PAINFUL INTERCOURSE (dyspareunia)

What is painful intercourse?

Painful intercourse is persistent or
recurrent genital pain that occurs just before, during or after intercourse. It may result from various reasons ranging from physical and medical problems to
psychological issues. Many women
experience painful intercourse at some point in their lives.

Symptoms of painful sex

The symptoms of painful intercourse may vary between women, but individuals with such conditions may experience one or more of the following:

    · Pain with only sexual penetration
    · Pain with every penetration, even while putting in a tampon
    · Pain with certain partners or just under certain circumstances
    · New pain after previously pain-free intercourse
    · Deep pain during thrusting, which is often described as "something being bumped"
    · Burning pain or aching pain

Causes of painful sex

These can be considered under deep pain and entry or superficial pain during sex.

Deep pain
Deep pain usually occurs with deep
penetration and may be more pronounced with certain positions.
1. Certain illnesses and conditions. The list includes:
a. Endometriosis
b. Pelvic inflammatory disease
c. Uterine prolapse
d. Retroverted uterus
e. Uterine fibroids
f.  Cystitis
g. Irritable bowel syndrome
h. Hemorrhoids
i.  Ovarian cysts

2. Infections or problems with your cervix:
Any infection or problems with the cervix will cause pain during intercourse. This is because they can cause tenderness of the areas around the cervix and deep
penetration would cause pain.

3. Surgeries or medical treatments. Scarring from surgeries that involve the pelvic area can cause painful intercourse.

4. Ectopic pregnancy: This is the pregnancy that takes place outside the womb (uterus), usually in the Fallopian tube. Pressure on it can be very painful.

5. Medical treatments for cancer, such as radiation and chemotherapy, can cause changes that make sex painful.

6. Emotional factors: Emotions are deeply intertwined with sexual activity and may play a role in any type of sexual pain.

7. Psychological problems. Anxiety,
depression, concerns about your physical appearance, fear of intimacy or relationship problems can contribute to a low level of arousal and a resulting discomfort or pain.

8. Stress. Stress conditions that cause painful sex because they induce tightening of pelvic floor muscles.

9. History of sexual abuse. The majority of
women with painful intercourse have
history of sexual abuse

Entry or superficial pain
The causes include the following:
1. Insufficient lubrication. Insufficient
vaginal lubrication may be due to
inadequate foreplay, nervousness, or
failure to relax during sexual intercourse.
It can also be caused by lowering levels of
estrogen after menopause, after childbirth
or during breast-feeding as well as certain
medications for birth control, high blood
pressure and depression

2. Injury, trauma or irritation. Injury to the
vulva or vagina can occur during rape or
sexual assault and later cause painful sex.
Others include injury caused by a
childbirth tear or the episiotomy cut that
is often made during labour.

3. Inflammation, infection or skin disorder.
These include infection with vaginal
thrush, trichomonas, blisters of herpes
and eczema.

4. Vaginismus. Involuntary spasms of the
muscles of the vaginal wall (vaginismus)
can make attempts at penetration very
painful.

5. Vulvitis: This means inflammation of
the vulva (the opening to the vagina). It
can be due to all sorts of causes,
including chemicals in bubble-baths or
soaps.

6. Hematoma of the clitoris: This is a bruise
(or collection of blood) in the clitoris
caused by excessive friction. Can cause
painful sex.

7. Urethral caruncle: This is a tender patch
that develops at the urinary opening

8. Vulvodynia: A distressing and long-lasting condition in which the outside
part of the sex organs (the vulva) is so
sensitive, just touching the area makes
the woman jump with pain.

Diagnosis
Diagnosis of painful sex includes the
following:
• Medical history: Taking medical history by
the doctor may entail asking some
questions to enable him or her to make
proper diagnosis and ascertain cause.
Some of the things the doctor might want
to know include:
· Any medical conditions
· When the pain began
· Exactly where it hurts
· How the pain feels
· Whether the pain is situational, all the
time, or with a particular sexual partner
· Any previous surgeries
· Childbirth experiences
These will guide the doctor in both the
diagnosis and deciding the direction or
course of treatment.

• Pelvic examination: This involves the
doctor checking the vagina and pelvic
areas to feel any signs of problems, or infections. A device called the speculum
might also be used to help with visual
examination of the vagina.

• Other tests: Ultrasound and other tests
might also be conducted if some
abnormalities are discovered during the pelvic examination.

Treatment of painful sex
Treatment of painful sex in women varies and depends on the cause. Some options include:

Vaginal lubricants: These are helpful in cases where the painful sex is due to
vaginal dryness and lack of lubrication.
They lubricate the vagina and make sex
more enjoyable. They are available in
different delivery forms such as creams,
gels, or suppositories. There are both
water-based and oil-based products
formulations of lubricants. The water
based products are preferred because oil
based lubricants interact with latex
condoms and cause them to break.

Topical estrogen: Estrogen formulations
either applied as a cream or vaginal
insert, are very useful in menopausal
women. These products can help
ameliorate painful intercourse from
vaginal dryness or sensitivity making sex
more comfortable for these women.
Painful sex after pregnancy can be
managed by waiting at least six weeks
after childbirth before attempting
intercourse. Make sure to practice
gentleness and patience.

Medications: For painful sex that is a result of an infection or medical condition,
treating the underlying cause may resolve your problem.

Psychotherapy
Psychotherapy can help a woman identify
problems in her life that may be
responsible for the painful sexual
intercourse. Some of these include past
sexual or other abuse, or traumatic sexual
encounters, attitude towards sex,
relationship problems etc.
The goal of psychotherapy is to identify
and get rid of these problems.

Sex therapy
The sex therapist identifies problems that
may be contributing to the condition, and
thereafter, recommends specific exercises
to re-focus the individual’s attention and
expectations.
Sex therapists may also use or
recommend any or combination of the
following methods or techniques
depending on the need and preferences of
the patients:
· Kegel exercises
· Sensate focus exercises
· Cognitive behavioural therapy
Kegel exercises
The Kegel involves squeezing and
releasing your pelvic floor muscles which
may help ameliorate painful sex.
Sensate focus
This is very helpful when painful sex
results from anxiety, nervousness or
insufficient foreplay.
Sensate focus is a type of sex therapy that
sexual partners complete together. In this
kind of therapy, both partners agree to
avoid sexual intercourse within a period
of time, between few weeks to months as
the case may be. During this period, they
can practice foreplay- massage, touch or
stroke each other, with or without clothes
on, but no touching of the genital area (or
a woman’s breasts).
After the agreed period of time has
passed, when the couple has well
explored each other’s body, they can
begin touching the genitals and this can ultimately lead to sexual intercourse.

Cognitive behavioural therapy (CBT)
Cognitive behavioural therapy (CBT) is
another form of counselling that may be
useful to ameliorate painful sex. This
technique basically helps the patient deal
with some negative thought pattern, as it
is believed that the way you feel is partly
dependent on the way you think about things.
The CBT therapist can help identify any unhelpful or unrealistic thoughts that may be contributing to the painful sexual
intercourse, for example thoughts about:
   Your self-esteem (the way you feel about yourself)
   Your sexuality
   Your personal relationships
Your CBT therapist will be able to help you to adopt more realistic and helpful thoughts about these issues.

References:
· Michael Castleman, Does Intercourse Hurt? A Guide to Women’s Sexual Pain
Psychology today May 2012
· Society for Women's Health Research (2007, November 13). Top Cause Of Painful Sex Uncovered. ScienceDaily. Retrieved
January 18, 2013, from http://
www.sciencedaily.com /
releases/2007/11/071109190251.htm
· Pain during intercourse,
emedicinehealth.com http://
www.emedicinehealth.com/
pain_during_intercourse/article_em.htm
accessed 15 November 2012
· Painful intercourse (dyspareunia),
netdoctor.com

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