Pain with Sex AKA “Dyspareunia”

Aug 20

Upwards of 40% of women (vagina-owners) experience pain with sexual activity at some point in their lives. “Dyspareunia” is the medical term and diagnosis for pain with sexual activity. So, you may see this word used interchangeably throughout. As a women’s health nurse practitioner, this is something I talk about almost every day I work with people. It is often a concern that is normalized (both by society and healthcare professionals), dismissed, ignored, etc. Many people experience pain with sexual activity for years and either do not seek help or have tried many times to no avail.

The goal is: zero pain or discomfort with sexual activity.

This is a goal I feel really strongly about. I have spent years attending sexual health conferences, reading research articles, participating in continuing education about pelvic pain and pelvic health, and working with individuals 1:1 who experience pain with sexual activity.

Common causes of dyspareunia (dis-puh-ROO-nee-uh):

Hormones.
Changes in hormone levels (specifically estrogen and testosterone) can affect the tissue of the vulva (external genitalia) and vagina. Common times people experience hormonal changes and are at risk of pain with sexual activity: breast feeding, menopause, using certain types of contraception, using certain acne treatments (like spironolactone).

Infection.
Infection causes inflammation and can cause pain. So, pain with sexual activity can be due to an active infection (like yeast/candida, gonorrhea, chlamydia), or even a history of recurrent infections. So, if you have a history of repeated yeast infections and now struggle with pain around the vaginal opening, the two could be related.

Pelvic floor dysfunction.
Think about the pelvic floor muscles like a hammock from the front to the back of your body. Your vagina, urethra, and rectum all cross through this hammock. The hammock is responsible for holding in urine and stool, as well as releasing them. If the muscles are weak, tight, uncoordinated - all of these states can affect how sex feels.

Endometriosis.
This is a condition where the lining of the uterus (endometrium) grows outside of the uterus. It’s a benign condition, however, it can cause deeper pelvic pain with sexual activity. It’s often also associated with more painful periods, and pain with bowel movements.

Congenital.
Some people are born with painful and sensitive skin around the vaginal opening (vestibule). So, if someone has always had pain with sexual activity, maybe even pain with tampon insertion - this would be a possibility. It’s sometimes associated with pain at the belly button too (with gentle touch).

This list isn’t exhaustive, but hopefully it gives you an idea of the many reasons people may have pain with sexual activity.

What can be done?

There are many different interventions for dyspareunia. The treatment plan is based on the cause. For example vaginal estrogen cream can be helpful for hormonal causes, physical therapy can be helpful for pelvic floor causes. Sometimes the treatment plan includes a combination of these.

My request to you - please don’t accept pain with sex as “normal.” If you see a healthcare provider and they tell you it is normal - find a new provider. If they tell you “just relax” or “have a glass of wine” - find a new provider. If they hand you a prescription for lidocaine - this is an OK start, but this shouldn’t be the only tool you’re given.

If you’re interested in an appointment with me, you can schedule a free consultation here.

If you’re not in the Portland/Vancouver area - check out The International Society for the Study of Women’s Sexual Health (ISSWSH) “Find a Provider” tool to find a sexual health specialist near you.

How to prepare for a visit:

I would highly recommend you track your symptoms and/or journal them. A provider should want to know when the pain started, the quality of the pain (is it sharp, burning, dull, aching, etc.), when does the pain happen (with intercourse only, with any touch, spontaneously without touch, etc.). Take written questions with you so you don’t forget anything and you’re able to take notes during the appointment.

If the provider isn’t knowledgeable about pain with sexual activity, ask for a referral to a sex medicine specialist (you can use that ISSWSH directory to find someone in advance of your appointment so you’re prepared).

If the provider wants to do an exam - know that you can always decline this if you don’t feel comfortable. However, an exam can be really helpful for us to figure out the cause. So, this is likely going to be recommended at some point in your journey. If you don’t feel comfortable at your first appointment, request to complete the exam at a follow-up and have a plan in advance. The plan can include having a support person, discussing safe words with your provider, and sometimes just having a full appointment length for the exam can make it feel less rushed and less anxiety-inducing.

Lastly, if your provider recommends a speculum exam (the internal/vaginal exam using that duck-bill type tool, a speculum) - you can request to insert this yourself if you have historically had pain with exams or anything insertional.