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Dyspareunia

What Is It, Causes, Signs, Symptoms and More

Author: Lily Guo

Editors: Alyssa Haag, Ian Mannarino, MD, MBA, Kelsey LaFayette, DNP, RN

Illustrator: Jessica Reynolds, MS

Copyeditor: Sadia Zaman, MBBS, BSc

What is dyspareunia?

Dyspareunia refers to recurrent or persistent pain within the genital or pelvic region associated with sexual intercourse. Individuals with dyspareunia experience pain just before, during, or after sexual intercourse, or other sexual activities that involve the genitals. The pain can be mild or severe, generalized or localized, lifelong or acquired, and idiopathic or secondary to another medical condition. 

What causes dyspareunia?

A common cause of dyspareunia in those assigned female at birth includes menopause, which occurs due to reduced levels of estrogen. Estrogen is responsible for the lubrication and elasticity of the vaginal mucosa, as well as maintenance of the overall integrity of the vaginal tissue. Up to 50% of postmenopausal women experience dyspareunia as a result of these lower estrogen levels. Those taking oral contraceptives which contain estrogen and/or progestin may also experience poor lubrication, dryness, and inflammation of the vagina, which may lead to dyspareunia. This is due to the small amounts of exogenous estrogen inhibiting the body’s natural production of estrogen and androgens. An additional cause of dyspareunia is endometriosis, which is a condition that results in endometrial glands and stroma occurring outside the uterine cavity (e.g., in the ovaries and fallopian tube). Alterations of the vaginal anatomy such as congenital anomalies (e.g., vaginal septum, lower vaginal atresia) and skin diseases (e.g., lichen planus, lichen sclerosus) can also cause dyspareunia. 

Causes of dyspareunia in those assigned male at birth include Peyronie disease, which involves scar formation on the tunica albuginea, the fibrous membrane covering the erectile tissue of the penis. This causes a pathological curvature of the penis and results in painful erections and chronic dyspareunia. 

Regardless of genitourinary anatomy, all individuals may experience genitourinary infections (e.g., urethra, prostate, seminal vesicles, or bladder) or sexually transmitted infections (e.g., gonorrhea, chlamydia) that can lead to intense burning, itching, and pain associated with sexual intercourse and ejaculation. Lastly, dyspareunia can be related to psychological factors such as anxiety, depression and low self-esteem.

What are the signs and symptoms of dyspareunia?

The signs and symptoms of dyspareunia in those assigned female at birth include pain at the entrance to the vagina, in the abdomen or near the cervix during initial penetration. Symptoms of dyspareunia in those assigned male at birth may include pain with erection and irritation of the skin on the penis with subsequent rash formation. The pain can be sharp or dull and throbbing in nature. An individual with dyspareunia may also experience burning pains, pelvic cramping, or muscle tightness or spasms. 

How is dyspareunia diagnosed?

Dyspareunia can be diagnosed with a detailed patient history and physical examination. The healthcare professional may look for both physical and psychological origins of pain by asking about the location, duration, and frequency of pain. The physical examination can include pelvic examination and pressure-point testing for individuals with vaginas, where the clinician systematically presses the individual's external anatomy with a moistened cotton swab and assesses for pain. Visual inspection of the labia can detect ulcers, fissures, labial hypertrophy, vaginal agenesis, and imperforate hymen. A colposcope, a tool that magnifies and shines light into the vagina and cervix, can be used to better visualize the anatomy.  Inspection of the penis can detect abnormal curvature, which may be more noticeable when erect. Laboratory testing including vaginal pH, microscopy, and testing for sexually transmitted infections can all help rule out underlying causes of dyspareunia. Transvaginal ultrasound can be used to evaluate for endometriosis, and tissue biopsy may be performed if there is a lesion indicative of underlying malignancy. 

In those assigned male at birth, the physical exam focuses on the genital area and rectal areas with particular attention to the prostate and anal sphincter tone. The scrotum may also be examined for testicular abnormalities. 

How is dyspareunia treated?

The treatment for dyspareunia depends on the underlying cause. If the pain is due to vaginal dryness or a lack of lubrication, water-based lubricants can help during intercourse. If there are secondary causes of vaginal dryness such as menopause, a healthcare provider can prescribe estrogen creams, tablets, rings or other medications. If oral contraceptives are causing dyspareunia, the individual may opt to choose another form of birth control (e.g., intrauterine device, birth control vaginal ring, or condoms). Alterations of vaginal anatomy and Peyronie disease may be treated using surgical approaches, and sexually transmitted infections or urinary tract infections may require the administration of antibiotics. For cases of sexual pain related to psychological conflict, sexual therapy and cognitive behavioral therapy might be helpful. Therapy may help individuals resolve guilt surrounding sexual intercourse, inner conflicts regarding sex, or feelings regarding past abuse.

Can dyspareunia be cured?

Many cases of dyspareunia can be cured. If there is a secondary cause, such as a structural defect (e.g., imperforate hymen, Peyronie disease) leading to painful intercourse, surgery can correct the condition and oftentimes resolve dyspareunia. Those with longstanding dyspareunia associated with an underlying psychological factor may need more extensive counseling to alleviate the symptoms. 

What are the most important facts to know about dyspareunia?

Dyspareunia refers to pain associated with sexual intercourse and is more common in those assigned female at birth compared to those assigned male at birth. Pain occurs as a result of various factors including hormonal changes related to menopause or oral contraceptives, anatomical defects of the vagina and penis, sexually transmitted infections, and psychological reasons. The symptoms of dyspareunia include pain that can be sharp or throbbing in nature, both at the opening of the vaginal canal or deeper in the abdomen. Individuals may experience pain with erection or due to a rash on the surface of the penis. Diagnosis can typically be made on physical examination and dyspareunia treatments can include medication, surgery, and counseling. 

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