Assessing Sexual Pain

I’ve talked before about dyspareunia, or pain with sexual intercourse. It’s a common problem; up to half of us are affected at least once during our lifetimes. This issue is a special focus for one of the MiddlesexMD medical advisors, Dr. Susan Kellogg Spadt, so I asked her to share her expertise.

The most common type of dyspareunia is referred to penetrative or superficial dyspareunia, meaning that it occurs at the opening of the vagina rather than deeper in the pelvis. Penetrative dyspareunia can be further classified as situational, secondary, or primary.

Situational penetrative pain may be related to transient factors like inadequate lubrication, certain thrusting techniques, a vaginal infection, or vulvar irritation. Secondary dyspareunia refers to the onset of consistent penetrative pain associated with each act of intercourse after a history of pain-free intercourse. Primary dyspareunia refers to the onset of penetrative pain at first intercourse, followed by consistent pain with each attempted act of intercourse.

Secondary and primary dyspareunia may be associated with a myriad of causative factors, including lack of estrogen in the vulvar tissues, vulvar dermatoses, scarring, fissures or adhesions, and psychogenic issues like past or current sexual abuse. One of the most common causes of pain is vulvar vestibulitis syndrome (VVS), also referred to as provoked vestibulodynia (PVD). This is characterized by localized redness, generalized rawness, itching, discomfort at the vaginal opening, and discomfort associated with a gentle cotton swab touch, upon exam, to the glands at the vaginal opening.

Definitive causes of VVS/PVD have not been identified. Events preceding symptom onset may include mechanical trauma caused by friction against atrophic tissues (tissues without sufficient estrogen, as happens after menopause) as well as irritation after vaginal infections, bladder infections, viral exposure, antibiotic use, or localized allergic responses.

Healthcare for the woman with VVS/PVD begins with competent and early diagnosis. Up to half of women are misdiagnosed. Most women are told that their symptoms are psychological, and that they need to “relax” or that they have an ongoing yeast infection. A simple physical examination can usually provide the correct diagnosis. In the “touch test,” vulvar structures like the glands of the vulva are tested with a cotton swab; the woman with sexual pain will often find these touches painful. Touch testing should be performed as part of a thorough pelvic and vaginal examination, including cultures for species identification for yeast (and bacteria, if necessary).

Managing dyspareunia often begins with anti-irritant hygiene regimens: avoiding scents, allergans, and irritants from soaps and other products. Other treatments a healthcare provider may prescribe include topical hormone creams, antifungal therapy, pelvic muscle physical therapy, biofeedback, and/or surgery.

Alternative approaches include use of topical creams like compounded creams containing capsaicin, amitriptyline, cromolyn, atropine, and other therapies such as acupuncture.

Women should be aware that symptoms are not “in their heads,” and that it may take months for pain to diminish. Patience is paramount. Maintaining a physical relationship (other than intercourse) with a partner is important, because “complete intimacy avoidance” can be common among women with sexual pain and can be detrimental to the couple's relationship.

relationship therapist can help women—and their partners—coping with sexual problems. Both patients and clinicians can learn more about the condition by visiting the National Vulvodynia Association website at

Q: What could cause this burning sensation?

A burning pain upon penetration is a classic symptom of vulvodynia (also known as vestibulodynia). The cause is not well understood, but it's more common in low-estrogen states--like menopause. The diagnosis is made by a careful examination of the area near the opening of the vagina or hymen; the area appears somewhat reddened and even touching lightly with a Q-Tip will cause discomfort.

I have seen significant improvement with "re-estrogenizing" the vagina, which is done with prescription localized estrogen that is absorbed only in the tissues in that area and does not circulate in significant levels throughout the body. Another successful option has been a compounded (custom-formulated by a pharmacist) topical combination of estrogen and testosterone, applied to the area twice a day for 12 weeks. These two options can also be beneficial in combination.

Finding the right practitioner who is familiar with this condition is critical. A gynecologist will be most helpful, and I recommend finding one who is NAMS (North American Menopause Society) certified and in your area by searching their website by zip code.

It is highly likely that this can be successfully treated and sex will be comfortable again!

Q: What do you recommend for pain that interferes with intimacy?

Your description of pain with the vaginal opening makes me think a really careful exam is your next step. It sounds like vulvodynia (also called vestibulodynia) should be considered. This condition results in pain with penetration, usually described as a burning or tearing sensation.

A lubricant can make penetration less uncomfortable, but it doesn't make it comfortable.

Another possibility is that the absence of estrogen has led to atrophy, resulting in the loss of caliber (size of the opening) of the vagina. If that's the case, using vaginal dilators may restore size and comfort.

In either case, I'd encourage you to see your healthcare practitioner. Stick with it! I know you can be comfortable and revive your sex life!