Dyspareunia in Women

Dyspareunia is persistent or recurrent genital pain before, during or after sexual intercourse. It is common but frequently underreported, as many women feel substantial embarrassment and reluctance in raising it.

It is classified by anatomical location. Superficial (entry) dyspareunia reflects pathology at or near the vaginal introitus. Deep dyspareunia reflects pathology deeper within the pelvis.

This distinction directs the likely causes and the diagnostic and management approach. Assessment must be sensitive and thorough, given the frequently significant impact on quality of life, sexual function and intimate relationships.

Classification and pathophysiology

• Superficial dyspareunia most commonly reflects genitourinary syndrome of menopause (vulvovaginal atrophy), a particularly common cause in postmenopausal women.
• Other causes of superficial dyspareunia are vulvodynia, vulvovaginal infection (including candidiasis and other infective causes) and, less commonly, vulvar dermatological conditions (including lichen sclerosis).
• Vaginismus is involuntary spasm of the pelvic floor and vaginal musculature. It is frequently associated with psychological or relational factors, including previous painful intercourse establishing a self-perpetuating pain-anxiety-spasm cycle or, in some cases, previous sexual trauma.
• Deep dyspareunia most commonly reflects endometriosis, a particularly important and common cause. Pain is often related to the position of penetration, given involvement of the posterior compartment or uterosacral ligament.
• Other causes of deep dyspareunia are pelvic inflammatory disease and its sequelae (including chronic pelvic adhesions), uterine fibroids, ovarian pathology and pelvic floor dysfunction. These causes frequently coexist and contribute in combination.
• Psychological and relational factors contribute across both superficial and deep dyspareunia. They include anxiety, a history of sexual trauma and relationship difficulty.
• In a self-perpetuating cycle, anticipated pain produces protective pelvic floor muscle tension, which exacerbates the pain. Assess these factors sensitively alongside evaluation for any organic cause.

• Characterise the pain location (superficial versus deep), timing (at initial penetration, throughout intercourse, or persisting afterwards) and any relationship to position or sexual activity. This gives essential guidance to the likely cause.
• Superficial dyspareunia from genitourinary syndrome of menopause presents with vaginal dryness, burning and pain at initial penetration, typically in a postmenopausal woman. Examination shows thinning and pallor of the vulvovaginal mucosa.
• Vaginismus presents with involuntary, often severe pelvic floor muscle spasm on attempted vaginal penetration, whether during intercourse, tampon insertion or gynaecological examination. Significant anticipatory anxiety is frequent.
• Vaginismus can substantially impair sexual function and also access to routine gynaecological care and cervical screening. It warrants sensitive, specific clinical attention.
• Deep dyspareunia from endometriosis characteristically worsens with deep penetration, particularly in certain positions. It frequently coexists with other endometriosis-related symptoms (dysmenorrhoea and chronic pelvic pain).
• Deep dyspareunia from pelvic inflammatory disease sequelae or adhesive disease may present as a more constant, diffuse deep pelvic discomfort exacerbated by intercourse.
• The impact on the woman's psychological wellbeing, self-esteem and intimate relationships warrants sensitive, proactive enquiry, as women are often reluctant to raise the concern. A supportive, non-judgmental approach has substantial value.

• A detailed history is the essential foundation of assessment. Explore the characteristics of the pain, and the menstrual, obstetric, sexual and psychological history, and any history of infection, surgery or trauma.
• Conduct the history with particular care, given the personal and frequently distressing nature of the complaint.
• Perform pelvic examination gently, with clear, ongoing explanation and explicit consent throughout. The examination itself can reproduce or exacerbate the symptom.
• In suspected vaginismus, examination may need to be deferred or approached with additional care and a structured, graduated approach.
• Examination assesses for vulvovaginal atrophy, infection and dermatological abnormality. On bimanual examination, uterine or adnexal tenderness or a palpable mass suggests endometriosis, fibroids or other pelvic pathology.
• Further investigation depends on presentation and findings. It includes vulvovaginal swabs where infection is a consideration, and pelvic ultrasound assessing for fibroids, ovarian pathology, or features suggestive of adenomyosis or endometriosis.
• Where deep dyspareunia and other symptoms suggest endometriosis, further evaluation follows the diagnostic principles detailed under that condition. It may include diagnostic laparoscopy where indicated.

• Genitourinary syndrome of menopause is managed with topical vaginal oestrogen and non-hormonal vaginal moisturisers and lubricants. This is highly effective for this common cause of superficial dyspareunia.
• Vaginismus management centres on structured, graduated desensitisation. It typically combines pelvic floor physiotherapy (pelvic floor muscle relaxation and awareness) with progressive vaginal dilator therapy.
• Where significant anxiety or a history of trauma contributes, add psychological support or sex therapy. The approach should be patient-centred and appropriately paced, respecting the individual's comfort level and readiness at each stage.
• An identified organic cause of deep dyspareunia, including endometriosis, fibroids or pelvic adhesive disease, is managed by the standard principles for the underlying condition.
• Pelvic floor physiotherapy is a valuable, evidence-based treatment across both superficial and deep dyspareunia. It addresses pelvic floor muscle dysfunction, whether hypertonicity or less commonly other patterns, a frequently underrecognised contributing mechanism.
• Psychosexual counselling or therapy addresses the psychological, relational and behavioural dimensions. It can be standalone where psychological factors predominate, or an adjunct to medical or physiotherapy-based treatment of an organic cause. Physical and psychological factors interact in a complex way.
• Ongoing, supportive, non-judgmental clinical engagement throughout assessment and treatment underpins effective management. Involve the woman's partner where relevant and desired.
• This is a common but frequently underreported complaint with significant impact on quality of life.