Dyspareunia is the term used to describe genitopelvic pain that is provoked by sexual activity. It is a sexual problem, a diagnosis that merits treatment, but it is also the norm for women insofar as normality is defined in statistical terms. Studies have shown that 3 out of 4 women report having experienced dyspareunia at least once, and between 10% and 20% of women experience it chronically.¹ Men may also experience it, as 1% to 5% of men also report pain with sexual intercourse, but these numbers are low enough to be unambiguous in their abnormality.² In contrast, women are taught to expect sex to be physically painful, at least at first, and that expectation, normalization, and encouragement to tolerate coital pain remains a persistent theme in female sexual education.

Dyspareunia is often assumed to be due to penetrative intercourse and to be a gendered phenomenon caused by penovaginal penetration and experienced exclusively by the penetrated female partner. This assumption is reflected in the International Classification of Diseases and Diagnostic and Statistical Manual of Mental Disorders coding systems, both of which place the symptom dyspareunia under the diagnosis of genitopelvic pain‒penetration disorder, a hyphenated condition that is gendered female. By design, this system neglects the pain of men who prefer receptive anal intercourse, men who experience pain with orgasm whether they are acting as top or bottom, and the pain women may experience by genital contact in the absence of penetration, which tends to be even more debilitating than vaginismus as it occurs in both erotic and nonsexual contexts.

How we conceptualize pain and define dyspareunia are foundational to accurate diagnosis across the various populations who experience it and to effective therapy. As biomedical knowledge has evolved over time, so has our understanding of pain: it is variously understood as a response to an aversive physical stimulus or tissue pathology, a peripheral neurologic phenomenon that can be mapped onto specific nerve routes, or a somatosensory psychological experience. This last conceptualization de-emphasizes peripheral pathophysiology in favor of focusing on its central nervous and especially supratentorial, cognitive, and emotional aspects. These different ways of thinking about pain and its causes are represented in our current understanding of dyspareunia, its causes, and their best treatments.

For example, considering dyspareunia as a response to an aversive genital stimulus encourages us to examine the affected area with more thoughtful care in order to seek, find, and eliminate the underlying cause. A recent paper in JAMA Dermatology described treatment of chronic dyspareunia in a male patient by excision of a glanular pilonidal sinus, acquired due to ingrown hairs many years prior and identified on dermoscopy.³ A similar phenomenon of dyspareunia in the setting of hairs, keratin pearls, smegma, and other debris trapped below the prepuce is often overlooked in women, whose genital examination conventionally ignores the clitoris. When these are addressed by lysis of adhesions and surgical repair of preputial phimosis, there can be significant improvement of pain and increased sexual pleasure.⁴

Often, the aversive stimulus causing pain is endogenous and hormone mediated, whether secondary to endometriosis, uterine fibroids, or genitourinary syndrome of menopause (GSM). This suggests that we treat the problem through hormone manipulation and other means of altering the diseased genital and pelvic parts. Conventionally, endometriosis and fibroids have been treated with surgical excision and attempts to suppress formation with oral contraceptive pills, though this is not always successful. Relugolix, a gonadotropin-releasing hormone antagonist familiar to urologists in the context of treatment for prostate cancer, is also Food and Drug Administration approved for treatment of pain due to endometriosis and uterine fibroids. Just as relugolix can cause symptoms of hypogonadism for the men who take it, its female parallel, relugolix/estradiol/norethisterone, and oral contraceptive pills can induce the symptoms and vulvovaginal atrophy characteristic of GSM. For women who are reluctant to treat GSM with estrogens, the PIVoT (Prevention of Recurrent Urinary Tract Infection Using Vaginal Testosterone) randomized controlled trial supports the use of topical vulvovaginal testosterone as an off-label alternative.⁵

For patients who wish to avoid hormonal treatments altogether, energy-based therapies are a compelling strategy that merits further research and exploration. However, the checkered track record of vaginal CO₂ lasers is a caution against too-early adoption of novel devices: only after they were widely advertised and invested in was it recognized that these devices may worsen vulvovaginal pain, rather than improve it.^6,7 Less risky, nontissue ablative interventions such as low-intensity shock wave⁸ and photobiomodulation devices have all shown promise as research interventions for dyspareunia in women,⁹ and the AUA guideline for Peyronie’s disease endorses the use of shock wave therapy for painful erection, gesturing to its potential benefit for other forms of dyspareunia as well. While most research focuses these energies on the genitalia, some have shown reductions in dyspareunia with application of shock waves to the spinal nerve roots and near-infrared light to the brain.

The relationship of dyspareunia to the central nervous system, its conceptualization as a radiculopathy and/or a central nervous phenomenon, has been best elaborated on in the context of persistent genital arousal disorder, also known as genitopelvic dysesthesia. The International Society for the Study of Women’s Sexual Health consensus paper mapping the genital pain of persistent genital arousal disorder onto 5 distinct but interactive regions within the body has relevance for other forms of dyspareunia as well, pointing to the promise of treatments that target areas outside the genitalia and true pelvis.¹⁰ Orthopedic and neurosurgical interventions, physical therapy, as well as meditation and medications that target central sensitization to pain all show promise as treatments for dyspareunia, though the utility of any one of these will of course vary with specific patient phenotype and endotype. A thoughtful balance of both lumping and splitting, inclusive health care and precision medicine, is essential to the accurate diagnosis and treatment of dyspareunia.