Painful Sex Dyspareunia

Painful Sex Dyspareunia

What is dyspareunia?
Dyspareunia is the term used to describe pain before, during or after vaginal intercourse. Pain with intercourse affects about 8-22% of women and is more likely to occur in younger women, mainly in the 16-39 year old age group. Postmenopausal women can also experience dyspareunia, due to changes to their vaginal walls, increased vaginal dryness and narrowing of the vaginal opening.

Women often keep silent about experiencing pain during vaginal intercourse because they feel they have a duty to meet their partner's sexual needs and/or may be embarrassed to discuss the issue with their partner or health practitioner. If dyspareunia is not managed, it may result in a loss of sexual interest, mood changes and other psychological symptoms.

Types of dyspareunia
There are two main types of dyspareunia, which are classified according to the site of pain.
Superficial Dyspareunia is pain on attempted penetration. This may be due to size disparity (the erect penis is too large for the vaginal entrance), an intact or thickened hymen, or vaginismus (spasm of the pelvic floor muscles that causes temporary narrowing of the vagina).
Deep Dyspareunia is pain at the top of the vagina related to thrusting, often associated with pelvic disease, e.g. endometriosis.
Pain can include burning, tearing or aching sensations.

What causes dyspareunia?
There are many physical and psychological causes of dyspareunia, with the cause of the pain depending on its location.
Entry pain:
Insufficient lubrication: when a woman is sufficiently aroused (-turned on'), her vagina and glands around the vaginal entrance secrete fluids that reduce friction and allow penetration without pain. If you are not sufficiently aroused before attempting penetration, you may feel dry and experience a stinging, burning, tearing or throbbing sensation.
Insufficient lubrication can also be caused by a drop in oestrogen levels, which occurs after menopause, after childbirth and while breast-feeding. After menopause, the vaginal and vulval skin thins and loses elasticity. This can lead to narrowing of the vaginal entrance, causing pain with penetration.
Emotional and psychological factors, as well as certain medications, can affect your libido (sex drive), which can also impact on arousal and lubrication.

Inflammation, infection or skin disorder: infections of the genital area or urinary tract can cause painful intercourse. Skin problems include eczema, lichen sclerosis, psoriasis, vulvar vestibulitis and -thrush'.

Vaginismus: involuntary spasms of vaginal wall muscles. This creates a feeling of tightness that makes penetration painful, difficult and at times impossible. Vaginismus can occur for many reasons, including fear, anxiety, stress, partner issues, inadequate sex education or abuse.
Triggers may include trauma during childbirth or surgery, endometriosis, recurrent urinary tract infections, or past history of traumatic events. Deep pain…

Illnesses or conditions: including endometriosis, adenomyosis, pelvic inflammatory disease (PID), ovarian cysts, irritable bowel syndrome, uterine prolapse, uterine fibroids, cystitis and haemorrhoids.

Infections: of the cervix, uterine (fallopian) tubes or uterus.

Surgeries or medical treatments: scars from surgeries in the pelvic area such as hysterectomy, vaginal repair for prolapse or episiotomy for childbirth, or medical treatments such as chemotherapy or radiation therapy.

Emotional factors
Feeling stressed, self-conscious, depressed or afraid of intimacy can affect your libido and make sex painful.
Sometimes dyspareunia begins as a physical problem but subsequently affects your mental wellbeing and relationships, causing stress and anxiety. Some women with dyspareunia may have a history of trauma including sexual or emotional abuse.

How is dyspareunia diagnosed?
Medical history: Your doctor may ask questions such as when the pain began, what triggers it, how it feels and if it occurs with every sexual experience. Your sexual history, surgical history and childbirth experiences may also be relevant.

Pelvic examination: This is a physical examination where your doctor will check for signs of infection, irritation or anatomical problems. This may involve gently touching the genital and pelvic area to locate the site of the pain and inserting a speculum into the vagina.

Further tests: You may need further tests such as pelvic ultrasound or laparoscopy if the cause is a condition inside the pelvis. A laparoscopy is a surgical procedure where a small incision is made in the pelvic wall and a thin viewing instrument (laparoscope) is inserted to view the pelvic organs.

How is dyspareunia treated and managed?
The right treatment depends on the cause of the pain. If the dyspareunia has a physical cause, treating underlying medical conditions may alleviate the pain. In postmenopausal women, lack of lubrication can often be treated with oestrogen therapy, by using a cream, pessary or vaginal tablet.

Treatment options for dyspareunia caused by psychological factors will often include some sort of individual, couples or sexual counselling. If you are in a relationship, encourage your partner to be involved in your treatment, particularly the counselling sessions.

For some women, the solution may be a change in sexual techniques. Trying different sexual positions, engaging in longer or different types of foreplay and using a personal lubricant may help reduce pain.

Pelvic floor physiotherapy can often help by using hands-on techniques such as trigger point therapy and gentle soft-tissue massage in the pelvic area and in the vagina. Physiotherapists can teach specific relaxation techniques and pelvic floor awareness exercises to help reduce over-activity of muscles and therefore decrease pain.

How can I prevent dyspareunia occurring?
To prevent painful sex depends on the potential cause. There are things you can do to help prevent some causes of painful sex, which include sensitivity foreplay to increase natural lubrication, using oestrogen preparations if post menopausal, using lubricants, and practising safe sex to prevent STIs, which may cause dyspareunia.

Seeking help
If you are experiencing painful sex it is important to seek help from your health practitioner and receive appropriate treatment and/or management at the earliest time. Seeking help early can also reduce the risk of further impact on your sexual relationships.

Where can I find more information?– Sexual Health Australia Gynaecological Awareness Information Network

Published with the permission of the Jean Hailes Foundation for Women's Health

Tollfree number 1800 151 441 for women seeking further health information