Painful sex (dyspareunia)

What is painful sex (dyspareunia)?

This refers to pain felt in the pelvis or vagina during sex, which can sometimes last up to 24 hours afterwards. It is common but under-reported by women.

What is the cause of painful sex?

• Vaginismus
  This is a condition where vaginal muscles involuntarily contract when penetration is attempted. Although this does not affect sexual arousal, it can prevent penetration from happening. This may be linked with past trauma or emotional factors.

• Insufficient lubrication
  Lack of foreplay, rough sex or sex toys can result in insufficient vaginal lubrication which causes sex to be painful.

• Pelvic inflammatory disease
  This is a condition where there is inflammation of a woman’s uterus, fallopian tubes and ovaries, usually caused by an infection that spreads upwards from the vagina and cervix.

• Endometriosis
  Tissue from the womb lining is found outside the womb, most commonly in the pelvis, where it can affect the ovaries, fallopian tubes and intestines. These tissue respond to hormonal changes and bleed during periods, causing pain and inflammation. The resultant scarring can cause a women to feel pain during deep penetration.

• Vagina scarring or abnormalities
  Scarring from an episiotomy/tear following childbirth or previous vaginal surgery may cause sex to be painful. Certain abnormalities of the vagina e.g. abnormal covering or septum may also result in painful sex.

• Chronic pelvic pain
  This refers to pain in the pelvis that lasts for 6 months or longer, and can manifest in painful sex.

• Menopausal changes (atrophic vaginitis)
  Menopause women have low estrogen which causes thin and dry vaginal skin (vaginal atrophy).

• Pelvic organ prolapse
  This refers to a drooping of the uterus, bladder or rectum beyond the vagina, and is more common in older women with previous childbirth. The sagging pelvic organs can cause a woman to feel discomfort during sex.

• Bladder pain syndrome
  Previously known as interstitial cystitis, this is a condition involving bladder discomfort or pain associated with urinary symptoms which can also manifest in painful sex.

What complications can dyspareunia cause?

It can result in an inability to have sex, which in turn may lead to relationship strain and difficulty in getting pregnant. It can also impact on one’s psychological well-being and self-esteem.

What tests do I need?

Your gynaecologist will take a detailed medical history and perform a gentle pelvic examination with your permission to check your vagina and pelvic organs. Depending on your symptoms, you may require an ultrasound scan and vaginal swabs.

How can my painful sex problem be treated?

Treatment options depend on the cause of dyspareunia. Vaginismus therapy typically involves sex counselling, with education of your anatomy, involved muscles and what happens at arousal, foreplay and intercourse. This may involve your partner, relaxation techniques and working on other forms of sexual intimacy first e.g. oral sex, sensual massage and mutual masturbation with gradual progression. Infections will need to be treated with antibiotics. Treatment of endometriosis will depend on severity of other symptoms, stage of endometriosis, and fertility plans. Vaginal scarring and abnormalities may require surgery. Menopausal changes (atrophic vaginitis) can be treated with topical vaginal estrogen creams and tablets. Painful bladder syndrome will need lifestyle and dietary modifications and sometimes medications.