Painful sexual penetration, dyspareunia, is not
only an extremely aggravating medical problem, but
is also a very difficult symptom for doctors to treat.
Once painful sex starts, the body and emotions react
physiologically to produce vaginal dryness and vulvar
contraction, which in turn make pain with sex even
worse. After a while, who is to say which came first
- the emotional stress that causes painful sex or
the medical condition that causes pain first and then
increased pain with sexual penetration?
A recent journal article, Marin MG, King R, Dennerstein
GJ, Sfameni S: Dyspareunia and Vulvar Disease. J Reprod
Med 1998; 43:952-58, is able to answer a few questions
along this line.
What are the general causes of painful sexual penetration?
unaroused sex - without adequate sexual stimulation,
the normal physiologic processes such as increased
vaginal lubrication, relaxation of the pelvic floor
muscles, enlargement of the vaginal space, and engorgement
of the labia which reveals the vaginal opening, do
not take place making sexual penetration much more
difficult.
medical disease - e.g.,yeast infections.
vulvar skin damage - e.g., frictional or chemical
trauma, contact or irritant dermatitis.
hormonal - e.g., breast feeding, menopausal estrogen
deficiency status, use of DepoProvera® for contraception
or ovarian or endometriosis suppression.
emotional - distress, anxiety, anger, depression,
personality style
How does painful sex develop?
In the beginning there is an original cause of dyspareunia.
Once the pain is produced, however, there is a psychological
distress, and a fear of pain again with each attempt
at sexual intercourse. This distress in turn causes
a lack of arousal which inhibits the normal sexual
lubrication and vaginal muscle relaxation and dilatation.
These factors in turn reinforce the pain with sex
that occurred in the first place. As you can see,
after awhile the original cause may disappear but
the painful sexual relations persists. Then the doctor
can't find an abnormality and doesn't know how to
medically treat this problem.
What are vulvar skin conditions that can cause painful
sex?
In this study by Marin et al., they looked at the
different diagnoses in women who presented to a dermogynecology
clinic and had a primary complaint of pain with sexual
penetration. Of those women in whom a physical, visual
change was found in the vulvar skin at the vaginal
opening, the following diagnoses were assigned:
Diagnosis Frequency (%)
candidiasis (yeast) 32.5%
contact dermatitis 28.6%
skin inflammation etiology unknown 27.2
other cause 11.7
If my doctor can't find a cause for pain with sex,
does that mean it can't be treated?
No. Marin et al, found no differences between groups
of women with and without vulvar skin findings and
pain with sex with respect to stress, anxiety or depression.
In each group, about 40% of the woman perceived an
increase in symptoms with stress. Women with vulvar
skin conditions had more stress at the time of onset
of their symptoms and women without any skin problems
had less coping skills, but for the most part all
the women need the same treatment regardless of whether
there is a visible vulvar disturbance. Education is
needed to make sure that sexual behavior changes so
that the pain problem is not aggravated, i.e., stop
having sexual relations if it causes pain. from 82
to 98% of women in these groups continued having sex
even though there was no desire.
The stress, depression and coping skills all need
to be treated whether there is a vulvar skin problem
or not. If there is a chance to offer or receive these
therapies early in the disease process, it needs to
be taken. Once vaginismus (involuntary vaginal muscle
tightening) starts, the cycle is very difficult to
break.
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