Dyspareunia · What Is It, Causes, Signs, Symptoms and More

Assigned Female at Birth 

A common cause of dyspareunia in those assigned female at birth includes hormonal changes such as those that occur during menopause or while breastfeeding. Estrogen is responsible for the lubrication and elasticity of the vaginal mucosa, as well as maintenance of the overall integrity of the vaginal tissue. Reduced levels of estrogen occur during both menopause and while breastfeeding. 

Another 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). Additionally, pelvic floor dysfunction or alterations of the vaginal anatomy such as congenital anomalies (e.g., vaginal septum, lower vaginal atresia) and skin conditions (e.g., lichen planus, lichen sclerosus) can also cause dyspareunia. Sometimes the cause of dyspareunia may be unknown or multifactorial, as is the case in vulvodynia (i.e., chronic pain of the vulva).  

Assigned Male at Birth 

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.  

Other 

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.  

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.  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. Inspection of the penis can detect abnormal curvature, which may be more noticeable when erect. The scrotum may also be examined for testicular abnormalities.  

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.  

Pelvic floor dysfunction causing pain may be treated with pelvic floor physical therapy. 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 or vaginismus (i.e., the involuntary contraction of pelvic floor muscles with penetration), 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.