Female Sexual Dysfunction & Dyspareunia

Painful sex is common — around 14% of Australian women report dyspareunia in the past year. This page covers the presentation of dyspareunia (superficial vs deep), and the two commonest specific sexual-pain conditions: provoked vestibulodynia and vaginismus. Vulval skin causes are on Vulvar disorders; deep causes (endometriosis, adenomyosis, PID, fibroids) on their own pages.

Dyspareunia — sorting superficial from deep

Superficial (entry) dyspareunia

• Insufficient lubrication / arousal — hormonal (postpartum, breastfeeding, menopause, DMPA), vaginal/vulval atrophy, or psychological factors/medications.
• Inflammation, infection or skin disorder — candidiasis, trichomonas, HSV; eczema, lichen sclerosus, lichen planus, psoriasis, contact dermatitis; provoked vestibulodynia.
• Anatomical / muscular — intact or thickened hymen, tight/overactive pelvic floor, vaginismus.
• Neuropathic — pudendal neuralgia.
• Other — endometriosis, recurrent UTIs/genital infections, birth or surgical trauma.

Deep dyspareunia

• Endometriosis, adenomyosis, PID, ovarian cysts, uterine fibroids, uterine prolapse, cystitis/interstitial cystitis, IBS, haemorrhoids.
• Post-surgical/treatment: pelvic surgery scarring, hysterectomy, prolapse repair, episiotomy, pelvic radiotherapy/chemotherapy.

The emotional loop

Stress, self-consciousness, depression, fear of intimacy and a history of sexual/ emotional abuse all reduce arousal and worsen pain — and pain that begins physically then generates anxiety, which worsens the pain. Address both sides.

Management

Treat the identified cause; the toolkit spans HRT/topical oestrogen for atrophy, a change of contraceptive method, lubricants, treating infection/skin disease, pelvic floor physiotherapy, psychology/psychosexual counselling, and gynaecology referral (especially for deep dyspareunia).

Provoked vestibulodynia

Severe vulvar/vestibular pain on touch or attempted entry — the archetype is a young, nulliparous, sexually active woman in her 20s–30s with superficial entry dyspareunia, often after a 2–3-year diagnostic delay.

• Examination: a tender vestibule on pinpoint cotton-bud pressure, with an otherwise normal-looking vulva.
• Management: education and validation; multidisciplinary care; pelvic floor physiotherapy (awareness and elasticity of the introital tissues); psychosexual counselling for the relational impact; generous lubricant for intercourse.

Vaginismus

Persistent or recurrent difficulty allowing vaginal entry of a penis, finger, tampon or any object despite wishing to — from involuntary pelvic floor/introital muscle contraction, often driven by fear of penetration (fear of damage, of pregnancy, learned negative attitudes, or past sexual trauma).

• Diagnosis is clinical, after excluding other causes/comorbidities (vulvodynia, skin disease, infection, atrophy).
• Management is multidisciplinary and multimodal, and takes patience and some trial and error:
  • Validate the experience and educate on anatomy/physiology — the GP role here is pivotal.
  • Pelvic floor physiotherapy for down-training/relaxation.
  • Graded vaginal trainers/dilators, used by the patient at her own pace, in a comfortable position, with lubricant.
  • Psychology / CBT / psychosexual therapy, especially where fear or trauma underlies it.
  • Treat any contributing pain condition.