What causes painful sex (dyspareunia)?

Dyspareunia is a very distressing problem, which may have dire effects on a relationship. Two types of dyspareunia relating to their site are recognised.

Superficial dyspareunia is pain around the entrance to the vagina.

Superficial dyspareunia may be due to vulval problems (1), vestibulitis (13) or vaginal problems such as vaginitis (vaginal infections). Another possible cause is vaginismus where there is tension or spasm of the muscles around the vaginal entrance. The spasm may be such that the couple believe that there is an obstruction requiring surgical correction. Sometimes there is deeper pain and vaginismus is a protective mechanism. More frequently there is no disease but a functional problem due to an earlier sexual encounter, fear of pregnancy or inadequate arousal.

Deep dyspareunia is pain deep inside the vagina and pelvis.

Endometriosis (18) and pelvic inflammatory disease (Q 20.2)may produce deep dyspareunia. Local inflammation within the womb (endometritis) may be due to an intrauterine contraceptive device or infection after childbirth or a miscarriage. The womb is tender to touch. Ovarian cysts (8) and ectopic pregnancy (Q12.23) can present with pain at intercourse. When ovaries are conserved at hysterectomy (hysterectomy), they may become stuck in adhesions near the vault of the vagina resulting in dyspareunia.


Topical oestrogen (creams and pessaries) are commonly used in postmenopausal women to improve the quality of the vaginal epithelium in atrophic vaginitis. Fifteen percent of premenopausal women, 10-40% of postmenopausal women, and 10-25% of women receiving systemic hormone therapy experience urogenital atrophy. The most common symptoms are dryness, burning, pruritus, irritation, and dyspareunia (painful sexual intercourse). Topical Estrogen or hormone replacement therapy (ERT-HRT) is the treatment of choice in postmenopausal women.0101

If genital symptoms, such as vaginal dryness, pain during lovemaking or perhaps bladder symptoms are troubling you, these could be due to reduced oestrogen levels in the tissues around the genital area. These symptoms usually respond to HRT or to topical preparations (oestrogen creams or pessaries). On occasion, local symptoms may fail to respond to HRT anyway and additional topical oestrogen may be required. To begin with, the creams or pessaries are introduced each night for ten days to two weeks and then reduced to a maintenance regime varying from twice weekly to perhaps no more than once each month depending on symptoms, age and response. There are a variety of topical oestrogen preparations (Table 28.1).

Estring (Pharmacia and Upjohn), a synthetic soft rubber ring which slowly releases oestradiol can be introduced into the vagina and replaced at three monthly intervals. If the uterus is still present intermittent courses of progestogen should be considered to encourage endometrial shedding (HRT and progestogen). The ring is as effective as oestrogen creams and some women find the ring more acceptable.

Table 28.1






Ortho-Gynest Pessaries

Oestriol 500 g


Ortho-Gynest Cream

Oestriol  0.01%


Ovestin Cream

Oestriol 0.1%


Ovestin Pessaries

Oestradiol 1mg


Premarin  Cream

Conjugated oestrogens 625 mg


Vagifem Pessaries

Oestradiol 25 microg

Novo Nordisk

Estring Ring

Oestradiol (7.5 microg release/day)

Pharmacia and Upjohn




Almost invariably, unless you are taking HRT, there will be some degree of vaginal atrophy after the menopause. Quite frequently, patients are referred with vaginal discomfort and a physical examination reveals a prolapse (1). The only way to determine how much of the discomfort is due to the vaginal atrophy and how much to the prolapse is to treat the atrophy with topical (local cream or pessary) oestrogen and then reassess the symptoms.

Related Medical Abstracts - Click on the paper title:-

Deep dyspareunia may not necessarily be related to gynaecological problems. The urethra and bladder are close to the front wall of the vagina and the rectum, lower colon and small bowel are behind. Disease in these organs, including irritable bowel syndrome (34), may cause pain during intercourse. Bowel symptoms together with dyspareunia may alert the clinician to this diagnosis.

The majority of women presenting with deep dyspareunia and pelvic pain will have no detectable disease. During sexual arousal (foreplay) the inner two thirds of the vagina expands and the uterus, ovaries and Fallopian tubes are lifted up. If arousal is not complete deep penetration can cause pain.

Women's Health

Please click on the required question.


  • 18 What is endometriosis?
  • 19 How prevalent is endometriosis?
  • 20 What causes endometriosis?
  • 21 How can my endometriosis be treated?
  • 22 How can my doctor determine the cause of my pelvic pain?
  • 23 What investigations might be recommended by my gynaecologist to investigate my pelvic pain?
  • 24 What is laparoscopy?
  • 25 What are pelvic adhesions?
  • 26 I have chronic pelvic pain. Could this be related to adhesions?
  • 27  What is uterine retroversion (retroverted uterus)
  • 28  Does a retroverted uterus (backward tilted uterus) cause symptoms?
  • 29 How is a retroverted uterus - backward tilted uterus - treated?
  • 30 What is pelvic congestion?
  • 31 What causes pain associated with sexual intercourse (dyspareunia)
  • 32 How can painful sexual intercourse (dyspareunia) be treated?
  • 33 What is a pelvic mass?

  • 34 What is irritable bowel syndrome?
  • 35 How can we find out if I have irritable bowel syndrome?
  • 36 Is irritable bowel syndrome (IBS) a common condition?
  • 37 What causes IBS?
  • 38 What is the pain associated with IBS like?
  • 39 Can IBS be mistaken for gynaecological problems?
  • 40 How can my IBS be treated?
  • 41 What other treatments are available for IBS?
  • 42 What can be done to reduce the amount of bowel gas(flatus)
  • 43 What is constipation?
  • 44 What causes constipation?
  • 45  How can constipation be treated?
  • 46 How could we summarise the treatments that are available for my pelvic pain?
  • 47 Where can I obtain more information?
  • 48 Pelvic Pain Support Groups.
  • 49 Endometriosis Support Groups.
  • 50 IBS Support Groups.
  • Women's Health


    The aim of this web site is to provide a general guide and it is not intended as a substitute for a consultation with an appropriate specialist in respect of individual care and treatment.

    The aim of this web site is to provide a general guide and it is not intended as a substitute for a consultation with an appropriate specialist in respect of individual care and treatment.

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