Dyspareunia

Content written by Irwin Goldstein MD

OVERVIEW:

Pain during intercourse, dyspareunia, is one of the most common complaints in gynecologic practice. This syndrome used to be called vulvar vestibulitis syndrome, or VVS (an less commonly vestibular adenitis.) The World Health Organization, reported that between 8%-22% of women experience dyspareunia lasting at least 3 months. A study in Sweden of over 3000 women showed that at any given time, more than 4% of women in their 20’s have dyspareunia. This means that at least 20 million American women will experience chronic dyspareunia in their lifetimes.

For many years, it was the common belief among physicians that most dyspareunia was caused by psychological reasons. Women were labeled as “frigid,” “anxious,” or “hysterical.” Often, they were told that they had been the victims of “sexual abuse that they just didn’t remember.” However, finally, the medical community is beginning to recognize that almost all dyspareunia has a physiologic (physical) cause, and recent controlled studies have failed to find an association between sexual abuse and dyspareunia.

CAUSES:

Dyspareunia, is not one specific disease. Instead, it is a symptom with many different causes, the most common of which are listed below.

VULVODYNIA/ VESTIBULODYNIA/ VULVAR VESTIBULITIS SYNDROME (VVS):

This syndrome used to be called vulvar vestibulitis syndrome, or VVS (an less commonly vestibular adenitis.) But vestibulodynia is not a single condition; rather, it is a constellation of at least a dozen different conditions in which the pain originates from the entrance to the vagina- the vulva vestibule. It is the most common cause of sexual pain in premenopausal women and one of the most difficult for most doctors to correctly diagnose and treat. The most common causes of PVD are hormonal changes, tight (hypertonic) pelvic floor muscles, and an increased number of nerve ending in the mucosa of the vestibule.

HYPERTONIC PELVIC FLOOR MUSCLE DYSFUNCTION:

This condition, is also know as vaginismus. is when the muscles that surround the vagina (also the bladder and anus) are in spasm. This causes pain at the vulvar vestibule which leads to pain upon penetration. Tight (hypertonic) pelvic floor muscles can also cause constipation, rectal fissures, urinary frequency, urgency, hesitancy, and incomplete emptying. In addition, if the muscles are in severe spasm it can cause generalized vulvar burning and is a large component of generalized vulvodynia.

VULVAR AND VAGINAL ATROPHY:

One of the most common causes of sexual pain comes from hormonal changes (decreased estrogen and testosterone) that causes vaginal and vulvar tissue to become thin. This leads to dryness, irritation, tearing, and pain at the vestibule (vestibulodynia.) There are many causes of these hormonal changes including hormonal contraceptive, infertility medications, treatment for endometriosis, removal of the ovaries, and menopause. In our experience, hormonal birth control (pills, patches, rings) is the leading cause of atrophy, and therefore, the leading cause of sexual pain in premenopausal women.

VULVAR AND VAGINAL SKIN DISORDERS:

The skin of the vulva and the mucosa of the vagina are susceptible to inflammatory skin disease that can cause ulcers, erosions, and scarring of the vulva. The most common of these disorders are lichen sclerosus and erosive lichen planus. 

INTERSTITIAL CYSTITIS (IC):

(also know as Painful Bladder Syndrome) is a condition in which the bladder lining becomes severely inflamed. The causes frequent urination (up to 60 times a day!) and severe pelvic pain and dysapareunia. Seventy-five percent of women with IC say that sex makes their pain and need to urinate worse.

ENDOMETRIOSIS AND CHRONIC PELVIC PAIN:

Endometriosis, a condition in which uterine tissue grows outside the uterus, is one of the most complex, frustrating – yet common—conditions in gynecology. Women with endometriosis often experience severe pain, sometimes at certain times of the month, sometimes throughout the month. In addition to the chronic pelvic pain these women experience, they also suffer from deep dyspareunia.

GENERALIZED VULVODYNIA:

This condition results in pain in the vulvar area even when women aren’t trying to have sex. Most commonly the pain is caused by a combination of tight pelvic floor muscles and injury of the pudendal nerve.

GASTROINTESTINAL CONDITIONS:

Conditions such as irritable bowel syndrome, and ulcerative colitis can contribute to painful sex.

INFECTION:

Numerous infections, including sexually transmitted infections including yeast infections, trichomonas, genital herpes, chlamydia, and gonorrhea, can cause sexual pain. However, it must be emphasized that while most women (and their doctors) think that their sexual pain is related to an infection, it is only infrequently the cause.

PUDENDAL NEURALGIA:

With this condition, the pudendal nerve, which carries feeling from the external genitals, the lower rectum and the area between the genitals and the rectum (perineum), becomes damaged or entrapped. Women with this condition feel severe burning and aching pain when they try to sit and often have problems with their bladder and bowels.

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