Painful sex in women or dyspareunia can be either superficial or deep. The problem may be presented openly or may come to light indirectly during examination for some other reason, such as a cervical smear.
A woman may use another symptom, such as recurrent vaginal discharge or pelvic pain, as a way of introducing the subject and it is important that the medical professional uses this opportunity to pick up the cues by enquiring about sex.
A physical cause must be excluded. Ask whether the problem is primary or secondary and when it started.
Establish why the patient has presented now.
A review of any other associated symptoms relating to gynaecological, urological, bowel or musculoskeletal systems may help.
It is important to pinpoint when and where the patient feels the pain, and if it occurs every time she has sex.
A brief social, obstetric and sexual history including discussion of current relationships may be relevant. Establish whether the pain precludes all sexual activity and ask whether she is orgasmic with non-penetrative sex.
More information may be gleaned if the patient's partner is not in the room. Ensure any chaperone present is unobtrusive.
Take note of the patient's demeanour, for example if she is tense, nervous or reluctant to have an intimate examination. Is she relaxed or detached from the whole process?
First carefully examine the vulva for any skin conditions, such as lichen sclerosus or eczema.
Check for any pinpoint tenderness. Look for any discharge and if possible, proceed to bimanual and speculum examination, taking swabs if necessary.
Examination may reveal no pain at all and everything may look normal. Allow the patient to voice any fears and thoughts that may be revealed at this time.
Vulvodynia and vestibulodynia describe vulval or vestibular pain/burning in the absence of obvious skin conditions or infections. The cause is not known.
Point tenderness is found on examination with a cotton swab. Pain may be present all the time or only when provoked as during sexual intercourse. Sometimes there is secondary vaginismus.
Local treatments, such as anaesthetic creams, lubricants and gels, may help but often oral medication, such as amitriptyline, is necessary.
Vaginismus is an involuntary contraction of the vaginal wall muscles accompanied by pain. There are varying degrees.
In severe cases, a woman may also have adductor spasm and be unable to abduct her legs. Most commonly the vagina is clamped shut and the doctor is unable to perform an internal examination. This must be distinguished from rare physical problems, such as imperforate hymen.
With care and patience it might be possible to enable the patient to become aware of the contraction and subsequent relaxation of her muscles.
Explain how the pain is generated (see figure above). Some patients use dilators, which can be prescribed on the NHS.
Establishing the cause of vaginismus is often difficult and may take several sessions of psychosexual counselling. On the other hand, it can sometimes be surprisingly simple if it is secondary, for example to an episiotomy or episode of thrush.
The realisation and reassurance that there is no pathology and that the pain is being generated by reflex muscle spasm may be a revelation. However, deep-seated, often unconscious fears, sometimes related to previous traumas, may take longer to unravel.
5. Treating painful sex
Excluding a physical cause may necessitate investigations, such as pelvic ultrasound or laparoscopy, especially if deep pain or a mass is found on examination. Beware of ordering unnecessary investigations without an understanding of any psychosexual issues.
PID may also need exclusion, and it is often forgotten that bowel problems, such as irritable bowel or colitis, can cause pain on intercourse. Bladder problems or fear of incontinence should be addressed.
Musculoskeletal conditions also cause dyspareunia and discussions relating to use of different coital positions can help. Practical advice regarding the timing of analgesics or the use of cushions may be useful. Atrophic vaginitis can be treated with systemic or topical HRT. Vaginal moisturisers and lubricants can also help.
Beware of becoming too prescriptive and risking ignoring the emotional content and feelings of the patient. Reassurance can help but will not do so if the woman's fears and thoughts have not been fully addressed.
Referral to a psychosexual counsellor may be necessary, but do not underestimate the amount that can be achieved by a sensitive assessment and exploration of the woman's fears.
- Dr Denman is a GP in Oxford and a member of the Institute of Psychosexual Medicine
- Institute of Psychosexual Medicine www.ipm.org.uk
- Relate www.relate.org.uk
- College of Sexual and Relationship Therapists www.cosrt.org.uk
- Vulval Pain Society www.vulvalpainsociety.org
- Skrine RL, Montford AH. Psychosexual Medicine - An Introduction. London, Hodder Arnold, 2001.