What is dyspareunia?

Dyspareunia is pain in the vagina or lower pelvis that occurs during or after penetrative vaginal sex. It can take a toll on your physical, mental, and sexual health. 

Pain with penetrative sex is quite common: about 15% of people with vaginas will experience dyspareunia during their lifetimes. This estimate may even be low, as many people with the condition don’t report their symptoms to healthcare providers..

Some people use the terms “dyspareunia” and “painful sex” interchangeably. This may be related to the fact that society often frames penis-in-vagina intercourse as the only “real sex”. Remember that intercourse is just one way to have sex. Not everyone wants or enjoys it, and that’s okay!  

If you want to engage in intercourse, though, painful penetration presents a big problem. In this breakdown, we’ll discuss what dyspareunia is, who it affects, what causes it, and how you can find relief.

Dyspareunia at a glance

What it is: Pain in the vagina or lower pelvis that occurs during or after penetrative vaginal sex. 

Common causes:

• Muscular: Tightness, tenderness, or incoordination in the pelvic floor muscles
• Hormonal: Decreased estrogen levels after menopause or during postpartum breastfeeding, or hormonal contraceptive use, can cause vaginal dryness and tissue changes
• Structural: Childbirth injuries (episiotomy or perineal tearing) and gynecologic pain conditions such as endometriosis
• Psychosocial: History of sexual or physical trauma
• Gynecologic: Recurrent vulvovaginal infections (UTIs, yeast infections, STIs); vulvar skin disorders

Main treatment approaches: Pelvic floor physical therapy is a first-line treatment for dyspareunia and often combines multiple treatment approaches. Effective treatment often requires multidisciplinary care that combines pelvic floor physical therapy with medications, counseling, and other treatments.

What causes dyspareunia?

Different issues can trigger dyspareunia in different people. Common dyspareunia causes include:

• Excessive tightness in the pelvic floor muscles that surround the vagina
• Injury to the pelvic floor structures due to childbirth, falls or accidents, etc.
• Inflammation and irritation of the vaginal tissues or vulvar skin 
  
  • Infections such as UTI and STI can cause this kind of irritation.
• Vaginal dryness due to hormonal changes during the postpartum period or menopause transition
  
  • Certain medical conditions and treatments can also cause vaginal dryness that leads to pain.

Pelvic floor muscle dysfunction is a common cause of dyspareunia that Origin clinicians identify and help to treat in their patients. The pelvic floor consists of three muscular layers: the superficial (outermost), the middle, and the deep layers. These muscles are critical to sexual function in people of all sexes. 

When the pelvic floor and vaginal walls are healthy, they can allow for natural lubrication, comfortable penetration, and orgasm. However, when dysfunctions such as weakness, resistance to stretching, and incoordination show up in one or more of these layers, they can cause dyspareunia. 

What do dyspareunia symptoms feel like?

If you experience pain with penetration, you may feel pain during initial entry, pain with every thrust, or pain that lasts for hours after intercourse. You may also have pain using a tampon or during pelvic exams. 

Although these latter two symptoms fall outside the official definition of dyspareunia, they often co-exist alongside it. For some people with dyspareunia, vaginal penetration of any kind can trigger pain.

People with this condition describe their dyspareunia symptoms in many different ways. Some say it feels like a deep, unpleasant pressure, while others describe it “like razor blades tearing up my insides”. Regardless of how the pain of dyspareunia feels to you, it’s real, valid, and importantly, treatable.

Who gets dyspareunia?

Anyone with a vagina can experience dyspareunia, but not everyone will. Some people experience painful penetration from their very first attempt, whether that’s during sex or when trying to use a tampon or have a pelvic exam. Others develop dyspareunia symptoms much later in life, often after a medical event, injury, or significant hormonal change.

When does dyspareunia occur? 

Dyspareunia affects people of all ages, though the rate increases in postmenopausal populations. It is also common in postpartum and nursing people.

Dyspareunia after menopause

Pelvic floor muscle dysfunction is just one potential trigger of painful penetration. Dyspareunia can also result from decreased vaginal lubrication and vaginal tissue changes, both of which are common after menopause.

Estrogen levels decline throughout the menopause transition, leading to vaginal tissue changes (including dryness) that can cause painful sex. As estrogen levels decrease, the vaginal walls become thinner, drier, and less flexible. These changes can make the stretching and friction of penetrative sex less pleasant and even painful.

Painful sex is one of several symptoms that make up the genitourinary syndrome of menopause.

Dyspareunia postpartum

The menopause transition isn’t the only time when estrogen levels decrease. During breastfeeding, estrogen levels are also low, and this can lead to vaginal dryness and pain with penetration. These symptoms fall under the umbrella of the “genitourinary syndrome of lactation”.

Dyspareunia is also common after a vaginal delivery, particularly if you had an episiotomy or perineal tearing. Delayed healing of these scar sites and/or hypersensitivity of the scar tissue can cause painful penetration. 

Dyspareunia and the pill 

Oral contraceptives (aka “the pill”) can also contribute to dyspareunia in some people, even those with no previous history of pregnancy, delivery, or pelvic pain. The science behind this phenomenon is still incomplete, but the current research suggests that hormones play a role. In some people, hormonal contraception may contribute to irritation around the vaginal opening (aka vestibulodynia) that causes painful penetration.

Other causes of dyspareunia

Hormonal changes and major life events aren’t the only causes of pain during sex. Some people with a history of sexual or physical trauma may develop dyspareunia after these traumatic events. 

Other causes include recurrent UTIs, repeated yeast infections, STIs, endometriosis, PMOS (formerly PCOS), or vulvar skin disorders. In short, dyspareunia can strike at any time, for lots of reasons. Fortunately, there are also lots of ways to address it: more on that to come.

Is dyspareunia the same as vaginismus?

Not exactly. Dyspareunia focuses on an individual’s experience of pain and discomfort during penetrative sex. Vaginismus, in contrast, focuses on the behavior of the pelvic floor muscles: namely, how these muscles can spasm so intensely that they partially or completely prevent insertion, often creating pain in the process.

Let’s examine the similarities and differences between four related conditions that can cause painful sex. Note that the table below simplifies and generalizes some concepts: every human experiences these conditions slightly differently.

The latest version of the foundational guide to psychology practice, the DSM-5, lumped all of these conditions together under a single umbrella term: genito-pelvic pain/penetration disorder, or GPPPD. This change has been controversial in medical communities, and many healthcare providers still use the terms above to distinguish between different presentations. 

For the average person experiencing painful sex, distinguishing dyspareunia vs. vaginismus vs. another pain condition is usually less important than finding treatment that reduces the pain. 

How is dyspareunia treated?

There are almost as many treatments for dyspareunia as there are names for painful sex. Many people find that a multidisciplinary approach is most effective: combining medication, mental health care, and pelvic floor physical therapy can help more than any single approach alone. Let’s explore a cornerstone of treatment: pelvic floor physical therapy.

What does pelvic floor therapy for painful sex involve?

Pelvic floor physical therapy is an effective treatment for painful sex, and it often involves multiple treatment types. To help their patients with dyspareunia, Origin’s pelvic floor physical therapists employ techniques including (but not limited to): 

• Manual (hands-on) therapy to the muscles, joints, nerves, and connective tissues in and the pelvis
  
  • Note that manual therapy isn’t just something a physical therapist does for you: at Origin, our virtual care clinicians can teach you how to perform manual techniques on your own body at home.
• Flexibility and coordination exercises for the pelvic floor muscles and surrounding muscles
• Breathwork and relaxation training for nervous system regulation
• Vaginal training (aka dilation) and/or pelvic wand use to desensitize tender muscles
• Biofeedback training that uses visual and/or auditory cues to help your muscles learn a new, relaxed baseline
• Dry needling to address muscles spasms and painful trigger points
• Education about and modifications to everyday activities that affect your symptoms

If your pelvic floor muscles are resistant to stretch or “tight”, for example, your therapist will help you learn to relax and lengthen your pelvic floor. If your symptoms are related to scar tissue, your clinician may focus on scar mobilization and movement to reduce these tissue restrictions. 

At Origin, our clinicians look at your entire history to identify the underlying cause(s) of your symptoms. This comprehensive approach treats you as a whole human, from your pelvic floor muscles to the ways you work, exercise, and even breathe.

How long does dyspareunia treatment take?

Like the people who live with dyspareunia, treatment times for the condition vary a lot from person to person, and it depends on the cause of your symptoms. 

For those whose dyspareunia symptoms are connected to low estrogen, for example, hormonal treatments and vaginal salves can start acting quickly, within a few treatments. When treatment requires retraining of the pelvic floor, it can take months to fully resolve symptoms. 

At Origin, a typical course of treatment lasts anywhere from 3-12 months. While this may sound like a long time, don’t despair: many people start seeing initial improvements after just a few visits.

Ready to start your journey to recovery from painful sex? Schedule your visit with an Origin clinician here!

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