What Are Common Causes of Dysparenia?

As many as 3 of 4 women will have pain during intercourse, known as dyspareunia,¹ at some point in their lives.² Dyspareunia has historically been classified as a sexual disorder. After some significant research, it is now treated with an integrated pain-model approach.³

Dyspareunia can occur for myriad reasons, from psychological issues to structural abnormalities,¹ and can cause negative emotional effects and problems in a relationship.⁴ It also can be a sign of a gynecological problem, such as endometriosis, menopause, or ovarian cysts, or it can be caused by sexual response issues, such as a lack of arousal or desire stemming from an array of circumstances.² Patients may complain of a general aching or burning sensation or localized pain or simply express disinterest and dissatisfaction with intercourse, stemming from discomfort.³

SEXUAL RESPONSE ISSUES

These are the most common causes of dyspareunia²:

• Partners who have conditions. If a partner experiences sexual problems, such as an inability to gain or sustain an erection or premature ejaculation, this may create anxiety. If, on the flip side, the partner is taking medication for erectile dysfunction, this can cause painful, prolonged intercourse.²
• Medical/surgical conditions. Conditions, such as arthritis, cancer, diabetes, and thyroid conditions, can indirectly affect the sexual response.²
• Medications. Some antidepressants, antihistamines, antihypertensives, birth control, or sedatives can affect sexual arousal and desire. These can decrease lubrication, potentially making intercourse painful.^2,3 Several pain medications also can decrease the desire for intercourse.²
• Mental state. Negative emotions, such as awkwardness, embarrassment, fear, guilt, and shame, stemming from anxiety, hostility, phobic reactions, or sexual aversions, may result in dyspareunia by decreasing arousal.^2,3 Fatigue and stress may also cause a lack of sexual response.²
• Relationship issues. Discord can contribute to dyspareunia, be it from different levels of desire or tension between partners.^2,3

GYNECOLOGICAL PROBLEMS

Dyspareunia can be a warning sign of many gynecologic conditions that may lead to other problems if not treated,² including the following:

• Insufficient lubrication. Often the result of too little foreplay, insufficient lubrication can also be caused by changes in estrogen levels resulting from breastfeeding, childbirth, menopause, pregnancy, and perimenopause.¹
• Skin disorders. Various skin disorders can affect the genitalia, including the clitoris, labia, and vaginal opening, also known as the vulva.⁵
• Vulvodynia. Some women feel chronic pain that affects the external sex organs, including the clitoris, labia, and vaginal opening.⁵
• Pelvic inflammatory disease. This is an infection of the female reproductive organs usually caused by sexually transmitted bacteria making its way up from the vagina to the fallopian tubes, ovaries, or uterus, causing bleeding or pain during intercourse.⁶
• Endometriosis. This condition occurs when the endometrium, the tissue lining the uterus, grows outside the uterus. It grows most often behind the uterus, in the fallopian tubes, on or under the ovaries, or on the bladder, bowels, or tissues that hold the uterus in place. Rarely, endometrium can grow on the lungs or other parts of the body.⁷
• Adhesions. Pelvic adhesions occur when scar tissue causes internal organs stick together. These adhesions are often the result of more severe stages of endometriosis, previous pelvic infections, or surgeries.⁸
• Ovarian cysts. These are fluid-filled sacs within the ovaries that are usually harmless but can cause severe pain if ruptured. One symptom of ovarian cyst is pain during intercourse, typically on the side of the affected ovary.⁹
• Ectopic pregnancy. When a fertilized egg implants itself someplace other than the uterus, most often the fallopian tube, this is known as an ectopic pregnancy. This can cause pain during intercourse and be life-threatening to the mother.¹⁰
• Sexually transmitted infections. These can include chlamydia, genital warts, gonorrhea, herpes, and syphilis.⁴
• Injury or irritation. This can include injury from an accident or irritation from chemicals, episiotomy, female circumcision, or pelvic surgery.¹
• Congenital abnormality. This is a birth defect, such as an imperforate hymen or vaginal agenesis.¹

WHEN TO SEEK MEDICAL ATTENTION

Pain during intercourse is usually associated with an underlying condition and should be checked by either a gynecologist or primary care provider. Patients may also consult psychiatrists, psychologists, or urologists.

Patients should always see a medical professional if they experience bleeding, discharge following intercourse, or new or worsening pain. Although these symptoms are not usually considered a medical emergency, patients should go to the emergency department or an urgent care facility if they experience more severe or new pain that lasts beyond a few minutes. Also considered an emergency would be bleeding following pain, especially new onset or severe pain. Other symptoms that require emergency treatment are nausea, a new discharge, rectal pain, or vomiting following intercourse.¹¹

TREATMENT

Treatment of dyspareunia depends on the underlying cause. Physical causes are treated with medical mediation; antibiotics or antifungals may be used to clear up infections. If dyspareunia is caused by vaginal dryness, because of hormonal fluctuations, topical hormones such as an estrogen cream may be used.⁵

Psychological causes might require psychotherapy or sex therapy. Some individuals may need to resolve psychological issues dealing with sex, such as guilt, inner conflicts or feelings, or past abuse.⁵

PREVENTION

Kegel exercises can improve vaginal muscle control. Silicone- or water-based lubricants can help prevent vaginal dryness, even if it is the result of hormonal issues. However, caution patients not to use baby or mineral oil or petroleum jelly with condoms, as these can cause condom failure and dissolve latex.²

Avoid or discontinue the use of chemical-based products, such as bubble baths, douches, pantyliners, perfumed soaps, scented or tinted toilet paper, tight synthetic undergarments (eg, hose), or vaginal perfumes.¹¹ Communication between partners is necessary. They should make plans for sex when neither party is anxious, in a negative state of mind, or tired. In addition, discussing when and where the pain is felt, as well as what each partner finds pleasurable, is important.²

Moving toward sexual activities that do not cause pain can be helpful, as can sensual—not sexual—activities, such as massage.2 Also, steps taken immediately before sex can help lessen pain, such as emptying the bladder or taking an OTC pain reliever or warm bath.²

Kathleen Kenny, PharmD, RPh, has more than 25 years of experience as a community pharmacist and is a freelance clinical medical writer based in Colorado Springs, Colorado.

REFERENCES

• Painful intercourse (dyspareunia). Mayo Clinic website. websitemayoclinic.org/ diseases-conditions/painful-intercourse/symptoms-causes/syc-20375967. Accessed March 20, 2019.
• When sex is painful. The American College of Obstetricians and Gynecologists website. acog.org/Patients/FAQs/When-Sex-Is-Painful. Published September 2017. Accessed March 20, 2019.
• Heim LJ. Evaluation and differential diagnosis of dyspareunia. Am Fam Physician. 2001;63(8):1535-1544.
• Sexual health: female pain during sex (dyspareunia). Cleveland Clinic website. my. clevelandclinic.org/health/diseases/12325-sexual-health-female-pain-during-sex-dyspareunia. Updated November 6, 2018. Accessed March 20, 2019.
• What women need to know about pain during sex. Cedars-Sinai website. blog.cedars-sinai.edu/pain-during-sex/. Accessed May 10, 2019.
• Pelvic inflammatory disease (PID). websitemayoclinic.org/diseases-conditions/pelvic-inflammatory-disease/symptoms-causes/syc-20352594. Accessed April 9, 2019.
• US National Library of Medicine. Endometriosis. MedLine Plus website. medlineplus.gov/endometriosis.html#summary. Updated March 18, 2019. Accessed April 9, 2019.
• UNC School of Medicine. Pelvic adhesions (scar tissue). UNC Department of Obstetrics and Gynecology website. med.unc.edu/obgyn/patient_care/specialty-services/ migs__trashed/our-services/pelvic-adhesions-scar-tissue/. Accessed April 9, 2019.
• US Department of Health and Human Services. Ovarian cysts. Womenshealth.gov website. womenshealth.gov/a-z-topics/ovarian-cysts. Updated April 1, 2019. Accessed April 9, 2019.
• Ectopic pregnancy. American Pregnancy Association website. americanpregnancy. org/pregnancy-complications/ectopic-pregnancy/. Updated July 20, 2017. Accessed April 9, 2019.
• Painful intercourse (sex). E-medicine-health website. emedicinehealth.com/ pain_during_intercourse/article_em.htm. Accessed March 20, 2019.