Dyspareunia

Dyspareunia or painful intercourse is a common condition that occurs in women. It is a persistent or recurrent genital pain that can occur before, during and after intercourse.

The causes of painful intercourse include structural and psychological problems. The treatment of dyspareunia is aimed at identifying and treating the underlying cause.

Symptoms of painful intercourse (Dyspareunia) include the following:

• Pain only at sexual penetration (entry)
• Pain with every penetration, even when putting in a tampon
• New pain after previously pain-free intercourse
• Deep pain during thrusting
• Burning or aching pain
• Throbbing pain which can last for several hours after intercourse

Physical causes of painful intercourse differ, depending on whether the pain occurs at entry or with deep thrusting. Emotional factors can be associated with many types of painful intercourse.

• Entry pain. Pain during penetration may be associated with a range of factors, including:
• Insufficient lubrication. This is often the result of not enough foreplay. Insufficient lubrication is also commonly caused by a drop in estrogen levels after menopause, after childbirth or during breastfeeding.
• Certain medications are known to inhibit desire or arousal, which can decrease lubrication and make sex painful. These include: antidepressants, high blood pressure medications, sedatives, antihistamines, certain birth control pills.
• Injury, trauma or irritation: This includes injury or irritation from an accident, pelvic surgery, female circumcision or a cut made during childbirth to enlarge the birth canal (episiotomy).
• Inflammation, infection or skin disorder: An infection in the genital area or urinary tract can cause painful intercourse. Eczema or other skin problems in the genital area also can be the problem.
• Vaginismus: Involuntary spasms of the muscles of the vaginal wall (vaginismus) can make attempts at penetration very painful.
• Congenital abnormality: A problem present at birth, such as the absence of a fully-formed vagina (vaginal agenesis) or development of a membrane that blocks the vaginal opening (imperforate hymen), could be the underlying cause of dyspareunia.
• Deep pain: Deep pain usually occurs with deep penetration and may be more pronounced with certain positions. Causes include:
• Certain illnesses and conditions: The list includes endometriosis, pelvic inflammatory disease, uterine prolapse, retroverted uterus, uterine fibroids, cystitis, irritable bowel syndrome, hemorrhoids and ovarian cysts.
• Surgeries or medical treatments: Scarring from pelvic surgery, including hysterectomy, can sometimes cause painful intercourse.

Medical treatments for cancer, such as radiation and chemotherapy, can cause changes that make sex painful.

Emotional factors

Emotions are deeply intertwined with sexual activity and may play a role in any type of sexual pain. Emotional factors include:

• Psychological problems: Anxiety, depression, concerns about physical appearance, fear of intimacy or relationship problems can contribute to a low level of arousal and a resulting discomfort or pain.
• Stress: The pelvic floor muscles tend to tighten in response to stress in life. This can contribute to pain during intercourse.
• History of sexual abuse: Most women with dyspareunia don't have a history of sexual abuse, but if a woman has been abused, it may play a role.

Sometimes, it can be difficult to tell whether psychological factors are associated with dyspareunia.

Initial pain can lead to fear of recurring pain, making it difficult to relax, which can lead to more pain. As with any pain in the body, a woman might start avoiding the activities that are associated with the pain.

For the diagnosis of painful intercourse, doctors require a thorough medical history which can help to identify:

• when the pain started,
• the exact location of pain,
• the intensity of the pain,
• whether it happens with every sexual partner and different sexual positions.

Doctors may also require for a sexual history, surgical history, and previous childbirth experiences. A pelvic examination is also important for the diagnosis of painful intercourse.

It allows doctors to check for signs of skin irritation, infection or anatomical problems that may be causing this condition. Pressure may also be applied to the genital and pelvic muscles to identify the exact location of pain.

A visual exam of the vagina may also be performed. A speculum, an instrument that helps to separate the vaginal walls can be used during this examination.

Some women may experience pain during this exam. Doctors may stop this exam if the pain intensifies or is unbearable. Another test that can be used is a pelvic ultrasound.

Treatments for painful intercourse include:

• Medications. Most postmenopausal women may experience dyspareunia due to low estrogen levels. For this reason, they may be recommended to take topical estrogen that can be applied directly to the vagina to increase lubrication. Another drug that can be given to women with inadequate lubrication is ospemifene (Osphena). It acts like estrogen on the lining of the vagina. However, it lacks the estrogen harmful effects on the breasts and lining of the uterus. Adverse effects of ospemifene include hot flashes and an increased risk of having stroke and blood clots. Another drawback for this drug is that it is expensive.                                                                                                                                                                                                

• Different types of therapy including desensitization therapy and counseling or sex therapy.                                                                                
  • Desensitization therapy includes helps women to learn  vaginal relaxation exercises that can help to reduce pain. Pelvic floor exercises (Kegel exercises) may be recommended.                                    
  • Sex therapy and counseling may be required for women who may experience negative emotional response to sexual stimulation even after treatment. Negative emotional response to sexual stimulation mostly occurs in women who have been experiencing painful intercourse for a long time. Talking to a counselor and improving communication with a sexual partner can help to resolve these issues.                                                                            
  • Cognitive behavioral therapy can also be helpful in changing negative thought patterns and behaviors.

Lifestyle modifications are necessary in order to cope with painful intercourse (dyspareunia).

Pain can be minimised by making a few changes to the sexual routine. These changes may include:

• Switching to more comfortable positions. Some women who experience sharp pain during thrusting, due to the penis striking the cervix or stressing the muscles of the pelvic floor, may try being on top of their partner. This position may help them to regulate penetration.
• Communication with a partner about what feels good and what doesn't.
• Avoid rushing. Longer foreplay can help to stimulate lubrication. Pain may be also reduced by delaying penetration until a woman is fully aroused.
• Using lubricants that make sex more comfortable.

A woman and her partner may look for other ways to be intimate until vaginal penetration becomes less painful and bothersome.

Other ways to be intimate include sensual massage, kissing, and mutual masturbation.