen sclerosus has a bimodal distribution affecting prepubertal girls and postmenopausal women—do not overlook this in young patients 3

Inadequate Lubrication

• Insufficient vaginal lubrication during arousal causes superficial pain with attempted vaginal insertion 1, 2
• This may result from inadequate arousal time, hormonal changes, or medications 6

Structural and Deep Pelvic Causes

Endometriosis and Pelvic Pathology

• Endometriosis causes deep dyspareunia through pelvic inflammation and adhesions 6
• Pelvic masses, uterine retroversion, and adnexal pathology can be identified on bimanual examination 1
• Pelvic adhesions from prior surgery or infection contribute to deep pain 6

Vaginismus

• Vaginismus involves involuntary spasm of the pelvic floor muscles, preventing or causing painful vaginal penetration 1, 2
• This may be noted during examination with insertion of an examining finger or speculum 6

Cancer Treatment-Related Causes

Treatment-Induced Sexual Dysfunction

• Young cancer survivors treated with chemotherapy, radiation, or endocrine therapy frequently experience dyspareunia from vaginal dryness, scarring, and hormonal changes 3
• Pelvic radiation specifically causes vaginal stenosis and fibrosis leading to pain 4
• Body image changes after cancer treatment (surgery, hair loss, weight changes) affect sexual health and contribute to dysfunction 4

Psychological and Relationship Factors

Associated Mental Health Conditions

• Depression may be an important contributing cause, including decreased libido, difficulty with arousal and orgasm, and dyspareunia itself 4
• Women with sexual pain are at increased risk of sexual dysfunction, relationship distress, diminished quality of life, anxiety, and depression 1
• Fear and anxiety about pain during intercourse can perpetuate the pain cycle and interfere with sexual performance 4

Critical Diagnostic Pitfalls to Avoid

• Do not dismiss postpartum dyspareunia as normal—it requires specific treatment as 40% of cases persist beyond 12 months 3
• Do not overlook lichen sclerosus in young patients—it has a prepubertal peak and may be asymptomatic or mistaken for other conditions 3
• Do not assume psychological causes until organic causes are ruled out—the current treatment approach favors an integrated pain model over historical psychologic theories 6
• Do not forget that sexual dysfunction is often multifactorial—physiologic, psychologic, disease-induced, medication-induced, and interpersonal factors frequently coexist 4