Dyspareunia in women

Last updated: February 4, 2025

Summary

Dyspareunia in women is pain that occurs with vaginal intercourse or penetration. The pain may be superficial (with vaginal entry), deep (on deeper penetration or thrusting), or both. Causes include vulvar dermatoses, genitourinary infections, low estrogen states, and structural abnormalities. Clinical evaluation involves a detailed medical and psychosocial history and pelvic examination. The diagnostic approach depends on clinical findings and can include testing for infections, hormonal testing, and advanced studies such as imaging, cystoscopy, or biopsy. Common diagnoses of exclusion are vulvodynia and genito-pelvic pain/penetration disorder. Management is specific to the underlying cause.

Definitions

Superficial dyspareunia: pain that occurs on vaginal entry
Deep dyspareunia: pain (e.g., pelvic pain, rectal pain) that occurs with deep penetration or thrusting
Primary dyspareunia: no history of intercourse without pain
Secondary dyspareunia: new onset of pain with intercourse after previously not having pain

Etiology

Superficial dyspareunia ^[1]^[2]^[3]

Vulvar dermatoses
Bartholin gland cyst and abscess
Vulvodynia: vulvar pain lasting ≥ 3 months without a clear underlying cause ^[4]^[5]
- Generalized vulvodynia: pain that affects the entire vulva
- Localized vulvodynia: pain that affects a specific area of the vulva (e.g., vestibulodynia, which is pain localized to the vaginal vestibule)
Genito-pelvic pain/penetration disorder, including vaginismus ^[6]^[7]
Neuralgias (e.g., postherpetic neuralgia, pudendal neuralgia)

Deep dyspareunia ^[1]^[2]^[3]

Pelvic infections (e.g., pelvic inflammatory disease)
Interstitial cystitis
Structural
- Endometriosis
- Adenomyosis ^[8]
- Pelvic adhesions
- Uterine retroversion
- Uterine fibroids
- Ovarian cysts or masses
Gastrointestinal conditions (e.g., irritable bowel syndrome, inflammatory bowel disease)
Musculoskeletal conditions (e.g., arthritis. hip labral tear)

Superficial and/or deep dyspareunia ^[1]^[2]^[3]

Vulvovaginal atrophy and/or inadequate lubrication
- Low estrogen states
  - Primary ovarian insufficiency
  - Bilateral oophorectomy
  - Genitourinary syndrome of menopause
  - Pituitary dysfunction
  - Postpartum and/or breastfeeding
  - Medications (e.g., tamoxifen, GnRH agonists, aromatase inhibitors)
- Diabetes mellitus
- Cancer treatment (e.g., chemotherapy, radiation)
- Lack of arousal
Infectious or inflammatory
- Vulvovaginitis (e.g., bacterial vaginosis, vulvovaginal candidiasis, trichomoniasis, noninfectious vulvovaginitis)
- Urinary tract infections
- Genital herpes simplex
Structural
- Pelvic floor dysfunction (e.g., hypertonic muscles, pelvic floor muscle spasms, pelvic organ prolapse) ^[9]
- Hysterectomy
- Vulvar and vaginal injuries (e.g., perineal laceration, episiotomy, female circumcision)
- Vulvar and vaginal cancer
- Anomalies of the vulva and vagina (e.g., hymenal variants, vaginal septae, urethral diverticulum)

Postpartum dyspareunia can be related to multiple factors, including vaginal dryness due to breastfeeding, perineal trauma during delivery, postpartum depression, and/or relationship changes. ^[10]

Clinical evaluation

Use a nonjudgmental, trauma-informed approach with all patients, and provide affirmative care.

Focused history ^[1]^[3]^[11]

Pain characteristics, including:
- Duration
- Location (superficial dyspareunia vs. deep dyspareunia)
- Severity
- Specific provoking sexual activities
- Any relationship to menstruation ^[12]
Associated symptoms
- Vaginal or pelvic symptoms (e.g., vaginal discharge, vaginal bleeding)
- Other symptoms (e.g., urinary, GI, and/or musculoskeletal)
Changes in hormonal status (e.g., pregnancy, breastfeeding, menopause)
Risk factors for STIs
Past medical and surgical history
Psychosocial stressors (e.g., relationship and other life events); consider:
- Screening for depression
- Screening for generalized anxiety disorder
- Screening for IPV and sexual abuse (current or previous)
Medications (prescription and over-the-counter)

Assess patients for psychosocial factors (e.g., severe relationship stress, intimate partner violence, mood disorders) that can be risk factors for and/or consequences of dyspareunia. ^[1]^[12]

Focused examination ^[1]^[2]^[3]^[12]

Perform an abdominal and pelvic examination in all patients.

External genital examination
Vulvar cotton swab test ^[4]^[13]
Single-digit transvaginal examination ^[12]^[14]
Bimanual examination
Speculum examination
Assess for pelvic organ prolapse and cervical motion tenderness
Rectovaginal examination (in patients with rectal pain and/or deep dyspareunia)

Patients with dyspareunia may have anxiety about and/or difficulty tolerating a complete pelvic examination. Use a trauma-informed approach, clearly explain the examination steps, and emphasize that the examination can be stopped at any time. ^[1]^[3]

Diagnostics

Obtain diagnostic studies based on clinical presentation.

Laboratory studies ^[1]^[2]^[3]

Testing for suspected vulvovaginitis, e.g.:
- Vaginal pH test
- Amine test
- Microscopy (vaginal wet mount)
- Vaginal culture
STI testing, e.g.:
- NAAT for gonorrhea, chlamydia, and/or trichomoniasis
- Syphilis testing
- HIV testing
- Diagnostics for HSV infection
Pregnancy test
Urinalysis and urine culture
Hormone testing (e.g., prolactin, gonadotropins)

Other studies ^[1]^[2]^[3]

Pelvic imaging (e.g., transvaginal ultrasound, MRI pelvis): for suspected uterine or adnexal pathology
Vulvar skin biopsy: for suspected vulvar dermatoses or malignancy
Cystoscopy and urodynamic testing: for suspected interstitial cystitis ^[15]
Diagnostic laparoscopy: for suspected endometriosis

If an underlying cause cannot be identified in dyspareunia lasting ≥ 6 months, assess if the patient fulfills the diagnostic criteria for genito-pelvic pain/penetration disorder and manage accordingly.

Causes of superficial dyspareunia

Common causes of superficial dyspareunia ^[1]^[2]^[3]
	Characteristic clinical features	Diagnostic findings	Management
Vulvar dermatoses	Skin findings, e.g.: White plaques in lichen sclerosus Skin thickening in lichen simplex chronicus Six Ps of lichen planus Vulvar burning, itching, and/or pain	Clinical diagnosis Confirmatory skin biopsy in cases of uncertainty Identification of allergens on patch test for suspected contact dermatitis	See “Treatment of lichen simplex chronicus.” See “Treatment of lichen sclerosus.” See “Lichen planus.” See “Treatment of contact dermatitis.”
Genital herpes	Painful genital blisters or ulcers Flu-like symptoms with initial outbreak Prodromal symptoms with lesion recurrence	Clinical diagnosis Confirm HSV infection. See “Diagnostics of HSV infection.”	Antiviral medications Long-term suppressive therapy, if indicated Management of sexual partners See “Treatment for genital herpes.”
Bartholin gland cyst and abscess	Unilateral mass in posterior vaginal introitus Tenderness to touch with abscess	Clinical diagnosis	Sitz baths Incision and drainage Antibiotics in certain patients See “Bartholin gland cyst and abscess.”
Pudendal neuralgia ^[16]^[17]	Unilateral vulvar burning pain, paresthesias, and allodynia Pain worsens when sitting Pain may be triggered by defecation Urinary urgency and frequency Pain on palpation of ischial spine	Clinical diagnosis Diagnostic criteria for pudendal neuralgia: All of the following should be met. ^[17] Pain in the pudendal nerve territory Pain worse on sitting No nocturnal pain No sensory loss Symptomatic improvement on pudendal nerve block	Pelvic floor physical therapy Behavioral modification Pain management (see “Pharmacological treatment of peripheral neuropathy”) Pudendal nerve block
Vulvodynia ^[4]^[5]	Persistent vulvar pain lasting ≥ 3 months, often burning in nature with no skin findings Pain can be generalized or localized.	Diagnosis of exclusion Pain on vulvar cotton swab test	Avoidance of vulvar irritants Topical anesthetics (e.g., lidocaine ointment) Oral pharmacological treatment (e.g., tricyclic antidepressants) Interventional analgesia Biofeedback and pelvic floor physical therapy Psychotherapy
Genito-pelvic pain/penetration disorder ^[11]^[18]	Chronic difficulty, pain, or pelvic floor muscle tightening with vaginal penetration or intercourse Fear or anxiety related to the pain	Diagnosis of exclusion	Vaginal dilators Pelvic floor physical therapy Psychotherapy See “Genito-pelvic pain/penetration disorder.”

Causes of deep dyspareunia

Common causes of deep dyspareunia ^[1]^[2]^[3]
	Characteristic clinical features	Diagnostic findings	Management
Cervicitis ^[19]	Vaginal discharge Postcoital bleeding Cervical inflammation on examination	Clinical diagnosis Pathogen identification (e.g., NAAT for chlamydia and gonorrhea)	Treatment of underlying infection STI management of sexual partners See “Treatment of cervicitis.”
Pelvic inflammatory disease (PID) ^[19]	Lower abdominal pain Fever, nausea, vomiting Vaginal discharge Cervical motion tenderness	Clinical diagnosis Pathogen identification (e.g., NAAT for chlamydia and gonorrhea)	Empiric antibiotic therapy for PID Hospitalization for severe cases See “Treatment of PID” for details.
Interstitial cystitis ^[15]^[20]	Chronic suprapubic pain relieved by urination Urinary urgency and frequency Painful urethra and/or base of bladder on pelvic exam ^[12]	Clinical diagnosis Urinalysis and urine culture: negative for bacterial infection Cystoscopy: Hunner lesions may be seen.	Behavioral modification Pelvic floor physical therapy Oral pharmacological treatment (e.g., amitriptyline) See “Treatment of interstitial cystitis.”
Endometriosis ^[21]^[22]	Chronic pelvic pain and dysmenorrhea Infertility Dysuria, dyschezia Adnexal masses, tender palpable nodules on pelvic examination ^[1]^[2]^[12]	TVUS: endometriomas Laparoscopic biopsy can be used for a definitive diagnosis. A negative diagnostic workup does not exclude endometriosis.	Hormonal therapy (e.g., oral contraceptives) Pain management (e.g., NSAIDs) Surgery See “Treatment of endometriosis.”
Adenomyosis ^[23]	Chronic pelvic pain and dysmenorrhea Abnormal uterine bleeding Enlarged, mildly tender uterus on examination	TVUS: heterogeneous and asymmetrically thick myometrium ^[24]	Hormonal therapy (e.g., oral contraceptives) Pain management (e.g., NSAIDs) Surgery See “Treatment of adenomyosis.”
Ovarian cysts or masses ^[25]	Unilateral pelvic pain Abdominal bloating An adnexal mass may be palpable.	Pelvic imaging: ovarian cyst or mass See also “Diagnostics for ovarian cancer.”	Ovarian cysts Functional cysts: expectant management Symptomatic, large, or complicated cysts: surgery Ovarian cancer: Treatment depends on cancer stage. See respective articles for details.
Irritable bowel syndrome (IBS) ^[26]	Abdominal pain related to defecation Changes in stool frequency or appearance Bloating	Clinical diagnosis See “Diagnostic criteria for IBS.”	Dietary changes (e.g., low FODMAP diet) Stress management Symptom-directed pharmacological treatment See “Management of IBS.”

Causes of superficial and/or deep dyspareunia

Common causes of superficial and/or deep dyspareunia ^[1]^[2]^[3]
	Characteristic clinical features	Diagnostic findings	Management
Vulvovaginal atrophy	Vaginal dryness, pallor, thinning, itching, and burning Dysuria	Clinical diagnosis Findings related to underlying cause	Vaginal moisturizers and lubricants Treat the underlying cause, e.g., Discontinue triggering medications. Treat genitourinary syndrome of menopause Treat radiation-induced sexual dysfunction.
Vulvovaginitis	Vaginal discharge Vulvovaginal itching, burning, and inflammation	Signs of infection on testing of discharge (e.g., high vaginal pH, positive amine test) Pathogen identification (e.g., on NAAT or culture)	Avoidance of vaginal irritants Treat the underlying infection. See “Vulvovaginitis.”
Urinary tract infection (UTI)	Urinary frequency and urgency, dysuria Suprapubic tenderness	Signs of infection on diagnostics for UTI (e.g., positive urinalysis and urine culture)	Antibiotic therapy See “Treatment of UTIs.”
Pelvic floor dysfunction ^[27]^[28]	Urinary or defecatory dysfunction Pelvic organ prolapse Uncontrolled tightness or contractions of pelvic floor muscles on pelvic exam ^[12]	Clinical diagnosis Features of the underlying etiology, such as: ^[27] Pelvic organ prolapse or defecatory dysfunction on imaging Abnormal findings on urodynamics	Pelvic floor physical therapy Pharmacological treatment (e.g., muscle relaxants) Trigger point injections Treat the underlying cause.
Vulvar cancer ^[29]	Vulvar pain, mass, or bleeding	Malignancy on biopsy sample during colposcopy	Surgery, radiation therapy, and/or chemotherapy

Treatment

Treat the underlying cause.
A combination of treatment modalities are often necessary and may include: ^[2]
- Vaginal moisturizers and lubricants
- Topical and/or oral analgesics
- Pelvic floor physical therapy
- Procedural interventions (e.g., injections, surgery)
Refer to specialists (e.g., gynecologist, urogynecologist, pain management, psychologist) as appropriate.

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