Clinical Review

Sexual Pain Disorders in Women

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Sexual pain disorders, for which women commonly present to the primary care provider, may impair sexual and interpersonal functioning and emotional quality of life. Numerous anatomical, physiological, endocrine, and psychosocial mechanisms may cause or exacerbate coital pain, making diagnosis challenging; treatment may require an integration of medical, surgical, and physical therapy, as well as cognitive behavioral interventions.


Though common, sexual pain disorders in women are often difficult to identify and treat because of the complexity of potential underlying causes. This article will define and describe these conditions in an effort to provide evaluation and treatment strategies for the primary care provider.


Dyspareunia is defined as genital pain that may occur before, during, or after vaginal penetration, thus interfering with sexual intercourse and causing marked personal distress and/or interpersonal difficulty.1 Categorization of the condition as lifelong (primary) or acquired (secondary), generalized or situational, may indicate possible underlying causes. Physiological, psychological, or combined factors may be at play. It should be noted that, according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DMS-IV-TR),1 painful penetration is not diagnosed as dyspareunia if it is solely the result of lack of lubrication, the physiological effect of a medication, or attributable to the patient’s general medical condition.

Painful intercourse is a prevalent symptom among sexually active women. Between 8% and 21% of women in the general population and 10% of those ages 57 to 85 have been estimated to experience significant dyspareunia.2,3 For some women, sexual pain leads to avoidance of sexual intercourse or contact. Other women remain sexually active despite persistently painful intercourse.

Transient pain during intercourse is predictable in certain situations, such as times of stress, with frequent intercourse (eg, in attempts to conceive), intercourse after a prolonged hiatus from it, or hymenal rupture at coitarche. Dyspareunia, particularly deep dyspareunia, may occur with midcycle intercourse due to normal local inflammation that occurs with ovulation (mittelschmerz).

A second sexual pain disorder experienced by women is vaginismus, which is defined as recurrent or persistent involuntary contraction or spasm of the musculature of the outer third of the vagina (the perineal and levator muscles) that interferes with vaginal penetration, whether associated with sexual intercourse, speculum insertion, or tampon use.1,4-6 Vaginismus may be a cause or a consequence of dyspareunia. This condition is perhaps best described as pelvic floor motor or muscular instability,7 because it can be characterized by:

1) Hypertonicity (reduced ability to relax)

2) Hypocontractility (reduced abil­ity to contract) or

3) Resting muscular instability (as measured by electromyelography [EMG]).8

According to DSM-IV-TR criteria,1 vaginismus also causes marked personal distress or interpersonal difficulty and is not due exclusively to the direct physiological effects of a general medical condition. Vaginismus may occur as a result of psychological factors, such as fear of penetration, or as a conditioned response to pain.

Dyspareunia and Vaginismus: A Clinical Case

Anna is a 30-year-old woman who has been married for three years. She reports that initially, intercourse with her husband was satisfying and pleasurable. She desired sex and was easily aroused and orgasmic. However, when she began to experience a burning pain during intercourse, she tried at first to ignore it, hoping that it would go away on its own. Anticipating pain, she started to avoid sex. When she finally saw her clinician, she was given a diagnosis of candidiasis and responded well to medication.

Although the physical cause of Anna’s dyspareunia was resolved, she continued to be tense when she anticipated an opportunity for sex, associating it with the prior painful experiences. When the couple did attempt vaginal intercourse, penetration was difficult and painful in a different way; it seemed as if the opening to her vagina was closing up, that it was becoming too tight. Anna felt frustrated with herself and her body and worried that her husband would give up on her.

She returned to her clinician, who referred her to a sex therapist. Anna was anxious and skeptical at first but also highly motivated to resolve the pain and resume her previously satisfying sex life. The therapist explained the connection between Anna’s original experience of dyspareunia and the anxiety/avoidance pattern that had developed, causing her pelvic floor muscles to overcontract involuntarily and to make penetration both difficult and uncomfortable. Even though the original physical source of painful intercourse was resolved, Anna had gone on to develop anticipatory anxiety, triggering secondary vaginismus—an automatic, protective response against anticipated pain.

A brief course of cognitive behavioral sex therapy helped Anna to resolve her anxiety, relax her pelvic floor muscles, and gradually return to satisfying sex.


There is a wide and confusing spectrum of causes of primary and secondary dyspareunia. Primary dyspareunia, the less common condition, is associated with imperforate or microperforate hymen, congenital vulvovaginal abnormalities, and acquired vulvovaginal abnormalities resulting from genital surgery, modification, or infundibulation.9


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