Understanding and Managing Intimate Pain
Paz Etcheverry, MS, PhD
February 2024
When a woman experiences pain during intercourse, the condition is known as dyspareunia. In the United States, the prevalence of dyspareunia ranges between ten and twenty percent and varies by age.[3][10] Women with this condition often describe feeling sadness, anxiety, heightened sensitivity to pain, negative body image, and low self-esteem; hence, a timely intervention is crucial to address this disorder.[9]
There are two types of dyspareunia that we need to be aware of– superficial and deep. When the woman experiences burning, stinging, or sharp pain at or near the entrance of the vagina on penetration, it is generally called superficial dyspareunia. Deep dyspareunia refers to pelvic pain experienced during deep vaginal penetration.[4]
Superficial Dyspareunia
Superficial dyspareunia has several causes. For example, it can be seen in patients with vaginismus—an involuntary response of the body causing spasms of the muscles in the vagina— or vulvodynia—a chronic pain condition of the vulva.[1][8][11] Other causes include congenital abnormalities such as vaginal agenesis—where a woman is born without a fully developed vagina—or imperforate hymen—where the hymen completely covers the vaginal opening.[4]
Superficial dyspareunia can also result from insufficient lubrication due to a drop in estrogen levels after menopause, childbirth, or during breastfeeding. Certain medications like antidepressants, antihistamines, antihypertensives, certain oral contraceptives, and sedatives may decrease sexual arousal, which in turn causes decreased lubrication, thereby leading to painful intercourse.[4]
Injury, trauma, or irritation to the vaginal region from accidents, pelvic surgery, procedures like female circumcision, and episiotomy—a surgical incision made between the vagina and anus— can also contribute to discomfort during sexual intercourse. Infections in the genital region, for example, candidiasis or herpes, or of the urinary tract can be another cause of pain. Women with conditions like eczema or dermatological issues such as psoriasis in the genital region may encounter discomfort during sexual intercourse.[4][6]
Deep Dyspareunia
Deep dyspareunia can result from scarring from hysterectomy, radiation therapy, and chemotherapy for cancer treatment. Other conditions associated with deep dyspareunia include cystitis, endometriosis, hemorrhoids, irritable bowel syndrome, ovarian cysts, pelvic floor dysfunction, pelvic inflammatory disease, and uterine fibroids.[4]
Treatments
During the treatment of dyspareunia, the goal is to treat both the physical and mental aspects associated with the condition. Here are some treatment approaches:
Proper Vulvar Care
It is important to stay away from irritants such as perfumed soaps, perfumed vaginal hygiene wipes, and perfumed paper sanitary napkins. Furthermore, prioritizing cotton underwear and avoiding snug clothing is essential. When cleansing, steer clear of hot water and apply a topical natural emollient or moisturizer. Olive oil and coconut oil are popular alternatives to off-the-shelf moisturizers. Always use a water-based lubricant without flavors, perfumes, or other irritants during intercourse.[6]
Pelvic Floor Physical Therapy
Under the guidance of a physical therapist, pelvic floor exercises can be quite helpful in the treatment of vulvodynia due to pelvic floor dysfunction.[2]
Psychotherapy
Cognitive behavioral therapy has proven to be a helpful tool when treating dyspareunia as it teaches pain controlling techniques.[7] Couples counseling can also be a beneficial tool as it might help reduce or eliminate feelings of shame and poor body image as well as enhance communication.[6]
Topical Treatments
Topical five percent lidocaine prior to intercourse (thirty minutes before) has also proven to be useful. Be mindful that lidocaine gel or ointment can result in an initial sensation of burning upon application and that the partner may experience numbing of the penis at first; hence, the use of condoms is encouraged.[6] Topical estrogen cream is another treatment option for vulvodynia.[12]
Oral Medications
Oral medications may be used alone or in combination with topical treatments. These medications include gabapentin, pregabalin, tricyclic antidepressants such as amitriptyline, serotonin and norepinephrine reuptake inhibitors, and selective serotonin reuptake inhibitors. For dyspareunia caused by endometriosis, the first line of treatment includes nonsteroidal anti-inflammatory drugs, combination hormonal contraceptives, and progestin-only contraceptives. If the patient does not experience significant pain relief, then the second line of treatment includes gonadotropin-releasing hormone agonists, gonadotropin-releasing hormone antagonists, danazol, and aromatase inhibitors.[4]
Surgical Intervention
Vestibulectomy, a surgical intervention, may be an option for the type of vulvodynia that is unresponsive to all forms of treatment. This, however, needs to be evaluated by a provider.[5]
When it comes to dyspareunia it is important to remember that addressing the condition is a journey. With the right support, there are treatments and coping strategies that can significantly improve comfort and well-being.
References
[1] Corsini-Munt, S., Rancourt, K. M., Dubé, J. P., Rossi, M. A., & Rosen, N. O. (2017). Vulvodynia: a consideration of clinical and methodological research challenges and recommended solutions. Journal of Pain Research, 10, 2425–2436. https://doi.org/10.2147/JPR.S126259
[2] Ghaderi, F., Bastani, P., Hajebrahimi, S., Jafarabadi, M. A., & Berghmans, B. (2019). Pelvic floor rehabilitation in the treatment of women with dyspareunia: a randomized controlled clinical trial. International Urogynecology Journal, 30(11), 1849–1855. https://doi.org/10.1007/s00192-019-04019-3
[3] Hill, D. A., & Taylor, C. A. (2021). Dyspareunia in women. American Family Physician, 103(10), 597–604.
[4] Hrelic, D. A., Wax, E. M., & Saccomano, S. J. (2023). Dyspareunia: Etiology, presentation, and management. The Nurse Practitioner, 48(11), 27–34. https://doi.org/10.1097/01.NPR.0000000000000111
[5] Kliethermes, C. J., Shah, M., Hoffstetter, S., Gavard, J. A., & Steele, A. (2016). Effect of vestibulectomy for intractable vulvodynia. Journal of Minimally Invasive Gynecology, 23(7), 1152–1157. https://doi.org/10.1016/j.jmig.2016.08.822
[6] Kumar, K., & Robertson, D. (2017). Superficial dyspareunia. CMAJ: Canadian Medical Association Journal = Journal de l’Association Medicale Canadienne, 189(24), E836. https://doi.org/10.1503/cmaj.161337
[7] Masheb, R. M., Kerns, R. D., Lozano, C., Minkin, M. J., & Richman, S. (2009). A randomized clinical trial for women with vulvodynia: Cognitive-behavioral therapy vs. supportive psychotherapy. Pain, 141(1-2), 31–40. https://doi.org/10.1016/j.pain.2008.09.031
[8] Pacik, P. T. (2014). Understanding and treating vaginismus: a multimodal approach. International Urogynecology Journal, 25(12), 1613–1620. https://doi.org/10.1007/s00192-014-2421-y
[9] Seehusen, D. A., Baird, D. C., & Bode, D. V. (2014). Dyspareunia in women. American Family Physician, 90(7), 465–470.
[10] Sorensen, J., Bautista, K. E., Lamvu, G., & Feranec, J. (2018). Evaluation and treatment of female sexual pain: A clinical review. Cureus, 10(3), e2379. https://doi.org/10.7759/cureus.2379
[11] Tayyeb, M. & Gupta, V. Dyspareunia. [Updated 2023 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562159/
[12] Ventolini, G. (2011). Measuring treatment outcomes in women with vulvodynia. Journal of Clinical Medicine Research, 3(2), 59–64. https://doi.org/10.4021/jocmr526w
