Intercourse Difficulties In Women:
Pain, Discomfort, And Fear

Female dyspareunia . . . may be one of the earliest recognized sexual dysfunctions . . . the most

common . . . possibly the most underreported . . . and the sexual dysfunction most linked to physiological

pathology. Perhaps one of the reasons why the literature . . . is filled with absolutes is

because of one further distinction - it is clearly the most underinvestigated . . .

Meana and Binik, 19941


The Problem

A 32-year-old nurse was seen in consultation with her 35-year-old husband. They

were married seven years and had two children. Their sexual experiences had always

been pleasurable and free of problems until two years ago. Immediately after the

birth of their second child, she experienced persistent pain whenever intercourse

was attempted. The pain was located at the entrance to her vagina and became evident

only with entry. Before her vaginal pain began, the frequency of intercourse was

several times each week but now was reduced to once or twice each month. She and

her husband remained sexually interested and sexual activity (excluding, by agreement,

attempts at intercourse) occurred several times each week.

The use of tampons had never been a source of difficulty for her but she stopped

using them after her last childbirth. Vaginal examinations by her doctor were uncomfortable

in the past but now they were associated with great pain. At her request her

husband stopped inserting his finger into her vagina during sexual experiences. On

examination by a gynecologist, there was vaginal spasm at the introitus and mild

reddening in the 4 to 9 o’clock area of the vestibule. The cotton swab test (see Figure

13-2 and `Physical Examination’ below in this Chapter) showed exquisite tenderness

in this same region, indicating a diagnosis of vulvar vestibulitis.

Anesthetic ointment relieved her pain temporarily but also diminished pleasurable

feelings. Vaginal dilators helped relieve the vaginal spasm so that when intercourse

occurred it was less painful. Surgery was discussed with her and while she

and her husband viewed this as a possible option, they preferred to wait until other

approaches were exhausted.


A 23-year-old school teacher was seen with her husband of eight months because

intercourse was attempted on many occasions but had never actually occurred

(either during her marriage or before). She reported experiencing vaginal discomfort
when intercourse was attempted. Both were born of families that emigrated

from Asia and had known each other since childhood. The marriage was born of a

love relationship rather than having been arranged but they nevertheless refrained

from including intercourse in their sexual activities before their wedding because of

family, religious, and cultural proscriptions. Both families were applying not-sosubtle

pressure on the couple to have children. No one else knew of their inability

to have intercourse. She was terrified of pain and expected to experience pain with

anything entering her vagina (or going out, hence also her fear of childbirth). Her

dread of pain with intercourse was so strong that she cried out when he neared her

vulva (a reaction that made him progressively less enthused about making any

attempt at vaginal entry).

In an initial inspection-oriented pelvic examination, the patient was in a semireclining

position and watched the procedure with a handheld mirror. Cotton swab

test was negative. When on a subsequent occasion the end of the physician’s finger

was introduced into the patient’s vagina, the physician could feel a ring of surrounding

muscle. The diagnosis of vaginismus was made and the patient and her

husband began a treatment program. About four months later, intercourse occurred

successfully on many occasions, and when last seen she was pregnant.



Terminology problems have more to do with health professionals than with patients

or the lay public. Vulvodynia is a general term recommended by the International

Society for the Study of Vulvar Disease (ISSVD) to describe any chronic discomfort

or pain in the vulvar region regardless of etiology and not necessarily related to

sexual activity.2 Dyspareunia is more specific in describing pain associated with sexual

intercourse. Dyspareunia could be felt at the point of vaginal entry, associated with

the back and forth movements of intercourse, or deep within the patient’s vagina.

Insofar as pain with intercourse is discussed, this chapter concerns itself principally

with the first.

However, patients may complain of vaginal “discomfort,” rather than pain, when

intercourse occurs. Whether such discomfort always represents mild pain, does so

sometimes, or is something else altogether is unclear. The multiplicity of problems

that are inherent in the present use of the word “dyspareunia” were outlined by

Meana and Binik and include issues such as unclear definition, disagreement over

the inclusion or exclusion of certain disorders (such as vaginismus and postmenopausal

vaginal dryness), confusion about the role of physical and psychological factors

in the etiology, and the meaning of not finding abnormalities on pelvic examination.

1 Another source of confusion can be found in the use of the word vaginismus,

which in the literature describes (1) a physical sign accompanying various casuses

of painful intercourse and (2) a specific disorder. (In this Chapter, the words “vaginal

spasm” will be used to describe the former, and “vaginismus” will refer to the


Vulvar vestibulitis (VVS) is a specific diagnostic term that is defined and discussed

below in this chapter.



While the heading “Sexual Pain Disorders” was not carried over from DSM-IV3 to

DSM-IV-PC4, both classification systems continue a tradition of asking clinicians to

think of two disorders (dyspareunia and vaginismus), and to do so in an either/or fashion.

The criteria for both are summarized in the PC version respectively as follows:

“recurrent or persistent genital pain . . . before, during, or after sexual intercourse,

causing marked distress or interpersonal difficulty” (p. 117) and “recurrent or persistent

involuntary spasm of the musculature of the outer third of the vagina that interferes

with sexual intercourse, causing marked distress or interpersonal difficulty” (p. 118).4


Classification Problems: Distinguishing Dyspareunia And Vaginismus

In relation to the problem of pain, discomfort, and/or fear of intercourse in women,

DSM-IV-PC4 definitions and accompanying clinical information often conflict with

clinical experience and result in confusion when trying to distinguish dyspareunia and

vaginismus. The two often occur together. For example, when intercourse is attempted

in the context of vaginismus, patients usually complain of pain (although fear of pain

may be much more prominent). Likewise, when persistent painful intercourse occurs

for reasons other than vaginismus, it is clinically commonplace to see associated vaginal

spasm. In such instances, vaginal spasm seemingly functions as a symptomatic and

defensive (usually involuntary) reaction of the woman to protect herself against anticipated



Subclassification: Descriptions

Theoretically, the subclassification of disorders that cause fear, discomfort, or painrelated

difficulties with intercourse in women involve the assessment of whether the

problem is lifelong or acquired, situational or generalized. In clinical practice, the first

two patterns described below are most commonly seen; the third probably occurs

frequently in the community but is uncommonly presented to health professionals.

The assessment of pain, discomfort, or fear associated with attempts at intercourse in

women is outlined in Figure 13-1.


Lifelong and Generalized

When hearing that pain or fear associated with attempts at intercourse have always

existed, the history is often that of an unconsummated marriage. Not only has a man’s

penis never entered her vagina, but the same story is also heard concerning her own,

or her partner’s fingers, tampons or a physician’s fingers or speculum. Alternatively,

vaginal entry of a current or previous partner’s penis may have taken place but pain

persisted through much of the experience of intercourse. Prior to intercourse attempts

(e.g., in the premarital period when a woman resolutely decides against having intercourse

before marriage), she often found herself sexually interested, wet, and possibly

orgasmic. While this response may have continued in the short run (e.g., after marriage),

the pattern may have altered in the long run as a result of pain and fear connected

to present attempts at penile entry. In such a situation, women typically feel




self-deprecatory, saying that they feel “abnormal” as women and as a marital and sexual

partner. In a frenzy of ambivalence, she may have explicitly suggested to her partner

that he “find himself someone else” while simultaneously fearful that he will do exactly

that. The agony of feeling unable to become pregnant through intercourse is often the

final straw that drives her to the humiliating admission that help is necessary to accomplish

what television, magazines, and billboards shout is a common event for the rest

of mankind.


A 22-year-old woman saw her family doctor because she had married three weeks

before but was unable to have intercourse despite numerous attempts. It was evident

that she was fearful of vaginal entry but it was not evident whether she also

experienced pain when intercourse was attempted. She and her husband were sexually

active with one another in the three years of their courtship but decided for

religious reasons that intercourse should be included only after they married. Their

sexual practices did not include vaginal insertion of his fingers, and, as well, she

never had intercourse with a previous sexual partner, did not like the idea of tampons,

and never had a vaginal examination from a physician. Neither she nor her

husband described any other difficulties with their sexual function.

A pelvic examination was scheduled for the following day when the physician

could allocate a greater amount of time. The external vulvar examination revealed

no structural pathology and a negative swab test. The physician then explained her

diagnostic impression of vaginismus and aspects of the anatomy and physiology of

the patient’s vagina, reassured the patient that there were no apparent structural

problems impeding intercourse, described the importance of control by the patient

in relation to vaginal insertion, and encouraged the patient to insert her own and

then the doctor’s finger part-way into her vagina. With patience and encouragement

from the doctor, finger insertion took place. The patient was enormously

pleased and felt a sense of accomplishment. She was encouraged to guide her husband’s

penis into her vagina in the same manner as her own finger. When seen one

week later, the patient related that intercourse occurred on three occasions, the

last two times without any difficulty.


A 38-year-old woman was seen alone because of a lifelong inability to have intercourse.

Her first marriage was annulled after five years, primarily because of “nonconsummation.”

She had pleasurable sexual experiences since her separation ten

years before but she always managed to avoid attempts at intercourse. Over the

years, she was unwilling to accept suggestions made by her family physician (aware

of the problem because of the impossibility of vaginal examinations) for referral to

a sex therapist. Presently, she was in the midst of a serious relationship and was

contemplating marriage. However, she was also fearful of the implications of her

inability to engage in intercourse. Her partner was accepting of this limitation but

at the same time was encouraging her to obtain medical care.

A vaginal examination, conducted by a consultant, resulted in a negative swab

test, and it was possible to only partially insert a single finger because of enormous

fear of pain and severe muscular tightness at the vaginal entrance. A suspected

diagnosis of vaginismus was confirmed. She remained unwilling to consult

a sex therapist and insisted on not involving her partner in the treatment program,

explaining that she had this problem long before their relationship began.

She was unable to insert the smallest dilator and felt pessimistic about the benefit

of this approach. When last seen she had remarried and was sexually active without



Acquired and Generalized

In this syndrome, the most commonly heard story concerning vaginal pain with intercourse

is that the woman had no prior difficulty. Typically, her previous sexual enthusiasm,

ease of arousal, and orgasm contrasts sharply with her present reticence. The

current experience of pain tends to be associated with anything entering her vagina

(penis, fingers, a vaginal speculum), and the discomfort is particularly located at the

vaginal entrance and especially in the “horseshoe” 4 to 8 o’clock area. The intercourse

pain is described as “tearing” and occurs with initial vaginal entry but is sometimes

characterized as burning and connected more with the friction of continuous coital

movement. Discomfort may continue for several hours after the sexual experience.


A 27-year-old woman, married four years, was seen by her family physician because

of pain associated with intercourse. She related that before the past two years, she

only rarely experienced pain during intercourse and it lasted only a matter of seconds

and was relieved by change in position. Her sexual interest was equal to that

of her husband and other male partners before she married, she had no difficulty

becoming vaginally wet when interested, and would easily come to orgasm. Since

the past two years, all of this had changed. Pain associated with vaginal entry had

become gradually more common and increasingly severe and as a result she found

herself only marginally interested in sexual activities, often used an artificial lubricant

because of insufficient vaginal lubrication, and only occasionally would come

to orgasm. She described the pain as in the 6 o’clock area of her introitus, burning

in character, and somewhat relieved by the cessation of intercourse, although the

discomfort after would necessitate her sitting in a bath to obtain some lessening of

the feeling of irritation.

On examination, the swab test was positive in many locations and a diagnosis

of vulvar vestibulitis (VVS) was made. With an initial focus on her diminished

sexual desire, psychologically oriented treatment was begun. Counseling also

focused on helping her and her husband explore other sexual practices other than

intercourse. Intercourse occurred periodically and was eventually experienced with

little or no discomfort on her part. Despite improvement on many levels, her lack

of sexual enthusiasm did not change and more aggressive treatment of her VVS at

that time was not something she thought desirable.


Acquired and Situational

In contrast to the lifelong form, the history reveals intercourse without difficulty in the

past, and in contrast to the generalized form, only vaginal entry of a man’s penis in the

present results in discomfort (rather than tampons, fingers, and speculum). Other features

of the syndrome may include the following:

• Variability in appearance of the pain, age of patient (youth), sexual


• The presence of psychosocial explanatory factors

• The lack of pathological findings with pelvic examination

None of these features are pathognomonic.


A 19-year-old single woman was concerned that since about six months ago, intercourse

was associated with pain—a facet of her sexual experiences that had never

occurred before in previous relationships. Although dyspareunia was frequent now,

it was also quite irregular. Her relationship with her boyfriend of ten months was

frequently stormy, and on two occasions they decided to stop dating. She was still

unsure about continuing the relationship and had not told him of her sexual discomfort.

She had no difficulty using tampons now or in the past during her menstrual

periods, and likewise, experienced no problems with pelvic examinations by

a physician. The pain that she experienced was not localized, would arise only with

vaginal entry, and disappeared when his penis left her vagina. Pelvic examination

revealed no structural pathology and the swab test was negative. When seen three

months later, she had begun a relationship with another man with whom she was

in love and found that her dyspareunia had disappeared.



In the general population study conducted by Laumann and his colleagues, respondents

were asked the following question: “During the last 12 months, has there ever been a

period of several months or more when you experienced physical pain during intercourse?”

5 (p.371) Overall, this was answered with a “yes” by 14% of the women (in

contrast to 3% of the men). The age group in which this was most commonly reported

was 18 to 24 (22%) and was least commonly reported in those over 50 (7% to 9%). As

with other sexual problems, pain with intercourse was positively correlated with the

respondent’s health status (p. 373) (9% of women who’s health status was “excellent”

compared to 23% of those in “fair” health). There was also a positive

correlation with “happiness” (p. 374) in that pain with intercourse was

reported by 12% of those who were “extremely happy” versus 28% of

those who were “unhappy most times.” While intercourse pain is obviously

common among women in the general population, vaginismus as

a specific disorder seems unusual. Subtypes of pain associated with intercourse,

and the subject of unconsummated marriages, were not addressed

in the Laumann5 or Kinsey6,7 studies.


When asked the question: “During the

last 12 months has there ever been a

period of several months or more when

you experienced physical pain with

intercourse?”5 14% of the women

answered “yes.”

Meana et al. completed a descriptive study of a nonclinical sample of 112 women

recruited by newspaper advertisement and ranging in age from 19 to 658 with pain

relating to intercourse. Subjects underwent thorough psychological and gynecological

examinations. The subjects were eventually grouped under four diagnostic subheadings:

• The largest (46%) were diagnosed as having vulvar vestibulitis

• The next largest (24%) had no dyspareunia-related physical findings

• The third (17%) was “mixed” (described by the authors as a “catchall”)

• The fourth (13%) was the vulvar/vaginal atrophy group

Apart from community studies, Goetsch provided information on the prevalence of

dyspareunia and vulvar vestibulitis in an unreplicated study of a general gynecology

practice.9 All patients (n = 10) seen by her in a six month period were questioned and

their examination included a swab test. Twenty percent described symptoms of pain

and all except three had a positive swab test. Thirty-one patients (15% of the entire

group) were diagnosed as having vulvar vestibulitis. Affected patients were typically


Information about the epidemiology of vulvar/vaginal atrophy (typically found in

postmenopausal women) and its consequences was assessed in a general population

study conducted in Sweden on a random sample of 5990 women ranging in age from

46 to 62 (five birth cohorts).10 Subjects were sent a questionnaire (response rate 76%)

that included questions on various climacteric symptoms. Vaginal dryness was reported

by 21% overall and showed a linear increase (4% to 34%) in each cohort. In spite of

lubrication difficulty, approximately 60% had a “regular sex-life” and only 8% of the

entire sample reported that vaginal dryness was the reason for the absence of sexual

activity (although 32% of the 62-year-old women said so).11 It is instructive to note

that in another study which involved the transition to menopause, one third of premenopausal

women reported vaginal dryness, thus indicating that factors other than

hormones can have a major influence on vaginal lubrication.12 In addition, a study of

48 postmenopausal women that included psychophysiological measurements supported

the notion that vaginal dryness in postmenopausal women might well be related to

nonhormonal sexual arousal problems.13

In a review of the incidence and prevalence of sexual dysfunctions in “sex clinics,“

vaginismus was found to vary from 12% to 17% “of the females presenting with problems

in sexual dysfunction clinics . . . reflecting a rather stable rate.”14 In the same

review, dyspareunia rates were estimated at 3% to 5% but the authors wondered if this

complaint was more often made to family physicians and gynecologists than sex therapists.

Support for this was given by the Laumann data5, and, as well, a survey of

physicians15 who reported that “dyspareunia, or painful intercourse” was the sixth most

common sexual problem seen out of a list of 20 items.



Entry dyspareunia that lasts for a short period of time (days to weeks) is probably common

and may result from vaginal irritation as a consequence of infection or allergy.

Although there are many explanations for more persistent entry dyspareunia,16 three

problems probably account for most cases of pain, discomfort, or fear of intercourse in


• Vulvar vestibulitis

• Postmenopausal vulvar/vaginal atrophy and consequent vaginal


• Vaginismus


Vulvar Vestibulitis

Friedrich17 coined the term vulvar vestibulitis (VVS) and described three

criteria for the diagnosis:

1. Severe pain on vestibular touch or attempted vaginal entry

2. Tenderness to pressure localized within the vulvar vestibule

3. Physical findings confined to vestibular erythema of varying degrees

Women with VVS are typically in their 20s and 30s and of Caucasian origin. Goetsch

(see Epidemiology above) provided details of her 31 subjects (plus seven who were

diagnosed with VVS before the beginning of her six month study).9 The median length

of the complaint was 8.5 years and half of the respondents first noted pain with tampon

use rather than with sexual intercourse. Half of the women always had pain dating

from the first attempt at intercourse (often designated as “primary”). A significant subgroup

(21%) experienced dyspareunia in the postpartum period, and delivery by cesarean

section made no difference in its appearance.

The etiology of VVS is unknown, giving rise to several theories.17-19 Infectious agents

have received much attention. Some observers note a high rate of repeated vaginal and/

or urinary tract infections (such as candidiasis). Human papillomavirus (HPV) is also

suspected. A majority of Goetsch’s patients had no known association with HPV. However,

“unusually large doses of fluorouracil cream . . . had caused severe chemical

burns in two patients and evolved into the most severe cases of vestibulitis seen in the

survey.”9 “The only infectious agent found to directly cause or worsen vestibulitis was

group B streptococcus” in two patients.9 Eighty percent of patients in the Goetsch study

who always had pain and who had sisters knew of a female relative with dyspareunia or

intolerance of tampons. There was no such association in those whose

pain began later. Investigators into the psychological status of patients

with dyspareunia generally found evidence of more symptoms than nopain

matched controls.8 However, no differences were found when

those who specifically had VVS were separated from other subtypes.

Goetsch concluded that swab testing demonstrated a continum

from those who were positive but had no clinical pain to those who

were dysfunctional.9 Likewise, she indicated that when pain was present,

it was “minor for many, and accommodation was aided even by

getting an explanation of the problem.”9 Last, she noted that many had

sensitivity that predated sexual exposure.


Three problems probably account for

most cases of pain, discomfort, or fear

of intercourse in women:

• Vulvar vestibulitis

• Postmenopausal vulvar/vaginal atrophy

and consequent vaginal dryness

• Vaginismus


Goetsch concluded that swab testing

demonstrated a continuum from those

who were positive but had no clinical

pain to those who were dysfunctional.9

Likewise, she indicated that when pain

was present, it was “minor for many,

and accommodation was aided even by

getting an explanation of the problem.”9

Postmenopausal Vulvar/Vaginal Atrophy

Vaginal lubrication largely depends on estrogen stimulation of the vaginal mucosa and,

therefore, vaginal dryness is usually considered to be associated with

the diminution of estrogen that accompanies menopause. Atrophic

alterations occur to the vaginal epithelium in the absence of estrogen

and are associated with increased vaginal pH, decreased vaginal fluid,

and decreased vaginal blood flow.20 Exogenous estrogens appear to

reverse these changes. However, a woman’s level of sexual activity

(including masturbation) and her circulating androgens have also been

demonstrated to influence the extent of vaginal atrophy.21 While vaginal atrophy and

dryness is often reported as uncomfortable, the extent to which actual pain is experienced

during intercourse is unclear.



Vaginismus represents an involuntary spasm of the muscles surrounding the outer third

of the vagina, resulting in narrowing of the vaginal entrance and inability or difficulty

in allowing vaginal entry in the waking state. The sex-related result of vaginismus is

the inability to engage in intercourse (either at all or without significant discomfort).

The history is usually lifelong (that is, since the patient tried to put anything into her

vagina) but not all such lifelong histories represent this disorder. A similar story may

be given in some instances of vulvar vestibulitis (see Vulvar Vestibulitis above).9

Patients give various explanations for vaginismus including22:

1. Thinking sexual activity to be sinful or offensive

2. Fear of pregnancy or childbirth

3. Lack of anatomical awareness

4. Homoerotic feelings

5. Dislike of semen

6. Aversion to a man’s penis or men in general

Some specialists view such phenomena as symptoms rather than

causes.23 As counterintuitive as it might seem, a history of genital

trauma or sexual violence in the histories of women with vaginismus is

unusual.24 When patients were asked their opinions about possible

causes, they placed fear of pain and fear of intimacy high on the list.25

Patients may describe pain with intercourse attempts but fear of vaginal

entry rather than the actual experience of pain may be the principal

factor that interferes with intercourse. Other sexual difficulties (e.g., a desire disorder)

may be present in the patient and may have antedated awareness of intercourse trouble.




History is only one element, albeit an essential one, in defining fear, discomfort, or

pain in women associated with intercourse attempts, and in many instances, helping to

delineate the cause. Issues to inquire about and suggested questions include:


While vaginal atrophy and dryness is

often reported as uncomfortable, the

extent to which actual pain is experienced

during intercourse is unclear.

When patients were asked for possible

causes of vaginismus, they placed pain

and fear of intimacy high on the list.

Patients may describe pain with intercourse

attempts but fear of vaginal

entry rather than the actual experience

of pain may be the principal factor that

interferes with intercourse.

1. Duration (see Chapter 4, “lifelong versus acquired”)

Suggested Question: “How long has this been a problem for you?”

Alternative Suggested Question if Intercourse Occurred in the Past: “Have you even

been able to have intercourse without experiencing pain?”

2. Intravaginal experience in the past (see Chapter 4, “generalized versus situational”)

Suggested Question: “What has been your experience with tampons?”

Suggested Question: “What has been your experience with inserting

your own finger into your vagina?”

Suggested Question: “What has been your experience with a sexual

partner inserting a finger into your vagina?”

Suggested Question: “What has been your experience with doctors

performing a pelvic examination and using fingers or a speculum?”

Suggested Question: What has been your experience with wearing

tight clothes such as jeans?

3. Intravaginal experience in the present (see Chapter 4, “generalized versus situational”)

Suggested Question: “What is it like for you now when a sexual

partner attempts to insert his penis (or his finger) into your


Additional Suggested Question: “Does it matter if you are with a different

sexual partner?”

4. Location of the pain (see Chapter 4, “description”)

Suggested Question if Intercourse Occurs: “Where do you actually feel

the pain? At the entrance? Within your vagina during intercourse?

Or deep inside?”

Additional Suggested Question for Entry Pain: “If you were to compare

the opening to your vagina to a clock, at which point on

the clock do you feel pain?”

Additional Suggested Question to Determine if Pain is Associated with Thrusting: “Is

the pain felt on the inside of your vagina as he is moving in

and out?”

Additional Suggested Question to Determine if the Pain is Deep: “When he

inserts his penis deeply, does it feel as though he is poking


5. Character of the pain (see Chapter 4, “description”)

Suggested Question: “Sometimes a person experiences fear of intercourse

more than actual pain. Does this ever happen to


Additional Suggested Question if Intercourse Occurs: “What does the pain

feel like? For example, does it feel as though it is tearing or


6. Factors that result in improvement or worsening (see Chapter 4, “description”)

Suggested Question: “Is there anything that makes the

pain better?”

Additional Suggested Question: “Is there anything that

makes the pain worse?”

Additional Suggested Question if Intercourse Occurs: “What does

it feel like when he ejaculates?”


Physical Examination

Any complaint of persistent pain associated with vaginal entry requires

a complete physical examination, which need not take place on the

first visit or be completed on one occasion. For example, in the context

of vaginismus, a vaginal examination might well be terrifying to the

patient and, as well, impair the physician-patient relationship. A speculum

examination under such circumstances may have even more severe consequences.

Rafla described a case in which a vaginal examination in the context of vaginismus

resulted in physical injury and a blood loss of 1000 ml.26 Considerably more time (and

patience) is usually required than in a more “ordinary” pelvic examination (see “Physical

Examination” in Chapter 6).

When the patient’s history is one where intercourse has never occurred because

attempts resulted in pain, discomfort, or fear, it is reasonable to engage in a preparatory

process before an actual intravaginal examination.27 The patient touches herself as

close to the introitus as possible, daily, in private, and for five to ten minutes. While

this is taking place, she is asked to imagine herself being examined, view her genitalia

with a mirror, and is shown how to insert her own fingertip around the anterior vaginal


Any complaint of persistent pain associated

with vaginal entry requires a complete

physical examination, which need

not take place on the first visit or be

completed on one occasion.

Considerabily more time (and patience)

is usually required for a pelvic examination

involving persisitent pain associated

with vaginal entry than is required in a

more “ordinary” pelvic examintion.

wall using diagrams or models. This preparation is meant to convey to the patient that

she will be in control of the examination when it does occur.

The actual pelvic examination in such a patient begins with an inspection of the

external genitalia. In the syndrome of vulvar vestibulitis, inspection may reveal varying

degrees of erythema of the vestibular mucosa.17 On this first occasion, there is no

necessary reason to extend the examination beyond inspection and explanation. However,

if the patient permits, the examiner can also gently probe the

vestibular openings to major and minor gland ducts (the “swab test”)

with a sterile water-moistened cotton-tipped applicator, to exclude the

possibility of vulvar vestibulitis (Figure 13-2). (The vestibule is bordered

medially by the hymenal ring, laterally by Hart’s line, anteriorly

by the frenulum of the clitoris, and posteriorly by the fourchette. The

area contains opening of major [Bartholin’s, Skene’s, and periurethral]

and minor vestibular glands.)28

When the swab test is positive, colposcopy might be “helpful in identifying discrete

lesions, which [are] often difficult to see without aceto-white staining and


When the swab test is negative, examination of the interior of the vagina might then

take place. One method of allowing the patient control over this part of the examination

is to have her hold the physician’s wrist while she slowly introduces one of the examiner’s

fingers into her vagina. This process may extend over several visits. Speculum and




Speculum and bimanual examination of

the patient with a history of lifelong

vaginismus should be delayed (barring

some urgent reason) until a later time

when vaginal entry is no longer associated

with pain, discomfort, or fear.

bimanual examination of the patient with a history of lifelong vaginismus should be

delayed (barring some urgent reason) until a later time when vaginal entry is no longer

associated with pain, discomfort, or fear.

Valins provided a vivid and poignant first-person account of the pelvic/vaginal

examination of a woman with vaginismus with a description of how her gynecologist

approached the examination29 (pp. 203-210).


Laboratory Examination

When vaginal infection is considered, several tests can be done to eliminate the possible

presence of various pathogens. In addition, biopsy of the vulvar epithelium on

a patient with suspected vulvar vestibulitis often shows evidence of chronic inflammation.

However, the normal histology of this area has not been well described. In a

comparison of tissues obtained by punch biopsy done on women with VVS and normal

controls, both showed evidence of inflammation, thereby casting doubt on the

value of finding evidence of inflammation on histological examination of vulvar epithelial




Lifelong and Generalized

Most women who have the lifelong and generalized form of vaginal pain or fear to the

extent that intercourse has never occurred will likely be diagnosed as having vaginismus

(although some will have primary vulvar vestibulitis [see below]). Drenth suggest

that when considering the treatment of vaginismus, couples should separate the issues

of wanting to overcome the intercourse difficulty from wanting to become pregnant,

decide which is of higher priority, and focus on that goal.31 In any

instance, primary care treatment may be sufficient.

Both partners should be involved in treatment, although the apparent

passivity of many husbands of women with vaginismus (noted by

many authors) may contribute to his relatively small contribution.32

(p. 34). On an impressionistic basis, many women with vaginismus

seem to have difficulty talking about their thoughts and feelings,

which in turn makes insight-oriented psychotherapy with them difficult.

With couples where the man is passive and the woman unexpressive,

visits are often brief and the focus is on progress using

dilators and other functional aspects of their care.

When the diagnosis is vaginismus and pregnancy is the principal

objective, Drenth suggests artificial insemination using (1) the husband’s

semen (AIH) and (2) the insemination procedure performed

by the couple themselves.33 When overcoming the fear/pain associated

with attempts at intercourse is the principal objective, couples

are initially advised to stop attempting to insert the man’s penis into

the woman’s vagina (or anything else such as his finger), and even to

not consider any form of vaginal entry even if the circumstances

seem favorable. (Emphasis on thoughts are crucial, since it is the


When overcoming the fear or pain associated

with attempts at intercourse is the

principal objective, couples are initially

advised to stop any form of vaginal

insertion even if the circumstances seem

favorable. (Emphasis on thoughts are

crucial, since it is the anticipation that

leads to worry.)


The word “dilator” is a misnomer when

used in the treatment of vaginismus

since dilatation does not occur and in

any case is not the purpose of the procedure.

The problem is not with the

structure of the muscle surrounding the

vaginal opening but rather with its


anticipation that leads to worry.) At the same time, they are encouraged to continue

enjoying the sexual activities other than intercourse that previously occurred.

After the diagnosis of vaginismus is confirmed and VVS excluded, as well as insufficient

knowledge of sex-related anatomy and physiology, vaginal dilator use could be

considered. (Flesh-colored, silicone dilator sets of four are available at 1-800-621-1278

through Milex Products, 5915 Northwest Highway, Chicago, ILL 60631). Although

recommended decades ago for this same purpose, vaginal dilators have become a

therapeutic mainstay since they were suggested by Masters and Johnson in 1970.34

The word “dilator” is a misnomer when used in the treatment of vaginismus since

dilatation does not occur and in any case is not the purpose of the procedure. The

problem is not with the structure of the muscle surrounding the vaginal opening but

rather with its function. A “dilator” works rather as an “accommodator” in providing

an opportunity for the woman to become used to having something in her vagina

without fear or pain, and entirely in her control.

Supervision of dilator use through the progressively larger sizes in a set can be readily

undertaken in a primary care setting. Insertion of dilators should occur daily for the

longest period of time that the patient can manage, and when she is alone so that the

process remains entirely under her control (rather than at the urging of her partner).

The largest dilator in the set that does not also cause discomfort should initially be

used. Liberal amounts of over-the-counter water-soluble jelly (e.g., K-Y Jelly) should

be applied to the dilator. Progression to the next size should only take place when

there is complete absence of discomfort with the size currently used. Eventually, when

she is comfortable with a size that approximates her partner’s erect penis, she should

be instructed to insert his penis almost as if it were another dilator. Since intromission

by the woman is accomplished relatively easily when she is in the superior position,

the couple should practice using that position before penile insertion is actually


If this appears to be a mechanical approach, it probably is a correct perception, but

only from the health professional’s viewpoint. Much more than mechanical manipulations

are taking place from the couple’s perspective. While hope extends backward to

the time the physician’s finger was first inserted into the patient’s vagina, only her

actual experience of painless penile insertion represents concrete evidence of change.

Paradoxically though, patients tend to be more subdued when describing the first

occasion of intromission than is the treating health professional. The explanation

might be an absence of confidence that the remainder of the therapeutic tasks can be

successfully completed. However, it is well to remember at this point that penile insertion

may not be immediately translated into feelings of pleasure for either person. This

depends on the extent of sexual freedom that the couple enjoyed before. Some couples

absorb the newly found sexual skills quickly and zealously. In other instances, pleasure

for the women may take place in an evolutionary way, extending over a period of time

and in the context of the confidence that is linked with not having to think about the

placement of body parts. Confidence in that circumstance tends to occur with repeated

successful experiences.

Most observers use intercourse (consummation) as the sole criterion for success in

the treatment of vaginismus. Masters and Johnson describe excellent treatment results

(100%) in their five-year follow-up.34 Van de Wiel et al. conducted a meta-analysis on

treatment results involving 20 surveys and 17 case studies published between 1960 and

1990.35 They conclude that several treatment approaches appear to be equally effective

(except surgery, which was not a subject of a published report) and that the average

rate of success was about 80%. Some describe a more modest outcome. Drenth et

al. reports on a questionnaire survey of 57 patients (response rate 86%) diagnosed with

“primary vaginismus.”33 Consummation occurred in 54% overall. In couples who

wanted to become pregnant, consummation occurred in 74% compared to 33% who

sought treatment only for the intercourse difficulty. Problems encountered in the treatment

of vaginismus31 include the following:

1. Lack of clarity around therapeutic aims

2. Intimacy difficulties on the part of the woman and consequent unwillingness to

involve her partner

3. The emergence of other fears

Desire for a child may be a stronger motivating factor for the treatment of vaginismus

than desire for intercourse. The survey by Drenth et al. also provided information on

obstetrical issues.33 Almost one half (25) of the patients became pregnant (10 as a

result of artificial insemination and 15 through intercourse). Patients who chose selfinsemination

did so for reasons that include the pressure of time (resulting from a delay

in seeking treatment) or slow therapeutic progress. The authors felt that insemination

by a physician represented “unnecessary medicalization” and, furthermore, might

unduly influence any ambivalence toward pregnancy experienced by the couple.

When self-insemination (also known as home insemination or AIH [artificial insemination

by husband] is undertaken, it, may be helpful for a physician to provide technical

advice to the couple and to review methods of ovulation detection. Briefly, the

insemination process is as follows*: The man ejaculates [volume of ejaculate is usually

in the range of 2 to 6 cc] into a clean, dry, plastic or glass container such as a urine

collection bottle from a medical laboratory. Regular condoms are undesirable for collecting

semen because they may contain a spermicidal agent. The semen is kept at

body temperature for about 10 minutes (the sample is then more liquid) and then is

drawn, with minimal accompanying air, into a narrow syringe (as small as 1 cc in

instances of severe vaginismus but perhaps as large as 10 to 12 cc). The syringe is

inserted as deep into the woman’s vagina as possible and the semen is deposited by

pushing on the plunger. During this process, the woman’s hips should be slightly elevated

with a pillow and she should remain in this position for about 20 to 30 minutes.

The same process can be repeated in about 24 hours.

Drenth et al. also reported on 26 deliveries and found that assisted deliveries were

10% higher in patients with vaginismus than in their clinic population.33 Reasons

included the presence of vaginismus and the (older) age of the mother. However, they

concluded that having vaginismus does not, in itself, require special precautions during

labor and delivery. They also observed that: however counterintuitive the notion might

be, childbirth does not automatically result in pain- and fear-free intercourse. “Obviously,
a pushing out movement is experienced quite differently from a pushing-in

*Personal communication, Stacu Elliott, M.D., Co-director, Vancouver Sperm Retrieval Clinic, VHHSC,



Acquired and Generalized

As outlined above (see Etiology in this chapter), vulvar vestibulitis and vulvar/vaginal

atrophy probably account for the majority of patients seen with the acquired and generalized

form of dyspareunia. When such disorders are resistant to definitive treatment

within the health care system, active involvement of the patient in her own care may

be necessary and beneficial. Membership in the National Vulvodynia Association

(NVA) may prove useful, especially since the organization produces an informative and

patient-oriented newsletter. (The NVA can be reached through its Web site [see

Appendix IV], by telephone at [301] 299-0775, or by mail at P.O. Box 4491, Silver

Spring, MD 20914-4491)


Vulvar Vestibulitis (VVS)

Bergeron and her colleagues19 reviewed the treatment of VVS and grouped the existing

studies into three categories:

• Surgical intervention

• Medical management

• Cognitive-behavioral/pain management therapy

Surgical interventions consist of vestibulectomy and laser therapy. Vestibulectomy has

been the most investigated VVS treatment and the one reported as having the best

outcome. Laser treatment is described as controversial and sometimes associated with

negative consequences. Surgery is usually undertaken after the failure of medial management.

The surgical procedure is typically described as a modified perineoplasty,

which is performed as day surgery under general anesthesia. Surgical success usually

has been measured through a one-time self-report rating of pain with intercourse, and

rates vary from 43% to 100%, with the majority more than 60%.19

Schover et al. reports an improved outcome when surgery is combined with sexual

counseling.18 They describe an eight-month follow-up study on the evaluation and

treatment of a group of 45 women with VVS. All were treated by conservative local

excision of the vulvar lesions. One of the factors that indicated a better outcome included

willingness to engage in initial psychological evaluation and brief post-operative sexual

counseling. Of 32 such patients, 50% reported that they were much improved. Other

positive predictors were higher socioeconomic status and localized (versus diffuse) areas

of pain. The authors hypothesize that women who could accept that their dyspareunia

and vulvar pain was multifactorial in origin took an active role in rehabilitative efforts

after surgery, and, as a result experienced a better outcome. They hypothesize that

patients who could not do so might be poor surgical candidates.

Medical management of VVS typically involves the use of topical ointments (including

anesthetics, antifungals, and antibiotics), systemic medications, and other treatments

such as interferon.19 Topical anesthetics are of limited value, since their effect is shortterm

and allergic reactions may occur. Nonscented lubricants are also of short-term

value but do not have adverse effects. Other topical ointments (antibiotics, antifungals,

antiviral, and corticosteroid creams) are considered to be ineffective but have not been

carefully studied. Acyclovir (oral), capsaicin (topical), and calcium citrate tablets have

been reported to be beneficial to some patients. Alpha interferon is not recommended if

colposcopy or biopsy lesions do not show evidence of HPV changes.

Pain management of VVS has consisted of biofeedback, behavior

and sex therapy, cold application, and acupuncture.19 Some patients

have found benefit from each of these four approaches. Since vaginal

spasm (often referred to as vaginismus in the literature) is often found

during the pelvic examination of a patient with VVS, some have found

the inclusion of vaginal dilators to be a treatment adjunct.36

Bergeron et al. compared treatment results for 78 patients with VVS

who were randomly assigned to surgery (vestibulectomy), biofeedback,

or sex therapy/pain management.37 Measurements were made pre- and

post-treatment and at six-month follow-up. Self-reported coital pain

was significantly improved in all groups from before and after treatment and from before

to 6 month follow-up. However, the vestibulectomy group was significantly better than

the sex therapy/pain management group post-treatment. All groups improved significantly

when the frequency of intercourse was compared post-treatment to 6 months

later. In summary, patients from all three groups reported significantly more subjective

improvement from post-treatment to 6 month follow-up. However, the vestibulectomy

group was significantly better than the sex therapy/pain control group.


Vulvar/Vaginal Atrophy

Estrogen replacement therapy generally reverses the vaginal changes associated with

menopause. However, restoration of vaginal tissue function may require up to 18 to 24

months. The long duration may explain the reason for continued vaginal dryness and

dyspareunia (if the woman is sexually active) in spite of hormonal and cytologic return

to premenopausal values.38 However, only a distinct minority of postmenopausal

women use hormone replacement therapy (HRT). Reasons include the following:

• Personal preference

• Adverse side effects

• It is contraindicated

In addition, some women find that even with HRT, there is little urogenital benefit.

Thus local (vaginal) forms of treatment have been developed to counter vaginal dryness

in women who are not on HRT or who need supplemental therapy for urogenital


Vaginal creams containing estrogen represent one example of a local form of treatment.

Since estrogen is absorbed from the vaginal mucosa, a fact that may limit its

acceptability in some patients, attempts have also been made to find nonhormonal

agents, or, alternatively, to minimize the absorption of estrogen.

The estradiol vaginal ring represents a second local treatment option

for vaginal dryness and other urogenital consequences of estrogen loss.

The development of the ring is based on the notion that compared to

the amount of estrogen necessary to reverse vasomotor symptoms (50

mg/day), the amount of estrogen necessary to alleviate urogenital atrophy

is much smaller (7 to 10 μg/day).39 The ring delivers a low dose of


“The ring provides a safe and effective

method of pharmacological therapy for

women who require treatment for symptoms

of urogenital aging.”40

Patients from three groups (vestibulectomy,

biofeedback, and sex therapy/pain

management) reported significantly

more subjective improvement from post

treatment to 6 month follow-up. However,

the vestibulectomy group was significantly

better than the sex therapy/

pain control group.

β-estradiol directly to the urogenital tissues and has a low level of systemic absorption.

Bachmann reviewed the results of 11 clinical trials with the estradiol vaginal

ring.40 She found that it reversed urogenital atrophy, induced minimal stimulation of

the endometrial lining, had few adverse side effects, and that a single ring was efficacious

for three months of continuous use. Of the 946 postmenopausal women with

treatments up to 96 weeks, “there were cytological, physiological, physician rating and

patient reporting of either elimination or amelioration of urogenital atrophy signs and

symptoms.”40 She concluded that” the risk/benefit ratio has a clear preference to benefit

with risks being very low. Therefore, the ring provides a safe and effective method

of pharmacological therapy for women who require treatment for symptoms of urogenital


A vaginal moisturizer is a third local treatment option. “Replens” is a nonhormonal

nonsystemic vaginal moisturizing gel that has a low pH, appears to bind to vaginal

tissue, and is applied three times per week. Replens is based on a polymer (called polycarbophil),

which becomes saturated with water, diffuses into vaginal epithelial cells,

and then is sloughed off with epithelial cell turnover.41 This substance has been studied

in nonhuman primates41 and humans.42-44 In two open-label studies of women, Replens

was compared to a locally applied estrogen cream and found to be safe and effective.

42,43 In one of the studies, both therapies exhibited statistically significant increases

in vaginal moisture, vaginal fluid volume, and vaginal elasticity with a return of the

premenopausal pH state. Replens has also been compared to a water-soluble lubricating

placebo in a double-blind study of women with a history of breast cancer and

similarly found to be effective.44

A fourth local treatment form that has been used for many years is an over-thecounter

lubricating gel (e.g., K-Y Jelly).


Acquired and Situational

Little is known about this syndrome except from patients who describe the problem

of vaginal discomfort with intercourse in the past, and who have watched it disappear

with the advent of a new relationship. On the assumption that the difficulty relates

to interpersonal or intrapersonal psychosocial conflicts, the most reasonable therapeutic

course of action is (1) reassurance to the woman about the integrity of her genitalia

and (2) psychotherapy, either individual or couple-related depending on the



Indications For Referral For Consultation Or Continuing
Care By
A Specialist

1. The evaluation of persistent pain associated with intercourse should always

include a physical/pelvic examination. Thus, medical consultation should always

be included when a patient with dyspareunia has been evaluated only by a nonmedical

health professional.

2. Lifelong vaginismus can often be successfully treated by primary care health

professionals regardless if the goal is sexual or reproductive. Consultation with

a physician should take place if the treating health professional is not a MD

to eliminate the possible coexistence of VVS. When artificial insemination

(AIH) is desired, the couple should be referred to a physician for advice and

possible assistance. When treatment that is aimed at overcoming vaginismus

becomes problematic, the couple should be referred to a sex therapist for

continuing care.

3. Primary (lifelong) VVS may be amenable to explanation and brief sexual counseling

within primary care. Consultation with a gynecologist for the purpose of

confirming the diagnosis may be helpful. The time and skills of a sex therapist

may be particularly useful when intercourse has never occurred in the past

because of discomfort, and for patients who are otherwise experiencing significant

sexual difficulty.

4. Secondary (acquired) VVS varies in the degree of pain experienced. The greater

the extent of pain and sexual complications, the more a primary care professional

would want to engage the assistance of other health professionals such as

gynecologists and sex therapists.

5. When dyspareunia in a postmenopausal woman persists despite adequate vaginal

lubrication, consultation with a sexual medicine specialist would be desirable to

consider the possibility of other contributing factors.



Penile-vaginal intercourse is sometimes accompanied in women by persistent pain, discomfort,

or fear. Pain can exist at the point of entry, or deep in the vagina. This chapter

is concerned with the former. Vulvodynia is a term that encompasses vulvar pain

regardless of etiology, whereas dyspareunia is specific to pain that occurs with intercourse.

DSM-IV suggests that “dyspareunia” and “vaginismus” should be separated.

However, if a clinician considers that “vaginismus” as described in the literature includes

both the disorder as well as vaginal spasm occurring in the context of several vaginal

disorders, then in fact, vaginismus and dyspareunia often occur together and separation

becomes clinically difficult.

In community studies, about 15% of women say they have experienced pain with

intercourse for a few months during the last year. When dyspareunia is lifelong and

generalized, the causes are usually vaginismus (the disorder) or vulvar vestibulitis

(VVS). When acquired and generalized, the etiology is usually VVS (the most common

cause in premenopausal women) or vulvar/vaginal atrophy with associated vaginal

dryness (the most common cause in postmenopausal women). When acquired and

situational, the genesis of dyspareunia is most often related to interpersonal or intrapersonal


The assessment of persistent vaginal pain involves a history and a physical/pelvic

examination. The latter should include a swab test whenever vulvar vestibulitis is considered.

In cases where vaginal entry has never occurred or where there is severe

introital pain, the pelvic examination may require more than one visit and a lengthy

period of time to complete.

Early or mild instances of vaginismus may respond to education and supportive

counseling. Treatment of patients who are not helped by such an approach depends

heavily on the use of dilators and the support of the patient’s partner and health care

clinician. Sometimes the couple is primarily interested in reproduction rather than

solving the intercourse problem. In such an instance, assisting in the process of artificial

insemination using the husband’s sperm (AIH) may be most productive.

Vulvar vestibulitis is sometimes amenable to explanation, but in other instances it

may be difficult to treat. Several medical, surgical, and sex therapy/cognitive-behavior

therapy methods have been suggested. Surgery (vestibulectomy) has received the most

attention in the VVS treatment literature and studies indicate this form of treatment to

provide the best results.

At least five approaches can be used in the treatment of women with dyspareunia

resulting from vulvar/vaginal atrophy and associated vaginal dryness: oral hormone

replacement therapy (HRT), estrogen cream, the estradiol vaginal ring (Estring), a

nonhormonal vaginal moisturizer (“Replens”) and nonhormonal and nonscented




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