Dyspareunia

What is dyspareunia?

Dyspareunia is the medical word for pain which is felt in the genital or pelvic area during or after vaginal sex.

It can be divided into either superficial or deep dyspareunia. Superficial means it is felt on the surface of the genital region. Deep dyspareunia is felt deep in the pelvis. They have different causes and treatments and, although it's possible to experience both at the same time, most women find that their dyspareunia is mostly one type or the other.

Superficial dyspareunia

This is pain felt in the lips (labia) of the vulva, at the vaginal entrance (introitus) and the lower part of the vagina. It typically begins with penetration or very soon after intercourse has begun. It is usually quickly relieved by stopping penetration, although the area may be sore for a while afterwards. The causes of superficial dyspareunia causing painful intercourse (pain during penetration) are usually local problems of the labial, vaginal and perineal skin. The perineum is the area of skin between the vaginal opening and the back passage (anus).

Deep dyspareunia

This is the term for pain felt deep in the pelvis during or after intercourse. It can also spread to involve the front or inner thighs. It may be sharp or dull, may stop when penetration stops or can continue for minutes or even hours afterwards. Deep dyspareunia is usually caused by conditions deep within the pelvis.

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Causes of superficial dyspareunia

• Scar tissue. Scar tissue at the very back of the vaginal entrance (introitus) is common after childbirth, particularly if you have had a cut between the vagina and back passage (anus) - a procedure called episiotomy. The scar tissue contains lots of nerve endings and if it is very sensitive it may cause pain.

• Hymen tissue. The hymen is a thin membrane that lines the vaginal opening. It usually has a hole in it from birth, which gradually enlarges as a child grows and is physically active. Any entering the vagina will break it down further, such as the use of tampons. The first time a woman has intercourse it may be further forced open and this can be painful. The pain is superficial, felt at the entrance to the vagina as soon as penetration is attempted.

• Vaginismus. Vaginismus causes a powerful and often painful contraction of the muscles around the entrance to the vagina, which makes penetration painful or impossible. It may also prevent the use of tampons and any sort of gynaecological examination. The spasm of vaginismus is not something you can cause deliberately; it's completely outside your control. It may seem to begin for no reason but can also result from a painful or worrying experience of sex, when it becomes a kind of protective reflex. In addition, some people may worry about not being able to become pregnant and have children. Vaginismus can be upsetting for both halves of a couple, as it can prevent the enjoyment of sex and can prevent sex completely. Once it has begun, fear of failure and nervousness about not being able to have sex can make it worse. It's important to seek help to break the cycle of anxiety and pain. Your doctor may refer you to a psychologist or a specialist physiotherapist.

• Vulvodynia. This is a very troublesome condition where the vulval area becomes painful and extremely sensitive. It can be accompanied by severe pain on attempted penetration. It can also cause the vulval area to be painful when touched and during activities of everyday living. The causes are uncertain but may involve the nerves in the area becoming much more sensitive than normal and the way the brain communicates with these nerves changing in some way. Treatment includes the use of emollient soap substitutes, creams that numb the area, medicines that lessen pain, physiotherapy and cognitive behavioural therapy.

• Vulval skin disorders. Any skin condition affecting the vulva can cause inflammation or broken areas of skin, which can be painful during sex or if the area is touched. This includes Lichen sclerosus, Psoriasis and Eczema.

• Female genital mutilation. Female genital mutilation (which used to be known as female circumcision) involves varying degrees of mutilating surgery to the genitals of a girl. In the more extreme forms, the vagina is stitched shut. Following genital mutilation there is usually permanent scarring, which may lead to damaged nerves and pain. Any of these issues can cause pain on penetration and may make sex impossible.

• Vaginal abnormalities. Very rarely, abnormalities of the vagina itself make sex painful or even impossible. These include pieces of extra tissue inside the vagina which are present at birth (vaginal septa).

Causes of superficial and deep dyspareunia

• Vaginal trauma and scar tissue. The vagina is pretty flexible and strong and usually recovers well from the stretch and (sometimes) small tears of childbirth. However, more significant injury to the vagina - for example, from difficult childbirth or mutilation - can lead to scarring and then to pain and difficulty during sex (intercourse).

• Vaginal or genital infection. Infections of the vagina or vulva cause inflammation of the tissues and so commonly cause pain during sex. A wide range of infections can infect the vagina and vulva. Some (but by no means all) are sexually transmitted.

See the separate leaflets called Vaginal thrush (Yeast Infection), Genital herpes and Bacterial vaginosis for more details. Some genital infections can cause pelvic inflammatory disease, which is discussed in more detail later in this article.

• Vaginal dryness. Sometimes pain during sex is because the vagina is too dry. Normally, the vagina produces secretions which keep it moist and this natural lubrication when you become sexually aroused. There are many possible reasons for vaginal dryness. It may be that you need more sexual arousal prior to penetration. There can be psychological reasons such as nervousness or anxiety, for example because sex has previously been uncomfortable or anxiety around waking your sleeping children. It can also happen because of physical reasons. Vaginal dryness can be caused by the menopause, medicines, pregnancy, breastfeeding and some auto-immune conditions.

• Vaginal atrophy. After the menopause the levels of hormones in your body fall - particularly oestrogen levels. Oestrogen is the hormone that keeps the vaginal wall strong and resistant. It increases the blood supply and the level of secretions and makes the vagina softer and more stretchy. Postmenopausal women are affected as the vaginal lining becomes thinner, less stretchy and less well lubricated.

See the separate leaflet called Vaginal dryness (Atrophic vaginitis) for more details.

Causes of deep dyspareunia

Deep dyspareunia can be caused by the genital organs themselves but may also be caused by other structures in the lower tummy (abdomen).

• Cervical pain. The neck of the womb (cervix) should not normally be painful. However, if can become infected by many of the organisms which can infect the vagina - particularly herpes. If the cervix becomes inflamed then knocking it with the penis during sex can be painful. The cervix may also become tender and sensitive if you have an intrauterine contraceptive device, particularly if it is sitting a little too low or falling out. This can cause sudden sharp pains in the cervix during sex. (Fortunately cervical cancer is very rare and does not usually cause painful sex.)

• Endometriosis. Endometriosis is a condition in which little bits of womb (uterine) lining become embedded in other areas of the pelvis.

See the separate leaflet called Endometriosis for more details.

• Ovarian cysts. The presence of cysts on the ovaries can cause pain during sex (intercourse). It's not unusual to have cysts on the ovaries, as cyst formation is a normal part of the period (menstrual) cycle. However, these 'physiological cysts' are typically very small and do not cause any pain during sex. Larger cysts can form because of several conditions and are more likely to cause pain during sex. See the separate leaflet called Ovarian cyst. Another, harmless form of pain from the ovary is called 'Mittelschmerz'. This is pain when an egg is released from the ovary. Pain from Mittelschmerz may not be related to sex at all, and typically lasts for two or three days in the middle of the month - but sex may make it worse when it's there.

• Fibroids and growths in the womb. Fibroids are non-cancerous (benign) growths in the muscle of the womb (uterus), which can cause the womb itself to become quite bulky. This is not always painful but it can lead to discomfort during sex. See the separate leaflet called Fibroids.

• Causes related to womb position. In some women the womb (uterus) tilts backwards, rather than forwards; the ovaries then tend to fall backwards too. This can lead to them being knocked in positions involving deep penetration. This can result in deep pain in the pelvis that is more noticeable with deep penetration and which settles slowly when penetration stops or when you change sexual position.

• Bowel pain. During intercourse the bowel is also knocked and moved. If the bowel is sensitive or tender then this can be the origin of pain during sex. This is particularly likely in women who have Crohn's disease, ulcerative colitis or irritable bowel syndrome, all of which are conditions that cause the bowel to be painful.

See the separate leaflets called Irritable bowel syndrome, Crohn's disease and Ulcerative colitis.

• Pelvic inflammatory disease. This is a condition of the Fallopian tubes, the womb and, sometimes, the ovaries. It is caused by infection and makes these organs inflamed. As they tend to move during sex, this is painful. The pain is typically felt deep in the pelvis, is worse with deep penetration and settles slowly when penetration stops. Pelvic inflammatory disease also tends to make you feel unwell, and may cause a temperature and a vaginal discharge.

See the separate leaflet called Pelvic inflammatory disease.

• Bladder pain. The bladder sits on top of your womb, just behind and above your pubic bone. The bladder moves and gets pressed on during intercourse, so, if the bladder is inflamed, this may hurt. Typical causes include urine infections and interstitial cystitis. This is a condition in which the bladder becomes sensitive and painful. It behaves like a urine infection but no infection is present.

Summary

Dyspareunia has many causes. Treatment options usually depend on the cause. It is a good idea to discuss these symptoms early with a healthcare professional so it is less likely to become a long-term issue.

Dr Mary Lowth is an author or the original author of this leaflet.