Intended for healthcare professionals

Practice Practice Pointer


BMJ 2018; 361 doi: (Published 19 June 2018) Cite this as: BMJ 2018;361:k2341
  1. Nikki M W Lee, speciality trainee in obstetrics & gynaecology1,
  2. Adam D Jakes, academic clinical fellow in obstetrics & gynaecology1,
  3. Jillian Lloyd, consultant obstetrician & gynaecologist1,
  4. Leila C G Frodsham, consultant gynaecologist, lead for psychosexual medicine, foundation training programme director, Schwartz Round medical co-lead, transition to F1 module lead, stage 3 MBBS, King’s College London1
  1. 1Guy’s & St Thomas’ Hospital NHS Trust, St Thomas’ Hospital, London SE1 7EH, UK
  1. Correspondence to: N M W Lee nmw.lee{at}

What you need to know

  • Dyspareunia can be caused by physical or psychosexual problems, with considerable overlap

  • A sudden onset of symptoms can suggest a psychosexual cause, while a gradual increase in symptoms is more likely to be physical or anatomical

  • Even in patients with a clear physical cause, psychological and social problems need exploration—consider referral to psychosexual services if available

  • Resist the urge to reassure. Explore the patient’s thoughts, feelings, and ideas

  • Perineal massage can be a useful method to reduce vaginismus and help vulvodynia

A 45 year old woman presents to her general practitioner with a five year history of painful sex. This had been so severe she has been unable to have intercourse for two years. She complains of being dry and tight, despite using oestrogen vaginal pessaries. She had one child 10 years ago, delivered by caesarean section. She recalled a midwife commenting her vagina was too small during labour. On further questioning she revealed that the problem had become much worse since her husband lost his job three years ago. She expresses concern about the toll this problem is taking on her marriage, and becomes tearful.

Dyspareunia is a common but poorly understood problem affecting around 7.5% of sexually active women aged 16-74 years.1 It describes persistent or recurrent pain with attempted or complete vaginal entry or penile-vaginal intercourse.2 Understanding whether the pain is superficial or deep can help to identify its cause.3 Dyspareunia is most common in women aged 55-64 years (10.4%) and those aged 16-24 years (9.5%).1 It is an important and neglected area of female health,45 associated with substantial morbidity and distress. Box 1 includes some comments from women who have experienced the symptoms.

Box 1

Patients’ accounts of dyspareunia

Patients’ views collected from an urban psychosexual clinic to illustrate the impact of dyspareunia.

  • “Vulvodynia and the …

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