Painful intercourse (dyspareunia) 

Diagnosis  

A medical assessment for dyspareunia typically involves the following steps: 

• Detailed Medical History: Your healthcare provider will conduct a comprehensive review of your medical history. They will inquire about when your pain started, its location, nature, and whether it occurs with different sexual partners or positions. Questions about your sexual history, surgical history, and childbirth experiences may also be asked. It’s essential to answer truthfully, as these details provide important clues about the underlying causes of your pain. 
• Pelvic Examination: A pelvic examination will be performed to look for indications of skin irritation, infections, or anatomical abnormalities. Your healthcare provider may gently apply pressure to your genital and pelvic muscles to pinpoint the source of your discomfort. In some cases, a visual examination of your vagina may be conducted using a speculum to separate the vaginal walls. If this causes discomfort similar to what you experience during intercourse, you can request to stop the exam. 
• Ultrasounds: Transvaginal ultrasound may be used to obtain a more detailed view of the female reproductive system. 
• Laparoscopy (Rarely): In exceptional cases, if other diagnostic tests yield inconclusive results, a laparoscopy may be recommended as a further investigative procedure. 

Treatment  

Depending on the cause of the discomfort, various treatments are available. 

Medications  

Treating the underlying cause of pain, such as infections or medical conditions, can often resolve the issue. Switching medications known to cause lubrication problems may also alleviate symptoms. 

Dyspareunia, a common issue in postmenopausal women due to low estrogen levels, can be addressed with topical estrogen directly applied to the vagina. The Food and Drug Administration (FDA) has approved ospemifene to treat moderate to severe dyspareunia by mimicking estrogen’s effects on the vaginal lining. However, it comes with potential drawbacks, including hot flashes and risks of stroke, blood clots, and endometrial cancer. 

Another option to ease painful intercourse is prasterone, a daily vaginal capsule placement.  

Other treatments  

Some non–pharmacological treatments can be beneficial for dyspareunia: 

• Desensitization therapy: This approach involves learning exercises to relax the vaginal muscles, reducing pain during intercourse.
• Counseling or sex therapy: When painful sexual experiences continue over an extended period, they can trigger adverse emotional responses to sexual stimulation. Furthermore, couples who have abstained from intimacy due to this pain may require support to enhance communication and restore their sexual connection. Seeking guidance from a counselor or a sex therapist can be beneficial in addressing these concerns. Additionally, cognitive–behavioral therapy can prove effective in changing detrimental thought patterns and behaviors linked to dyspareunia.