Understanding and managing painful sex (dyspareunia)

Dyspareunia is the medical name for persistent painful sexual penetration, whereby any attempt to penetrate the vagina causes pain. This pain, either with vaginal penetration or without, causes distress and can impact relationships, quality of life, and sexual function.

Dyspareunia affects 1-2 out of every 10 women and people with vaginas. The cause of this pain can vary quite widely between people, from a tight pelvic floor to endometriosis.

Dyspareunia can be rooted in a physical or psychological cause, or both. One of the major goals is figuring out the underlying cause so effective treatment and support can be provided.

Symptoms of dyspareunia

• Dyspareunia is the symptom
• Genital pain before, during or after sexual penetration
• No obvious cause (e.g. lack of lubrication)
• Pain is persistent (meaning, not a one-off)

Who gets dyspareunia?

Dyspareunia may appear in those with an otherwise healthy and happy sex life, great relationships and good emotional and mental health, and may be a physical symptom of another condition.

It can also be psychological, but it can combine many factors. We are not divorced from our bodies; they work as a functioning unit.

Diagnosis of dyspareunia

First, physical causes will be examined. This includes an examination of the pelvic floor muscles, which can contract involuntarily, called vaginismus, and some testing to determine the nature of the pain, its triggers and severity.

• A diagnosis is made based on recurrent or persistent genital pain before, during or after sex that doesn’t have an obvious cause. Obvious causes may be a lack of lubrication, trying to put something too big into something too small, or another finding.
• The dyspareunia needs to be established as acquired or ‘just born with it’ (congenital), and generalised (complete) or dependent on the situation you find yourself in, such as only sex with a particular partner.
• The pain will be examined: is it deep or just on the surface, and is it just at the vaginal opening or right inside?
• Onset of symptoms: a gradual increase in symptoms is more likely to be physical or anatomical, while sudden onset is more likely to be psychosexual

There has been some debate as to whether dyspareunia should be classified as a pain disorder or a sex disorder, with an acknowledgement of a pain disorder taking away the stigma from ‘women’s hysteria’.

Causes of dyspareunia

Causes of congenital dyspareunia

These symptoms occur only with the first attempts at penetration and don’t appear suddenly later on after a successful sex life.

• Vaginal septum (a partition in the vaginal structure)
• A thick hymen
• Hypoplasia of the introitus (a very small, underdeveloped vaginal opening)
• Differences in anatomy

Causes of acquired dyspareunia

These symptoms could occur after a happy and fulfilling sex life and creep up over time.

• Endometriosis, which causes inflammation in the pelvis with adhesions
• Pelvic floor dysfunction
• Inadequate lubrication
• Infection with yeast, chlamydia, trichomoniasis, urinary tract infections or pelvic inflammatory disease
• Vulvodynia (vulva or vulvovestibular pain)
• Uterine fibroids
• Atrophic vaginitis)
• Interstitial cystitis (IC or ‘painful bladder syndrome’)
• Uterine prolapse
• Lichenoid condition
• Female genital mutilation has resulted in a small vaginal opening, made worse by scarring
• Episiotomy (too tight post-birth vaginal stitches)
• Postpartum dyspareunia
• Bowel disease
• Ovarian cysts with deep pain
• Retroverted uterus
• Vaginismus (involuntary contractions of the pelvic floor)
• Dyspareunia is often the first sign of interstitial cystitis (IC), a painful bladder condition

Psychosexual causes of dyspareunia

• Previous trauma of any kind
• Fear and anxiety
• Unhappy relationships
• Sexual arousal disorders (could be physical or psychosexual)

Classifications of sexual pain

Sexual pain is categorised into vulvar pain (at the entrance of the vagina or in the vaginal lips), vaginal pain, or deep pain. It is often a combination of all three.

There may be subtypes of dyspareunia, with VVS the most common type among premenopausal women, along with deep dyspareunia or pelvic pain associated with ovarian cysts, endometriosis and pelvic adhesions.

Vulvar or vaginal atrophy occurs typically postmenopause. Issues might be caused by inflammation or congestion.

Understanding subjective pain

With dyspareunia, there may be a complex set of subjective symptoms. Subjective means that you describe them using words or drawings rather than them being measurable by any particular test.

Pain is one of those things we can sometimes make worse or better just by thinking it away, and dyspareunia is unfortunately often categorised in this way. Meaning, it could be all in your head! The brain is a powerful protector, even when it’s not doing what you want, and it tells the body what to do.

With anxiety, vaginal lubrication and dilation aren’t employed, resulting in a dry, tight vagina due to a tight pelvic floor muscle. This makes sex painful and dry, unpleasant at best, excruciating at worst.

The expectation of pain is also cited as the cause in some cases, so if something painful happened previously, you expect the pain, and voila, then it comes.

Treating dyspareunia

A clear discussion with a good and supportive doctor and pelvic physiotherapist is a good first step. Feel comfortable that your practitioner knows all the details and believes you are experiencing these symptoms.

Dyspareunia is almost always a temporary condition. Treatment advice may include learning how to touch yourself, figuring out what the triggers are and avoiding them if possible, sex therapy with or without a partner, and psychological care.

All of these are designed to loosen you up, lubricate you and get you ready to be penetrated (painlessly). Investing in some good-quality lubricant, using it liberally, and replenishing it often is smart. If the pain is in deep penetration, a change of position may be suggested.

Botox injections into the area may be an option.

Pelvic floor physical therapy is a first-line response when a tight pelvic floor is found. Where a hypertonic pelvic floor is found, ensuring adequate hormone levels using functional medicine reference ranges, including, importantly, progesterone (which relaxes the pelvic floor), may be useful.

See a My Vagina practitioner for 100% holistic clinical support.

Treating vaginal infections as a cause of pain

If you have an infection, proper testing and treatment are essential to clear it and restore a healthy vaginal and bladder microbiome. See your healthcare provider for support.

Vaginal atrophy and genitourinary symptoms of low estrogen (menopause, trans men on T, etc.)

If you have vaginal atrophy due to low estrogen levels, there are a handful of good options to explore. Fennelope and EstroBoost are 100% natural options that affect only the vaginal tissue.

Your doctor can prescribe estrogen cream or systemic estrogen support. Talk to your healthcare provider for advice.

Nonconventional therapies for addressing painful sex

There are a lot of non-conventional practitioners – highly trained and experts in their fields – who would be happy to help you.

Try pelvic physiotherapists, acupuncture, reflexology, herbal medicine, traditional Chinese medicine (TCM), osteopathy, or EFT/NLP.

References^​1–6​

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