Dyspareunia: Painful Intercourse
Written by Carol Petersen, RPh, CNP – Women’s International Pharmacy
The word dyspareunia is a general medical term referring to painful sex. Terms such as vulvodynia, vestibulodynia, and vaginitis refer to types of dyspareunia, and also indicate the origin of the pain.
Most of us usually don’t pay much attention “down there” until something goes awry. The issues can be a complex blend of emotional, psychological, and physical origin, thereby encompassing more than one medical specialty. Sometimes proper diagnosis and treatment of a physical condition can help emotional and psychological issues fade away, and vice versa.
Painful sex was the focus of the November 2012 meeting of The International Society for the Study of Women’s Health. Many of the case studies presented were about women who had consulted with many different practitioners, all of whom were unable to piece together the relevant information for proper diagnosis and treatment.
A critical aspect of proper diagnosis is the patient being familiar with and using proper terminology. Here’s a brief review for the purpose of this discussion: The vulva consists of the clitoris, urethra (for emptying the bladder), the opening to the vagina and the bit of tissue that surrounds the opening to the vagina, which is called the vestibule. The labia (lips) majora and minora fold around the opening to the vagina. The perineum is the tissue that extends from the opening of the vagina to the anus, which is the opening to the rectum. (For more information, please see the diagram in our newsletter on vaginal health titled Starting a Conversation About Vaginal Health)
One fairly common source of pain is the perineum tissue, which may sometimes tear and/or be cut and later stitched during childbirth. However, the part that tends to be the most troublesome and the source of the most pain is the vestibule.
Located on the inner side of the labia minora is Hart’s Line, which marks a transition between vaginal tissue and vestibular tissue. The vestibule is not made up of the same type of tissue as the rest of the vaginal area; it is the same tissue as that found in the urethra. Of particular interest is that this vestibular tissue requires adequate amounts of estrogen and testosterone to be healthy. Also of interest is that this tissue supplies the majority of the secretions that lubricate the area for sex.
Whether or not the vestibule is the source of pain can be detected by a simple cotton swab test. This involves touching the tip of a moistened cotton swab to the vestibular tissue and noting whether this touching elicits or increases the pain. Touching different parts of the vestibule can elicit different responses.
Causes for pain arising from the vestibule can include an excess number of nerve endings present since birth, nerve damage from childbirth, episiotomy (cutting the perineum), or accidents. Treatments vary from topical anesthetics to antidepressants, depending on the cause.
Pain can also stem from muscle spasms in the pelvic floor, which in turn causes problems with nervous system tissue. Treatments for muscle spasm include drugs such as Valium or muscle relaxants, physical therapy, or even hypnosis.
Dr. Irvin Goldstein maintains that the use of birth control pills is the greatest cause of vestibular pain. The interference of the synthetic hormones in birth control pills results in a deficiency of estrogen and testosterone in the vestibular tissue. Treatment consists of using preparations containing both of these hormones to restore the tissue to health. However, the type of cream or ointment used is key to avoiding or minimizing additional trauma to the painful area. Anti-inflammatory hormones, which are sometimes prescribed, provide little benefit. It is also important to stop any medications that may be interfering with the proper uptake of hormones to this tissue.
Dr. Deborah Coady has several suggestions to promote the health of the genital area. She advises against using soaps in the genital area because they are too drying, and avoiding creams containing benzocaine, alcohol, parabens, perfumes and propylene glycol. She also suggests wearing cotton underwear, changing it two or three times per day, and sleeping without underwear. She cautions against using minipads and recommends using hypoallergenic sanitary napkins.
To hydrate the area and reduce irritation due to friction, Dr. Coady suggests applying non-irritating products such as Aquaphor® healing ointment, vitamin E in grapeseed oil, or edible oils such as olive oil, safflower oil or coconut oil.
This discussion covers just a few important points to help begin the conversation about this sensitive topic. If you or someone you know is dealing with painful sex, please see the references below for more detailed information.
- When Sex Hurts: A Woman’s Guide to Banishing Sexual Pain by Andrew Goldstein, MD, Caroline Pukall, PhD, and Irwin Goldstein, MD; Da Capo Press; New York, NY; January 2011.
- Healing Painful Sex: A Woman’s Guide to Confronting, Diagnosing, and Treating Sexual Pain by Deborah Coady, MD, and Nancy Fish, MSW, MPH; Seal Press; New York, NY; November 2011.