Pain During Sex and Vulvar Skin Disease

Frederick R. Jelovsek MD

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.

• 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.

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:

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.