Diagnosis

A medical evaluation for dyspareunia usually consists of:

  • A thorough medical history. Your doctor may ask when your pain began, exactly where it hurts, how it feels, and if it happens with every sexual partner and every sexual position. Your doctor may also inquire about your sexual history, surgical history and previous childbirth experiences.

    Don't let embarrassment stop you from giving candid answers. These questions provide clues to the cause of your pain.

  • A pelvic exam. During a pelvic exam, your doctor can check for signs of skin irritation, infection or anatomical problems. He or she may also try to identify the location of your pain by applying gentle pressure to your genitals and pelvic muscles.

    A visual exam of your vagina, using an instrument called a speculum to separate the vaginal walls, may be performed as well. Some women who experience painful intercourse are also uncomfortable during a pelvic exam, no matter how gentle the doctor is. You can ask to stop the exam at any time if it's too painful.

  • Other tests. If your doctor suspects certain causes of painful intercourse, he or she might also recommend a pelvic ultrasound.

Treatment

Treatment options vary, depending on the underlying cause of the pain.

Medications

If an infection or medical condition contributes to your pain, treating the underlying cause may resolve your problem. Changing medications known to cause lubrication problems also may eliminate your symptoms.

For most postmenopausal women, dyspareunia is caused by inadequate lubrication resulting from low estrogen levels. Often, this can be treated with topical estrogen applied directly to your vagina.

The drug ospemifene (Osphena) was recently approved by the Food and Drug Administration to treat moderate to severe dyspareunia in women who have problems with vaginal lubrication. Ospemifene acts like estrogen on the vaginal lining, but doesn't seem to have estrogen's potentially harmful effects on the breasts or the lining of the uterus (endometrium). Drawbacks are that the drug is expensive, it may cause hot flashes, and it has a potential risk of stroke and blood clots.

Therapy

Different types of therapy may be helpful, including:

  • Desensitization therapy. During this therapy, you learn vaginal relaxation exercises that can decrease pain. Your therapist may recommend pelvic floor exercises (Kegel exercises) or other techniques to decrease pain with intercourse.
  • Counseling or sex therapy. If sex has been painful for a long time, you may experience a negative emotional response to sexual stimulation even after treatment. If you and your partner have avoided intimacy because of painful intercourse, you may also need help improving communication with your partner and restoring sexual intimacy. Talking to a counselor or sex therapist can help resolve these issues.

    Cognitive behavioral therapy also can be helpful in changing negative thought patterns and behaviors.

Lifestyle and home remedies

You and your partner may be able to minimize pain with a few changes to your sexual routine:

  • Switch positions. If you experience sharp pain during thrusting, the penis may be striking your cervix or stressing the pelvic floor muscles, causing aching or cramping pain. Changing positions may help. You can try being on top of your partner during sex. Women usually have more control in this position, so you may be able to regulate penetration to a depth that feels good to you.
  • Communicate. Talk about what feels good and what doesn't. If you need your partner to go slow, say so.
  • Don't rush. Longer foreplay can help stimulate your natural lubrication. And you may reduce pain by delaying penetration until you feel fully aroused.
  • Use lubricants. A personal lubricant can make sex more comfortable. Try different brands until you find one you like.

Coping and support

Until vaginal penetration becomes less painful and bothersome, you and your partner might find other ways to be intimate. Sensual massage, kissing and mutual masturbation offer alternatives to intercourse that might be more comfortable, more fulfilling and more fun than your regular routine.

Preparing for your appointment

If you have recurrent pain during sex, talking to your doctor is the first step in resolving it. Primary care doctors and gynecologists often ask about sex and intimacy as part of a routine medical visit. Use the opportunity to discuss your concerns.

Your regular doctor may diagnose and treat the problem or refer you to a specialist who can.

What you can do

To prepare for this discussion with your doctor:

  • Take note of any sexual problems you're experiencing, including when and how often you usually experience them.
  • Make a list of your key medical information, including any conditions for which you're being treated, and the names of all medications, vitamins or supplements you're taking.
  • Consider questions to ask your doctor and write them down. Bring along notepaper and a pen to jot down information as your doctor addresses your questions.

Some basic questions to ask your doctor include:

  • What could be causing my problem?
  • What lifestyle changes can I make to improve my situation?
  • What treatments are available?
  • What books or other reading materials can you recommend? Do you recommend any websites?

Questions your doctor may ask

Your doctor will ask questions about the symptoms you're experiencing and assess your hormonal status. Questions your doctor may ask include:

  • Do you have any sexual concerns?
  • When did the pain begin?
  • Where do you feel the pain?
  • Does the pain happen each time you have sex or only in certain situations?
  • Are you able to discuss your concerns with your partner?
  • Do any other, nonsexual activities also cause you pain?
  • How much distress do you feel about your sexual concerns?
  • Do you also experience vaginal irritation, itching or burning?
  • Have you ever been diagnosed with a gynecologic condition or had gynecologic surgery?
Jan. 24, 2015
References
  1. Ferri FF. Ferri's Clinical Advisor 2015: 5 Books in 1. Philadelphia, Pa.: Mosby Elsevier; 2015. https://www.clinicalkey.com. Accessed Dec. 6, 2014.
  2. Ebert MH, et al. Current Diagnosis & Treatment: Psychiatry. 2nd ed. New York, N.Y.: The McGraw-Hill Companies; 2008. http://www.accessmedicine.com/resourceTOC.aspx?resourceID=10. Accessed Dec. 8, 2014.
  3. Stewart EG. Differential diagnosis of sexual pain in women. http://www.uptodate.com/home/. Accessed Dec. 8, 2014.
  4. Lenz GM, et al. Comprehensive Gynecology. 6th ed. Philadelphia, Pa.: Mosby Elsevier; 2012. http://www.clinickey.com. Accessed Dec. 6, 2014.
  5. Dyspareunia. The Merck Manual Professional Edition. http://www.merckmanuals.com/professional/gynecology_and_obstetrics/sexual_dysfunction_in_women/dyspareunia.html?qt=dyspareunia&alt=sh. Accessed Dec. 8, 2014.
  6. Bachmann G, et al. Treatment of vaginal atrophy. http://www.uptodate.com/home/. Accessed Dec. 8, 2014.
  7. Rohren CH (expert opinion). Mayo Clinic, Rochester, Minn. Dec. 9, 2014.

Painful intercourse (dyspareunia)