Dyspareunia (Painful Sex)

Dyspareunia is genital or pelvic pain during or after sexual intercourse. It is a symptom rather than a disease, with causes ranging from infection and hormonal changes to pelvic conditions and muscle tension. Treatment is planned according to the cause. You do not need to regard painful intercourse as normal or endure it; it can be assessed and help is available. This information is general, not individual diagnostic or treatment advice.

What is dyspareunia?

The location of the pain is an important clue to its cause. It is traditionally considered in two groups.

Pain at entry (superficial pain)

Pain at entry is burning, stinging or aching felt as penetration begins or at the vaginal opening. It may be related to vulval and vaginal tissue, infections, low oestrogen levels or structural causes.

Deep pain

Deep pain is felt further inside, in the lower abdomen or pelvis, and often worsens in certain positions. This type of pain may be associated with pelvic causes.

The distinction is not always clear; some people experience both.

What may cause dyspareunia?

Infections and skin or mucosal causes

Vaginal and sexually transmitted infections, vulval skin conditions and irritation are among the common causes of superficial pain. It helps to tell the doctor about accompanying discharge, itching, burning or a change in smell.

Hormonal causes (menopause)

Falling oestrogen levels after menopause can lead to thinning and dryness of vaginal tissue, which may increase pain during sex.

Pelvic causes

Endometriosis, pelvic congestion, bladder symptoms and conditions involving the womb or ovaries may be associated with deep pain. The causal role of each varies between individuals. For example, finding endometriosis does not mean it is the only explanation for pain. Tenderness in the bladder and pelvic floor muscles is also known to play a role in pain severity. Assessment therefore relies on interpreting the history and examination findings together.

Pelvic floor muscles and psychosocial factors

Tension in the pelvic floor muscles, anticipation of pain, anxiety and past negative experiences may increase or maintain pain. These presentations overlap with conditions discussed on separate pages. Pain should not be regarded as only psychological: physical causes are assessed first, and several factors often play a role together.

Which symptoms need attention, and whom should you see?

It is appropriate to seek care if pain recurs, affects your sex life or relationship, or leads to avoidance. The first point of contact is usually an obstetrician and gynaecologist. Depending on the assessment, other professionals, such as a pelvic floor physiotherapist, sex therapist or psychologist, may become involved.

Severe, sudden pain, heavy bleeding or fainting is an emergency. Seek care at an emergency department without delay.

How is dyspareunia assessed?

Assessment begins with a discussion of the location and duration of pain, the movements that trigger it, its relationship to periods, urinary and bowel symptoms, medicines, infection risk and psychosocial factors. A pelvic examination is then performed with the person's consent. Its scope is agreed with you, and you can ask for the examination to stop. Infection screening, hormone assessment or imaging may be added if needed. A definite cause may not be found in every person. Conditions such as vulval pain and genito-pelvic pain are often considered after other causes have been excluded.

How is dyspareunia treated?

The shared principle of treatment is to address the cause identified. An infection receives appropriate treatment. For dryness and thinning related to low oestrogen, the doctor may consider local treatment or hormonal options judged suitable. If a pelvic disease is identified, treatment is planned for it. When pelvic floor muscles play a role, approaches such as physiotherapy and sex therapy may be considered. The choice and duration of medication are medical decisions. It is not possible to say in advance how long treatment will take or whether the pain will disappear completely; responses vary between individuals.

How can pain affect my relationship with my partner?

Painful sex may gradually lead to reduced desire, anxiety and avoidance of sex. This is an understandable response for many people. Talking openly with a partner about pain and reaching a shared understanding about being able to stop and set the pace may help. Forms of intimacy without penetration may also be an option during this time. Nobody has to continue having sex despite pain.

How do dyspareunia, vaginismus and vulval pain differ?

• Dyspareunia: The general name for the pain symptom; causes vary.
• Vaginismus and genito-pelvic pain: A specific condition in which fear of penetration and involuntary contraction of the pelvic floor muscles are prominent.
• Vulval pain: Vulval pain and vulval conditions that may persist independently of sex.

Not all pain during sex is vaginismus, and diagnosis requires medical assessment.