Synonyms
- Dyspareunia
- Painful sex
Subdivisions
General Discussion
Dyspareunia is a general term for pain with penetration during intimate sexual contact (fingers, toy, penis). Deep pelvic pain, or deep dyspareunia, usually emerges because of other existing disorders deep in the pelvis adjacent to or touching the deeper portions of the vagina. A few of the more common causes of deep pelvic pain include fibroid tumors of the uterus or other nearby structures, ovarian cysts/tumors, endometriosis, and/or scarring from these disorders. Scarring can occur prior to or following surgery for these problems, or from unrelated previous surgery (such as appendicitis) or pelvic/tubal infection (such as pelvic spread of gonorrhea and chlamydia). Fortunately, the deep pelvic pain that can result from these conditions is not nearly as common as the disorders themselves. Many will have a known gynecological history of these disorders, and a change in their underlying condition may be “announced” by new onset of deep pain during sex, or a new partner might trigger that pain for the first-time during sex.
Signs & Symptoms
Deep pelvic pain or deep pain with sex (dyspareunia) is the primary symptom. Additional symptoms may be present but will depend on the underlying condition(s).
Causes
Deep pelvic pain typically results from one of the disorders noted above causing scar tissue or restriction of the movement of the top, or apex, of the vagina during sex. The vagina, like many of the intra-abdominal organs, is meant to slide on its neighboring organs (i.e., ovaries, tubes, intestines, rectum, etc.). When the vaginal apex is restricted or “bumps up” against a tender neighboring organ or other disorder, like a fibroid or an ovarian cyst, during sex, it can cause deep penetration pain. Because the depth of penetration can vary depending upon the sexual position, size of one’s partner, and inherent length of the vagina, deep pelvic pain may occur only intermittently, e.g., only with sex in particular positions, with a particular partner, or with a particular partner in a particular position.
Affected Populations
Together the multiple underlining disorders that can cause deep pelvic pain are very common. Fibroid tumors, for example, occur in up to 70% of black women and 50% of white women. Fortunately, the symptom of sexual pain with these disorders is far less common.
Diagnosis
The cause of the deep pelvic pain may already be known, and many women have had one or more of the disorders above for long periods of time prior to developing deep pain during sex. If an underlying condition has not been established, a diagnosis can usually be determined using vaginal or abdominal ultrasound (sonogram). Vaginal ultrasound is preferred as the probe that’s inserted into the vagina to perform the examination can be used to reproduce or simulate the pain that occurred during sex, thereby demonstrating exactly where and how the pain is initiated. Because abdominal sonography requires a full bladder to fully outline the pelvic structures, it can distort the anatomy temporarily making it different than during sex, even moving an offending tissue mass out of the way entirely. Since endometriosis often goes undiagnosed for many years and can be difficult to diagnose, a complete evaluation may require an examination by an endometriosis specialist or other clinician familiar with the disorder, a careful rectal exam, as endometriosis causing deep sexual pain may best be felt on rectal exam, or even a diagnostic surgery, a laparoscopy, for complete evaluation.
Standard Therapies
Treatment of deep pelvic pain is usually focused on the underlying disorder. It may be surgical (i.e., fibroids, ovarian cysts, endometriosis, or scarring) or responsive to medication (i.e., fibroids, ovarian cysts, endometriosis). Multiple new medical therapies have recently been developed to shrink the size of fibroid tumors and reduce the heavy menstrual bleeding associated with them, and other medical treatments have been developed for endometriosis associated menstrual pain, non-menstrual pain, and deep sexual pain, all of which are associated with this disorder. Typically, a medical approach is favored initially, and surgery reserved as a last resort. However, exceptions to this rule are common. For example, if one suffers from fibroid tumors causing infertility or recurrent miscarriage and has related deep pelvic pain during penetration, it may be that surgery is the only choice that can address all three problems: the infertility, pregnancy loss, and deep pelvic pain.
Medical treatment is focused on the underlying disorder and an in-depth review is beyond the scope of this introduction to deep pelvic pain. Several medical treatments can reduce the size of fibroid tumors, shrink endometriosis, and reduce their associated pain, including deep sexual pain. These include oral contraceptives, and both the injectable GnRH agonists (i.e., leuprolide, triptorelin, gonadorelin) and the oral GnRH antagonists (i.e., Elagolix, Relugolix, Linzagolix). The GnRH modulating drugs are used to temporarily create a menopausal hormone milieu, because menopause typically shrinks these pathologies and clears the way for unrestricted movement of the upper vagina.
In addition to targeted therapy focusing on the underlying disorder, pelvic floor physical therapy, including additional treatments like trigger point injections and pelvic floor “botox”, can be helpful in reducing the reactive pain and un-learning the pelvic muscle guarding related to these disorders.
If pain occurs only with deep penetration, reducing the depth of penetration can help prevent pain during sex. Avoiding positions that allow deep penetration can help. Additionally, a wearable device named Ohnut was created to help customize penetration depth.
Investigational Therapies
Support Available
Beating Endo: How to Reclaim Your Life from Endometriosis by: Iris Karin Orbuch, MD
Support Available
- Beating Endo: How to Reclaim Your Life from Endometriosis by: Iris Karin Orbuch, MD
- http://Allianceforendo.com
- Endometriosisassn.org
- Endometriosis.org
- Endoinvisible.org
- Fibroidfoundation.org
- Thewhitedressproject.org
References
Yong PJ. Deep Dyspareunia in Endometriosis: A Proposed Framework Based on Pain Mechanisms and Genito-Pelvic Pain Penetration Disorder. Sex Med Rev. 2017 Oct;5(4):495-507. doi: 10.1016/j.sxmr.2017.06.005. Epub 2017 Aug 1. PMID: 28778699.
Donnez J, Stratopoulou CA, Dolmans MM. Uterine Adenomyosis: From Disease Pathogenesis to a New Medical Approach Using GnRH Antagonists. Int J Environ Res Public Health. 2021 Sep 22;18(19):9941. doi: 10.3390/ijerph18199941. PMID: 34639243; PMCID: PMC8508387.
Orr N, Wahl K, Joannou A, Hartmann D, Valle L, Yong P; International Society for the Study of Women’s Sexual Health’s (ISSWSH) Special Interest Group on Sexual Pain. Deep Dyspareunia: Review of Pathophysiology and Proposed Future Research Priorities. Sex Med Rev. 2020 Jan;8(1):3-17. doi: 10.1016/j.sxmr.2018.12.007. Epub 2019 Mar 28. PMID: 30928249.
Eid S, Loukas M, Tubbs RS. Clinical anatomy of pelvic pain in women: A Gynecological Perspective. Clin Anat. 2019 Jan;32(1):151-155. doi: 10.1002/ca.23270. Epub 2018 Dec 3. PMID: 30390350.
