Understanding Dyspareunia: The many causes of pain with intercourse.

Dyspareunia, or painful intercourse, is a condition that affects a significant number of individuals, particularly women. It refers to persistent or recurrent genital pain during or after sexual activity. This discomfort can occur in any part of the genital area, including the vagina, vulva, and surrounding tissues. While it’s not uncommon to experience occasional discomfort during sex, when pain becomes frequent or severe, it can interfere with both physical and emotional well-being. Understanding the causes of dyspareunia, such as vaginal dryness, fluctuating estrogen levels, STIs, and other contributing factors, can help in finding effective treatments. 

Vaginal dryness is one of the most common causes of dyspareunia. It occurs when the vaginal tissues don’t produce enough natural lubrication during sexual arousal, leading to friction and discomfort. This can result in pain during intercourse, which may be mild or severe. Vaginal dryness often correlates with hormonal changes, especially a decrease in estrogen levels. 

Estrogen, the primary female sex hormone, plays a critical role in maintaining the health and function of vaginal tissues. It helps keep the vaginal lining thick, elastic, and moist. When estrogen levels drop, such as during menopause, breastfeeding, or as a side effect of certain medications, the vaginal tissues may become thinner, drier, and less elastic, contributing to painful intercourse. 

Certain medical conditions, including autoimmune disorders like Sjögren’s syndrome, can also cause vaginal dryness, leading to discomfort during sex. Similarly, certain medications, particularly those used in the treatment of cancer or depression, can interfere with natural lubrication and cause dryness. 

Estrogen plays a crucial role in maintaining vaginal health. In addition to promoting lubrication, it also helps regulate the production of vaginal cells and supports the overall elasticity of the vaginal walls. As estrogen levels decrease, the tissues in the vaginal area become thinner and less resilient, making them more prone to irritation, inflammation, and pain during intercourse. 

The most common time that women experience a significant drop in estrogen is during menopause. As women transition into menopause, the ovaries gradually stop producing estrogen, leading to the hallmark symptoms of menopause, such as hot flashes, mood changes, and vaginal dryness. However, it’s not only menopause that causes low estrogen. Perimenopause, the years leading up to menopause, as well as childbirth and breastfeeding, can also lead to fluctuating estrogen levels and vaginal dryness. 

Women who undergo certain cancer treatments, like chemotherapy or radiation therapy, may also experience a drop in estrogen levels, leading to vaginal dryness and pain during sex. Hormonal imbalances or birth control methods that suppress ovulation, like certain types of birth control pills, can also cause lower estrogen levels, contributing to dyspareunia. 

Sexually transmitted diseases or STIs can also be a major contributor to dyspareunia. Infections like chlamydia, gonorrhea, and trichomoniasis can cause inflammation, irritation, and discomfort in the vaginal and pelvic areas. When left untreated, these infections can lead to long-term complications, including chronic pain during sex, scarring, and damage to the reproductive organs. 

Human papillomavirus (HPV), another common STI, can also contribute to pain during intercourse. HPV can cause genital warts, which may become inflamed or irritated during sexual activity, leading to pain. In more severe cases, the presence of abnormal cervical cells (due to HPV) may cause discomfort during vaginal penetration. 

The symptoms of STIs vary depending on the type of infection but commonly include burning sensations, itching, unusual discharge, and pain during intercourse. Any persistent pain or discomfort during sex should be addressed by a healthcare provider, who may perform tests to check for STIs and recommend appropriate treatment. 

For some women, pain isn’t limited to intercourse alone; they may also experience discomfort when inserting tampons or undergoing well-woman exams. Pain during tampon insertion can indicate vaginal dryness, a vaginal infection, or other conditions such as vulvodynia (chronic vulvar pain). It’s essential for women to listen to their bodies and address any pain or discomfort they experience during everyday activities like tampon use. 

A well-woman exam, which typically includes a pelvic exam and Pap smear, can also trigger discomfort for some individuals. The pressure and manipulation of the pelvic area during the exam can cause temporary pain, especially if the vaginal walls are dry, inflamed, or if the person has an underlying condition. For women with a history of painful intercourse, this experience may evoke anxiety or fear, which can further exacerbate the pain. 

Urinary tract infections (UTIs) and yeast infections are common conditions that can contribute to painful intercourse. Both infections can cause inflammation, irritation, and discomfort in the vaginal area. 

A UTI can cause symptoms such as a burning sensation while urinating, frequent urges to urinate, and pelvic pain. The inflammation caused by the infection can make the vaginal tissues more sensitive and prone to pain during sex. In addition, women with recurrent UTIs may also experience sexual discomfort due to the general sensitivity of the pelvic area. 

Yeast infections, caused by an overgrowth of the Candida fungus, can lead to itching, burning, and swelling in the vaginal area. These symptoms can make intercourse painful and uncomfortable. Yeast infections often occur when the balance of bacteria and yeast in the vagina is disrupted, which can happen after antibiotic use, during pregnancy, or due to high blood sugar levels. 

If you are experiencing pain during intercourse, it’s important to talk with your healthcare provider or pelvic floor PT. A proper diagnosis is key to determining the cause of the pain and developing an appropriate treatment plan. It’s important to have open and honest discussions with your pelvic floor PT or healthcare provider to find the best solution for managing symptoms. 

Dyspareunia is a complex condition with many potential causes, ranging from hormonal changes to infections and underlying health conditions. Understanding the role of vaginal dryness, fluctuating estrogen levels, STIs, and other factors is essential for effective management and treatment.  Painful intercourse doesn’t have to be a permanent part of your life, and with the right care, relief is possible. 

Jennifer Cumming, PT, MSPT, WCS