Pain During Sex (Dyspareunia): Causes, the Endometriosis Connection and What Helps

Two patterns, two sets of causes

Superficial (entry) dyspareunia is pain at the vaginal opening at the start of penetration: burning, stinging, tearing or a feeling of being too tight. Deep dyspareunia is pain felt inside, low in the abdomen or toward the back, with deep thrusting or certain positions; it is often described as hitting something, and may continue as a deep ache for hours or into the next day.

Many women have both, because years of deep pain teach the pelvic floor to tense protectively, which then causes entry pain. Describing which pattern you have, and when it started, is the most useful information you can give a clinician.

Causes of deep pain during sex

• Endometriosis, especially deep disease behind the uterus, on the uterosacral ligaments and in the rectovaginal space, which sits exactly where deep penetration presses.
• Adenomyosis and fibroids, which make the uterus tender and bulky.
• A uterus tilted backward (retroverted) and fixed by adhesions from endometriosis, infection or surgery.
• Bladder pain syndrome, where pressure on the bladder during sex causes pain and urgency.
• Pelvic inflammatory disease and ovarian cysts.
• Pelvic floor muscle tension and pelvic nerve pain, which amplify every other cause.

Causes of pain at the entrance

• Pelvic floor muscle hypertonicity or involuntary spasm (vaginismus), often secondary to chronic pelvic pain or past painful experiences.
• Vulvodynia and vestibulodynia: nerve-related burning pain at the vaginal entrance.
• Low estrogen from breastfeeding, menopause or some hormonal contraceptives, causing thinning and dryness.
• Infections, skin conditions such as lichen sclerosus, and scarring from childbirth or surgery.
• Insufficient arousal or lubrication, frequently a consequence of anticipating pain rather than its cause.

The endometriosis connection

Deep dyspareunia is one of the most specific symptoms of endometriosis, and in deep disease it can be the dominant complaint. The lesions behind the cervix and in the space between the vagina and rectum are directly compressed during intercourse, and the inflamed, scarred tissue does not stretch. Pain is often worst in the days before menstruation and after it, and may be accompanied by painful bowel movements, because the same lesions involve the rectum.

Women with endometriosis-related dyspareunia frequently report that the pain, more than any other symptom, has damaged relationships and self-image. It is also the symptom they are least likely to volunteer. Clinicians who treat endometriosis should ask about it directly, and patients should know that reporting it changes the evaluation.

How it is evaluated

A careful history establishes the pattern (entry or deep), the timing in the cycle, how long it has been present and what else hurts. The examination is done gently and in stages: inspection of the vulva and vestibule, a cotton-swab test for vulvodynia, a single-finger examination of the pelvic floor muscles for tenderness and tightness, and then a bimanual examination feeling for nodules behind the cervix, a fixed uterus or tender ovaries. Transvaginal ultrasound looks for endometriosis, adenomyosis and cysts. A woman can and should ask to stop the examination at any point.

Treatment

• Treat the cause: hormonal therapy and excision surgery for endometriosis relieve deep dyspareunia in most women; treatment of adenomyosis, infection or skin disease addresses those causes.
• Pelvic floor physical therapy: the cornerstone for entry pain and for the muscle guarding that accompanies deep pain. It includes manual release, relaxation training and, where helpful, dilators.
• Local estrogen for low-estrogen states; lidocaine or other topical agents for vestibulodynia.
• Lubricants, positions that limit deep penetration and control depth, and communication with a partner reduce pain while treatment takes effect.
• Nerve-directed treatment when pudendal or other pelvic nerve pain is involved.
• Psychosexual support for the fear-tension-pain cycle, as part of treatment rather than instead of it.

Talking to your clinician

Say whether pain is at the entrance or deep, whether it lingers afterward, how it relates to your cycle, and what else hurts. If the clinician does not ask about sex, raise it. If you are told the cause is psychological without an examination, ask for one or for a referral to a pelvic pain specialist. Deep dyspareunia with painful periods is endometriosis until proven otherwise.