Pain During Sex (Dyspareunia): Causes, Evaluation, and Management

Superficial or deep dyspareunia affects up to 20% of women. A systematic approach identifies treatable causes.

Common Etiologies

• Insufficient Lubrication: Hormonal (perimenopause, postpartum, OCPs), medications (antihistamines, SSRIs), inadequate arousal, Sjögren's.
• Pelvic Floor Dysfunction: Hypertonicity (vaginismus, levator ani syndrome), trigger points, myofascial pain — often primary or secondary to pain anticipation.
• Inflammatory/Infectious: Vulvovaginitis (candida, BV, trichomonas), STIs (chlamydia, herpes), cervicitis, urethritis.
• Dermatologic: Lichen sclerosus, lichen planus, contact dermatitis, vulvodynia (provoked vestibulodynia).
• Structural: Endometriosis, adenomyosis, fibroids, ovarian cysts, pelvic adhesions, congenital anomalies (imperforate hymen, vaginal septum).
• Post-Surgical/Post-Radiation: Scarring, stenosis, vaginal shortening.
• Psychosocial: Anxiety, trauma history, relationship distress, fear of pain.

Evaluation

Detailed pain history (location, timing, quality), pelvic exam (cotton-swab test for vestibulodynia, pelvic floor muscle assessment), STI testing, vaginal pH/microscopy, consider pelvic ultrasound/MRI if deep pain suggests structural pathology.

Management

• Lubricants (water-based, silicone) + vaginal moisturizers (hyaluronic acid, vitamin E)
• Topical estrogen (low-dose) for genitourinary syndrome of menopause
• Pelvic floor physical therapy (biofeedback, dilators, manual release) — first-line for hypertonicity
• Treat underlying infection/dermatosis/endometriosis
• Cognitive-behavioral therapy, sex therapy, mindfulness for pain catastrophizing/fear
• Surgical lysis of adhesions, vestibulectomy (refractory vestibulodynia)

Open communication with partner and a knowledgeable clinician (gynecologist, urogynecologist, pelvic PT) is essential.