Painful sex (the unintentional kind) can make life and relationships less satisfying. Sex is not a necessity–it is not like oxygen, food, or shelter–but it is important to many women.
“Dyspareunia” is the medical term for painful sex, and it is a common problem. Many women are embarrassed to discuss this with their healthcare providers. If this is an issue for you, you are not alone! Let’s talk more about this important issue.
There are two main categories of dyspareunia, deep and superficial. I will discuss each of these separately.
Deep dyspareunia means that the pain is deep in the pelvis, almost like a belly ache. Gynecologic conditions such as ovarian cysts can cause this kind of pain, but other organs live in close proximity including intestines, bladder and even muscles. Other potential causes of temporary pain include severe constipation and bladder infections. If you have pain and it goes away or occurs every once in a while, do not worry. If you have persistent dyspareunia, there are a few possible causes that should be considered:
Endometriosis. This tends to be a deep ache and is worse with certain positions. It is progressive, getting worse over time, and often persists for hours or even days after sex is finished. If this describes you and you also have very painful periods, you should be evaluated for endometriosis.
Myofascial pain. This is best described as a spasm of the muscles around the vagina and also tends to be progressive. I have had many patients that have had an instigating event such as complicated child birth, rough sex, assault, or perhaps just sex while unlubricated. They subsequently anticipate pain, sometimes unconsciously, and this leads to pelvic floor tension and pain. This type of dyspareunia responds very well to pelvic floor physical therapy. Yes, really.
Infection. Women with Pelvic Inflammatory Disease (PID) may have dyspareunia as their first symptom. PID is often accompanied by vaginal discharge, sometimes fever and malaise, and is a serious condition that requires immediate attention. In the past, we were taught that it was caused by an STD such as chlamydia or gonorrhea. Although these infections are still prominent in women with PID, this condition can occur in the absence of STDs.
Superficial dyspareunia describes pain in the vagina or vulva (external genitalia) and is more common in women who have gone through menopause. Instead of deep aching, a burning sensation is more common.
In younger women, superficial dyspareunia can be due to a yeast infection. However, there are other vulvar conditions that can mimic yeast and cause burning during sex.
Lichen sclerosis is an autoimmune condition that can affect both younger and older women. The skin of the vulva is thin and dry, described as “parchment-like.” There can be fissures and tearing of the skin making it feel itchy or like paper cuts.
Herpes can cause similar stingy pain. A big difference is that lichen sclerosis is more gradual and progressive versus herpes is more sudden and dramatic, with symptoms sometimes developing overnight.
Vulvodynia is the medical term for a painful vulva. Like the word “headache,” it describes a symptom but does not tell us the cause of the symptom. If you have persistent pain on the outside of your vagina, whether it is triggered by tight clothing or prolonged sitting or sex, you may have one of the many types of vulvodynia. This is a complicated condition. I’ll need to do another blog post just about vulvodynia.
In women over 50, the most common cause of superficial dyspareunia is low estrogen, most often due to menopause. We call this “atrophic vaginitis” and it is characterized by shiny, thin fragile skin. Unlike other menopausal symptoms (think hot flashes), this is something that typically does not start until years after menopause and gets progressively worse with time. Fortunately, it responds very well to topical estrogen. If you are not able to take estrogen, there are still other effective treatments.
Whether your pain is deep or superficial, please do not feel you need to suffer through sex or eliminate intimacy from your life. There are a lot of options. Speak up and let your provider know if this is something that bothers you! Feel free to contact me with questions.