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Painful Intercourse in Women: What Causes Dyspareunia?


Painful sexual intercourse is a common but poorly understood and frequently neglected female health problem affecting one’s quality of life, personal relationships, and self-image.

What is dyspareunia?

Dyspareunia (dys (Greek) – bad, ill; pareunia (Greek) – sexual intercourse) is a medical term describing the condition and characterized by recurrent or persistent pain occurring before, during, or after sexual contact with attempted or complete vaginal entry. It affects 10-28% of women worldwide in a lifetime, and the prevalence of dyspareunia varies from 10 to 20% in the United States.

Dyspareunia may stem from a single or multiple overlapping factors. These factors can be categorized into physical and psychosexual conditions. Moreover, painful symptoms may exist from the first sexual experience (primary dyspareunia) or may begin after some pain-free sexual activity period (secondary dyspareunia).

Physical causes

Gradually increasing symptoms are indicative of physical or anatomical causes. Detailed anamnesis, including age and menstrual status (premenopausal or postmenopausal), pregnancy, and birth history, may guide in identifying underlying reasons for the pain.

Depending on the origin of the pathology, pain could be located closer to the vaginal entry (superficial pain) or in the pelvic or abdominal region (deep pain). Construction or obstruction of vaginal orifice and decreased lubrication are the most common reasons for superficial pain. Pathologies involving abdominal and pelvic organs, including reproductive, digestive, and urinary system organs, result in deep pain during sexual intercourse.

Gynecological factors causing superficial pain:

  • Anatomical factors: Congenital malformations of the external genitalia and thick hymen are the anatomic factors causing primary dyspareunia. Missed or neglected management of these conditions may result in psychological difficulties in future sexual experiences. Anatomical changes causing superficial pain may also occur later in life due to cervical and vulvovaginal malignancies and cancer treatments, including surgeries, chemotherapy, and radiation. Pelvic organ prolapse is another anatomical cause of painful intercourse and presents as a protrusion of neighboring organs, such as the bladder, bowel, and uterus, towards the vagina.
  • Vaginismus: Vaginismus is an involuntary spasm of pelvic floor muscles surrounding the vagina. It results in pathologic tightness of the vaginal wall in response to some or all types of vaginal penetrations making the activity impossible or painful. Women with vaginismus may experience genital pain or report fear of vaginal penetration or pain. Prevalence of the condition in clinical settings varies between 5-17%. Although most psychological and organic pathologies have been implicated in the etiology of the vaginismus, none of them have been empirically supported.
  • Postpartum dyspareunia: This is female sexual pain occurring in 35% of women after childbirth and is the most common sexual disorder in the postpartum period. Episiotomy incision, lacerations, and perineal rupture can result in sclerotic healing. Moreover, hormonal changes, lactation, fatigue, depression, and body image disorders may also aggravate initial factors.
  • Vulvovaginal infections (yeast, viral, bacterial): These infections are associated with abnormal discharge or odor. Local skin disorders (lichen sclerosis, lichen chronicus) presented with abnormal skin color, erosions, and scarring can also be linked to female sexual pain.
  • Vaginal dryness: Intact vulvar and vaginal anatomy is not enough for an uneventful sexual experience. Estrogen is a female reproductive hormone and maintains tissue elasticity and lubrication during intercourse. Reduced estrogen production or antiestrogen therapy may result in vaginal dryness, increasing discomfort and pain during vaginal penetration. Vaginal dryness and vulvovaginal atrophy are components of genitourinary syndrome of menopause and are closely associated with postmenopausal dyspareunia.

Gynecological factors causing deep pain:

  • Endometriosis/Adenomyosis: Endometriosis is a complex inflammatory and hormonal condition occurring when the endometrium, the uterus's inner layer, is located outside of the uterus. Since this tissue is an active uterine tissue, it shows the same bleeding pattern during menstrual shedding, i.e., endometriotic lesion bleeds locally and attracts inflammatory cells and cytokines to the region. Pain observed in endometriosis may vary from mild to extremely severe depending on the location of the ectopic tissue and degree of dissemination. Adenomyosis is another condition with aberrant localization of endometrial tissue causing dyspareunia; in this case, ectopic tissue does not leave the uterus; it only moves into deep layers.
  • Ovarian and uterine lesions, including ovarian cysts, uterine fibroids, and tumors, can also result in painful intercourse.

Other conditions

Medical conditions causing female sexual pain are not limited to gynecological pathologies. Regional pain disorders such as pudendal neuralgia and sacral nerve dysfunction can result in superficial pain. Inflammatory conditions of urinary (interstitial cystitis/bladder pain syndrome (IC/BPS), urinary tract infections) or digestive tracts (irritable bowel syndrome (IBS)), muscular abnormalities (pelvic floor muscle spasm, fibromyalgia) are among possible reasons for deep dyspareunia.

Psychosexual causes

The sudden onset of female sexual pain symptoms is suggestive of psychosexual causes. Chronic pelvic pain is significantly associated with a history of depression, somatization, and chronic psychological distress. Devalued self-image, feeling "inadequate" as a woman or as a "failure," embarrassment, and shame about the genital self-image may also contribute to the depressive symptoms in women with dyspareunia. History of physical or sexual abuse is another contributing factor in vaginismus and dyspareunia etiology; based on a recent report, sexual abuse causes a 53% increase in dyspareunia and a 55% increase in vaginismus.

Key take-aways

  • Painful sexual intercourse is a common female health problem.
  • Dyspareunia may stem from a single or multiple overlapping factors categorized into physical and psychosexual conditions.
  • Female sexual pain or dyspareunia should be considered an essential part of medical evaluation; women should be encouraged to discuss any concerning moment with their physician to avoid factors affecting personal and sexual life quality.

References:

Banaei, M., et al., Prevalence of postpartum dyspareunia: A systematic review and meta-analysis. Int Gynaecol Obstet.

Cowan, F. and L. Frodsham, Management of common disorders in psychosexual medicine. The Obstetrician & Gynaecologist.

Gross, E. and L. Brubaker, Dyspareunia in Women.

Holanda, J.B.d.L., et al., Sexual dysfunction and associated factors reported in the postpartum period. Acta Paulista de Enfermagem.

Lahaie, M.A., et al., Vaginismus: a review of the literature on the classification/diagnosis, etiology and treatment. Womens Health.

Lee, N.M.W., et al., Dyspareunia. Bmj.

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