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The Female Body
|What Is Dyspareunia?
If a woman experiences vaginal pain during or after sexual intercourse she is said to suffer from dyspareunia (painful sexual intercourse). About 1 in 5 women will suffer from it at any given time and nearly all women will experience it at some point in their life. Pain during sex results from when there is not enough lubrication on the walls of the vagina to relieve friction between the vagina and penis. Or it can occur when penetration puts pressure on abnormal tissue deep within the vagina - for example, if the woman has endometriosis (painful growths of tissue). Treatment is determined by the underlying cause.
What Are The Symptoms?
• Pain occurs during or after penetration. It may be limited to the vulva area (entrance to the vagina) or spread deep into the vaginal canal. Pain is not usually severe enough to prompt the woman to seek medical attention.
• Women are more likely to complain of pain during intercourse, although some experience pain after and others complain of pain at both times.
• Women with dyspareunia are more likely to report pain when inserting a tampon or having a pelvic examination.
Your doctor will ask you to describe the exact type of pain you experience, this will help to diagnose the underlying cause. For example, he will want to know if the pain starts on entry or only when thrusting begins.
What Is The Cause?
There are many different possible causes, but identifying the location of the pain can help reduce the possible options.
Entry pain is associated with:
Not enough lubrication: Commonly caused by a drop in estrogen levels after menopause, childbirth or while breastfeeding. One study found that 45 percent of postpartum women experienced painful intercourse. Certain medications can also interfere including high blood pressure drugs, certain contraceptive pills and antidepressants.
Skin problems: Eczema and other skin disorders.
Inflammation and infections: caused by vaginitis, urinary tract infections, cystitis and interstitial cystitis.
STDs: Sexually transmitted diseases such as gonorrhea, chlamydia, herpes, genital warts and trichomoniasis can cause painful intercourse. Or it may be due to an allergic reaction to spermicides, condoms, diaphragms or vaginal deodorants.
Trauma: After an episiotomy or trauma to vaginal tissues after radiation therapy for a gynecological cancer.
Vaginismus: Relatively uncommon problem, this is where the muscles of the vagina spasm making penetration nearly impossible. It is more common in women who rarely have intercourse.
Deep pain is associated with:
Gyno Problems: Gynecological disorders such as uterine fibroids, ovarian cysts, endometriosis, pelvic inflammatory disease (PID), cystitis and uterine prolapse.
Surgery: Surgery that involved in the pelvic area such as hysterectomy can sometimes cause painful intercourse.
How Doctors Categorize It
Conditions Associated with Entry and Deep Dyspareunia
• Vulvodynia (chronic pain of the vulva).
• Vulvar vestibulitis (vulvodynia localized in one specific part of vulva).
• Vaginismus (vaginal muscle spasm).
• Vaginitis (inflammation of the vagina due to infection).
• Urethritis (inflammation of urethra which causes pain when urinating).
• Rarely, vulva cancer. See, symptoms of vulva cancer.
• Endometriosis (abnormal growths of endometrial tissue).
• Uterine polyps: Growths in the womb.
• Pelvic adhesions (scar tissue developing on the pelvic organs).
• Retroverted uterus (womb is tilted backwards instead of forward).
• Chronic cervicitis, pelvic inflammatory disease, endometritis.
• Pelvic congestion (caused by varicose veins in the lower abdomen).
• Urethral disorders.
• Ovarian cancer, cervical cancer or vaginal cancer (rarely).
• Inadequate lubrication (typically entry pain).
• Vaginal atrophy (vaginal dryness, thinning and drying of vaginal tissue).
• Postpartum response to childbirth and estrogen levels.
How Is It Diagnosed?
Your doctor will perform a physical and pelvic examination and ask you about your sexual history. If no obvious cause can be found, he may order tests to check for underlying disorders. These tests could include various blood tests, a transvaginal ultrasound, colposcopy and laparoscopy.
Types Of Questions Your Doctor Will Ask
Where (location) do you feel the pain?
When does the pain start? (on entry, vaginal, deep or after).
Does it feel pruritic (itchy), burning or aching?
How long have you felt this pain?
Do you have any other sexual problems such as arousal, lubrication or orgasmic difficulties?
Have you tried any self-treatments?
Exploring Potential Gyno Causes
Is there any vaginal discharge, burning or itching?
Do you have a history of lacerations or episiotomies caused by childbirth?
Have you had surgery or radiation therapy to the area?
Have you ever been diagnosed with fibroids, chronic pelvic pain or endometriosis?
What birth control method are you currently using and have you ever had an IUD device?
Exploring Other Potential Medical Causes
Do you suffer from any chronic disease?
What medications are you taking, including alternative, prescribed and over-the-counter?
Do you have any bowel or bladder problems?
Do you have any skin problems such as eczema, psoriasis or dermatitis?
How do you feel about the problem?
How does your partner feel about it and are you able to discuss the problem?
Is there a history of sexual or physical abuse?
Do you suffer from depression or other any other anxiety disorder?
How A Doctor May Differentiate Between Potential Causes
||Pain on entry, vaginal or deep.
||Unknown it may be caused by another condition listed in this table.
||No specific finding that will differentiate it from another condition.
||Consider psychological evaluation.
||There is well-defined pain on entry; vulva pain, burning, irritation and poor response to prior treatments.
||Often unknown; possibly due to infections or allergic reaction to irritants.
|Mild erythema (redness of skin); highly tender; leukoplakia (sores), ulcerations and raised pigmented lesions.
|Visual inspection with colposcopy. A biopsy of suspicious area may be taken and acetic acid applied to highlight areas.
|Vulvar vestibulitis (subset of vulvodynia)
||There is well-defined pain on entry; painful inflammation of vulvar vestibular area (opening lip of the vulva); dull ache, burning or pruritus.
||Flat non-ulcerated areas of red skin (erythema), the intensity varies (comes and goes); very tender to touch.
|Same as above.
||There is well-defined pain on entry; involuntary spasm of muscles making it difficult or impossible to penetrate with a penis, finger or tampon.
||Doctor finds it difficult to insert a speculum for physical examination, there is physical (palpable) spasm of vaginal tissue.
|Physical examination and consider psychologic evaluation based on history.
|Vaginal atrophy or lack of lubrication
||Pain on entry and internally in the vagina. Vaginal dryness, friction, irritation; difficulty and pain with penetration.
|Reduced estrogen levels, arousal difficulty; decreased lubrication; surgery.
|Visual inspection of pubic hair, plumpness of vaginal tissue, identification of fissures (small tears).
|Based on physical examination and discussion of foreplay and arousal sensations.
|Endometriosis and pelvic adhesions
|Deep pain; cyclic pain that comes and goes with the menstrual cycle; complaint of “something being bumped into”
|Unknown for endometriosis; prior surgery/infections can cause pelvic adhesions.
|Patches of unusual tissue.
|Adnexal pathology (a growth or lump)
||Deep pain; may be felt on one side.
||Ovarian cysts; infections.
||Enlarged adnexa (growth), tenderness.
|Retroverted uterus; uterine fibroids.
||Pain occurs on deep penetration.
||Usually occurs when the woman is on top during sexual intercourse.
||Uterus retroverted, prolapsed or enlarged.
||Patient asked to trial different sexual positions.
|Chronic cervicitis; pelvic inflammatory disease; endometritis
||Vaginal discharge, lesions, cervix is friable (easily irritated); uterine and cervix tenderness; area is sore when doctor presses down on it.
|Colposcopy; sample of discharge taken for culture; laparoscopy.
||Post coital ache; deep pain; pelvic pain
||Based on history.
|Urethral disorders; cystitis; interstitial cystitis.
||Need to urinate frequently and urgently.
||Tenderness along urethra or bladder when pressed.
How Is Dyspareunia Treated?
The treatment will depend on the underlying gynecological cause. If an infection is contributing to your pain, it will be treated with medications. Surgery may be required for other causes such as endometriosis, cysts and fibroids. For postmenopausal women suffering from vaginal atrophy, a prescription cream with hormones may be prescribed or a flexible ring that releases small amount of estrogen directly into the vagina (see low libido in menopause). In all instances using lubrication such as K-Y Jelly, Replens, Lubrin or Astroglide can be useful.
Desensitization Therapy: Women with vaginismus can benefit from relaxation exercises practiced at home. Usually a therapist will recommend several different types of exercises that are designed to relax the vaginal muscles making penetration easier. Vaginal dilators may also be used. Doing Kegel exercises with a dilator is in place can produce great results. Psychotherapy or hypnosis may also be helpful.
What are pelvic floor exercises?
How do you do pelvic floor exercises?