Vaginal Pain Dyspareunia - Treating Common Sexual Problems: Womens Sexual Health

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Vaginal pain (dyspareunia)

A particularly distressing sexual problem for women is chronic vaginal pain. About one in five American women may experience this problem at some point in her life. Like back pain or headache, dyspareunia is an umbrella term encompassing a variety of unpleasant sensations that have psychological or physical causes. The pain can be diffuse and intermittent, it may appear when pressure is applied to certain areas, or it may emerge only when a woman is attempting sexual intercourse. A woman who experiences painful intercourse may become reluctant or unable to have sex, which can strain an intimate relationship.

Diagnosing the problem

Obstetricians and gynecologists report that pain during intercourse is a frequent complaint. If you have this problem, your doctor will ask you about your symptoms. For example, he or she will ask you to describe the type of pain (burning, shooting, sharp, or dull) and to identify its location (deep within your vagina or around the vaginal opening). You may also be asked to point out the sensitive areas using a handheld mirror.

Next the doctor will do a complete physical exam. For women with vaginal pain, a pelvic exam can be traumatic. A good doctor will understand your fears and take extra care to perform the procedure slowly and gently.

One important element of the diagnostic workup may be the Q-tip test. Using a moistened cotton swab, your doctor will gently touch several sites on the inner labia and around the vaginal opening. You'll be asked to report the intensity of the pain on a scale of 1 to 10. Pain during the test indicates an inflammatory condition known as vulvar vestibulitis.

Your doctor will also look for signs of age-related vaginal changes that can make intercourse uncomfortable. Finally, he or she may perform laboratory tests to rule out the presence of an infection.

Types of pain

Vaginal pain is categorized based on your symptoms and what the doctor finds during your evaluation. These are some of the more common conditions.

Vaginal atrophy. Lower estrogen levels cause the vaginal lining to thin and secretions to diminish. The vagina also becomes shorter and less elastic, and the vaginal opening narrows. The result is often dryness and irritation, which can make intercourse or pelvic examinations painful or impossible. Thinning of the vaginal lining combined with changes in the pH balance can make the vagina vulnerable to infection — a condition known as atrophic vaginitis. If untreated, this problem may lead to further thinning and ulceration of the vagina.

Vulvodynia. Vulvodynia is pain with no identifiable cause that may come and go in different areas, including the clitoris, perineum, mons pubis, and inner thighs. Symptoms include burning, stinging, and irritation. The condition can make sexual intercourse uncomfortable or impossible.

Vaginismus. This condition is characterized by involuntary spasms of the muscles in the outer third of the vagina in response to any attempt at entry. It makes intercourse impossible. Vaginismus can be the result of painful intercourse, past sexual abuse, lack of sexual experience, or fear of or aversion to sexual activity.

Vulvar vestibulitis. This is a condition in which the inner labia and vaginal opening become chronically inflamed and irritated. Pressure to the area from any source such as the entry of a penis, insertion of a tampon, contact with a bicycle seat, or even wearing tight pants can cause extreme tenderness. The exact cause of vulvar vestibulitis is unknown.

Adhesions (internal scar tissue). Adhesions are bands of tissue that form in response to injury or infection inside the body. Abdominal surgery (including C-sections and hysterectomies) can create adhesions, which can bind internal organs together or to the pelvic wall. Scars from an episiotomy, an incision in the perineum to enlarge the vagina during childbirth, can also create adhesions. Adhesions can lead to painful sex and decrease a woman's ability to have an orgasm.

Treating vaginal pain

Treatment for vaginal pain depends on the root of the problem. Vaginal atrophy can be treated with lubricants that allow a return to sexual activity or hormone treatments that can reverse the atrophy. If vaginismus is a reaction to pain, sex therapy can alleviate the problem once the pain has been treated. Since vulvodynia and vulvar vestibulitis have no known cause or cure, treatment usually centers around pain-management techniques. Sex therapy can also help a woman deal with the effect of the pain on her sexuality and rebuild a pleasurable sex life.

Medication. An assortment of medications are used for vaginal pain, with varying degrees of success. Steroid creams are effective in treating vaginal atrophy. If the primary cause of the pain is vaginal thinning and dryness, estrogen — in the form of a ring, tablet, cream, patch, or oral medication — can help restore natural lubrication (see "Hormone therapy"). If the pain stems from an infection, your doctor may prescribe antibiotic creams or pills. While anesthetic ointments are sometimes used, these preparations can cause allergic reactions in some women. In the case of vulvar vestibulitis, interferon injections have been successful in controlling the inflammation. Other medications such as tricyclic antidepressants and certain anticonvulsant drugs work in some cases.

Surgery. If you have vulvar vestibulitis and medications have failed, laser or traditional surgery to remove the affected tissue may help. Approximately 60% of women who have this procedure report that intercourse is no longer painful.

Pelvic floor physical therapy. This technique shows great promise in treating unremitting vaginal or pelvic pain. It uses hands-on physical therapy to relax muscles in the lower pelvis. The physical therapist uses a massage-like technique, known as myofascial release, to help stretch and release the fascia (connective tissue between the skin and underlying muscle and bones). Pelvic floor physical therapy is also used to treat other causes of dyspareunia, such as vulvodynia and vulvar vestibulitis, as well as urinary incontinence.

Behavior management. Biofeedback has been used successfully to control vulvar pain. You begin by inserting special sensors into the vagina or rectum to help identify overly tense pelvic floor muscles, which can be a cause of vulvar pain. Then, you perform targeted exercises to relax these muscles. Acupuncture or the use of cold packs may also be helpful. In the case of vaginismus, you might try using a series of successively larger penis-shaped plastic dilators to learn how to relax vaginal muscles.

Sex therapy. Painful intercourse often causes people to feel anxious about sexual activity and to avoid it completely. Eventually this fear and withdrawal become as formidable as the pain itself. The fear of pain can also contribute to performance anxiety, creating a vicious cycle. By working with a sex therapist, you and your partner can learn to focus on sexual and sensual activities that are pleasurable. The therapist will use structured activities such as sensate focus techniques to direct your attention to activities and parts of the body that don't provoke anxiety or cause pain.

Last updated:	January 23, 2007