Dyspareunia
Dyspareunia is pain during sexual intercourse.
The pain of dyspareunia may be superficial, occurring in the genital area (in the vulva, including the opening of the vagina), or deep, occurring within the pelvis due to pressure on internal organs. The pain may be burning, sharp, or cramping.
Superficial pain during sexual intercourse has many causes. When women have sexual intercourse the first time, the membrane that covers the opening of the vagina (hymen), if still intact, may tear as the penis enters the vagina, causing pain and sometimes bleeding. When the vagina is inadequately lubricated, intercourse may be painful. (Inadequate lubrication usually results from insufficient foreplay or from the decrease in estrogen levels after menopause.) Inflammation or infection in the genital area (for example, affecting the vulva, vagina, or Bartholin's glands) or in the urinary tract can make intercourse painful. Herpes can cause severe genital pain. Other causes include injuries in the genital area, a diaphragm or cervical cap that does not fit properly, an allergic reaction to contraceptive foams or jellies or to latex condoms, a congenital abnormality (such as a rigid hymen or an abnormal wall within the vagina), and involuntary contraction of the vaginal muscles (vaginismus). Sexual intercourse may be painful for women who have had surgery that narrows the vagina (for example, to repair tissues torn during childbirth or to correct a pelvic floor disorder (see Section 22, Chapter 249)). Taking antihistamines can cause slight, temporary dryness of the vagina. During breastfeeding, the vagina may become dry because estrogen levels are low.
As women age, the lining of the vagina thins and becomes dry because estrogen levels decrease. This condition is called atrophic vaginitis. As a result, intercourse may be painful.
Deep pain after sexual intercourse may result from an infection of the cervix, uterus, or fallopian tubes. Other causes include endometriosis, pelvic inflammatory disease (including pelvic abscess), pelvic tumors (including ovarian cysts), and bands of scar tissue (adhesions) that have formed between organs in the pelvis after an infection or surgery. Sometimes one of these disorders results in the uterus bending backward (retroversion). The ligaments, muscles, and other tissues that hold the uterus in place may weaken, resulting in the uterus dropping down toward the vagina (prolapse (see Section 22, Chapter 249)). Such changes in position can result in pain during intercourse. Radiation therapy for cancer may cause changes in the tissues that make intercourse painful.
Psychologic factors can cause superficial or deep pain. Examples are anger or repulsion toward a sex partner, fear of intimacy or pregnancy, a negative self-image, and a traumatic sexual experience (including rape). However, psychologic factors may be difficult to identify.
Diagnosis and Treatment
The diagnosis is based on symptoms: when and where the pain occurs and when intercourse began to be painful. To try to identify the cause, a doctor asks the woman about her medical and sexual history and performs a pelvic examination.
Women should abstain from intercourse until the problem resolves. However, sexual activity that does not involve vaginal penetration can continue.
Superficial pain can be reduced by applying an anesthetic ointment and by taking sitz baths. Liberally applying a lubricant before intercourse may help. Water-based lubricants rather than petroleum jelly or other oil-based lubricants are preferable. Oil-based products tend to dry the vagina and can damage latex contraceptive devices such as condoms and diaphragms. Spending more time in foreplay may increase vaginal lubrication. Deep pain may be reduced by using a different position for intercourse. For example, a position that gives the woman more control of penetration (such as being on top) or that involves less deep thrusting may help.
More specific treatment depends on the cause. If the cause is thinning and drying of the vagina after menopause, using a topical estrogen cream or suppository or taking estrogen by mouth (as part of hormone therapy (see Section 22, Chapter 243)) can help.
Inflammation and infection are treated with antibiotics, antifungal drugs, and other drugs as appropriate (see Section 22, Chapter 247). If the cause is inflammation of the vulva (vulvitis), applying wet dressings of aluminum acetate solution may help. Surgery may be needed to remove cysts or abscesses, open a rigid hymen, or repair an anatomic abnormality. A poorly fitting diaphragm should be replaced with one that fits and is comfortable, or a different method of birth control should be tried.
If the cause of pain is the position of the uterus, a pessary, which resembles a diaphragm and is inserted into the vagina, can support and reposition the uterus. Using a pessary reduces the pain in some women.
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