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Superficial and deep pain

Dysparuenia

Pain during intercourse (dysparuenia) is pain or discomfort in a woman's labial, vaginal, or pelvic areas during or after sexual intercourse. The number of women who experience pain during intercourse is unknown because the symptoms vary. Pain during intercourse is one of the most common causes of problems in sexual relations. The prevalence of such pain seems to be increasing over time.

Pain During Intercourse Symptoms

Symptoms of pain related to intercourse can occur when entry is attempted or during or immediately following sexual intercourse. The most common symptom is pain on entry. The second most common symptom is deep pain. Other symptoms include feelings of muscle spasms, cramps, or muscle tightness.

Pain during intercourse may be described as primary or secondary, as complete or situational, and as superficial-entrance or deep types. Primary pain with intercourse is pain that has existed for the woman's entire sexual lifetime. Secondary pain develops after a symptom-free period of time.Complete pain means the woman experiences pain in all situations of intercourse.

Superficial-entrance pain is noticeable at penetration. Deep pain is located at the cervix or in the lower abdominal area and is noticeable during or after penetration.

Exams and Tests

A health care provider asks about the woman's history of pain during intercourse. A thorough history and an extensive physical exam often reveal the most probable cause of this pain.

A medical history identifying pain at the vaginal opening may suggest one of the following:

  • Inadequate lubrication during the arousal phase(may be associated with hormonal changes or medications)
  • Inflammation at the vulvar opening
  • Painful spasms of the vagina that prevent intercourse

Pain located in the entire vaginal area may indicate conditions such as chronic vulvar pain, or a vaginal infection (fungal, parasitic, or bacterial). At times, a specific area of discomfort may be identified that might suggest another cause for the pain, such as inflammation of the urethra (the tube through which urine exits the body).

Deep pain feels to the woman as if her partner is bumping into something during intercourse. This type of pain may suggest pelvic causes, such as endometriosis, adhesions, the uterus stuck in a tilt the wrong way or the ovaries being stuck in the pelvis.

Pain in the middle of the pelvis may suggest an origin in the uterus. Pain on one or both sides of the pelvis is more suggestive of pain originating from the fallopian tubes, ovaries, and ligaments.

The doctor will ask to perform an extensive physical exam of the pelvis and abdomen to better understand both her anatomy and the location of her pain. The exam may also allow the woman to better guide the doctor to the location of the discomfort.

Medical Treatment

Treatment of pain during intercourse depends on the cause. Entrance pain may be treated when the cause is identified.
    • Atrophy (thinning of the vaginal walls): Entrance pain caused by atrophy is common among postmenopausal women who do not take hormone replacement medication. Blood flow and lubricating capacity respond directly to hormone replacement. The most rapid relief of atrophy comes from applying topical estrogen vaginal cream directly to the vagina and its opening. This cream is available by prescription only.
    • Urethritis and urethral syndrome: With this condition, a woman may urinate frequently with urgency, pain, and difficulty, but a urinalysis can find no identifiable bacteria. These symptoms may be caused by chronic inflammation of the urethra (the tube through which urine exits the body) from muscle spasms, anxiety, low estrogen levels, or a combination of these causes. The doctor may prescribe low-dose antibiotics. At times, antidepressants and antispasmodics may also be prescribed.
    • Inadequate lubrication: Treatment of inadequate lubrication depends on the cause. Options include water-soluble lubricants (for use with condoms; other types of lubricants may damage condoms) or other substances such as vegetable oils. If arousal does not take place, more extensive foreplay might be needed during sexual relations.
    • Vaginismus: Painful spasms of muscles at the opening of the vagina may be an involuntary but appropriate response to painful stimuli. These spasms may be due to several factors, including painful insertion, previous painful experiences, previous abuse, or an unresolved conflict regarding sexuality. For a woman with vaginismus, her doctor may recommend counseling or surgery depending on the cause. A new treatment being offered is Botox. Your doctor will explain this to you if recommended.
    • Interstitial cystitis: This chronic inflammation of the bladder has no known cause; however, pain with intercourse is a common symptom. A health care provider may perform a cystoscopy (a procedure to look inside the bladder), or may distend (stretch) the bladder to examine the bladder wall.
    • Endometriosis: Endometriosis occurs when the lining of the uterus is found outside the uterus. Pain during intercourse caused by endometriosis is not uncommon. Relief of this pain often indicates success in treating endometriosis.
    • Vulvovaginitis (inflammation of the vulva and vagina): Whether recurrent or chronic, this problem is common.
    • Vestibulitis.

If not responsive to self-treatment with lubricating gels or initial treatment by a doctor, the woman may need a more thorough evaluation to identify the cause. Treatment is based on the presence of bacteria or other organisms. Often, no single organism is identified.

If recurring symptoms are shared with a sexual partner, both individuals should be tested for sexually transmitted diseases (STDs).

Treatment for deep pain includes 2 strategies;
1) Pelvic adhesions (tissue that has become stuck together, sometimes developing after surgery): Pain with intercourse caused by pelvic adhesions can be relieved by removing the adhesions.
2) Uterine Retroversion: The doctor may find physical causes of the pain, including ovarian cysts, pelvic inflammatory disease or endometriosis.

 

Deep pain

A guide to endometriosis

Endometriosis is one of the most common problems in gynaecology. It was first described in 1869 and yet endometriosis remains a poorly understood disease of the female reproductive system. It affects women in their reproductive years and may cause pain and infertility. Some women with endometriosis have no symptoms, but others suffer painful periods and pain during intercourse. These symptoms may occur alone, or in any combination and in varying degrees of severity.

Endometriosis is a condition where tissue similar to the lining of the womb, the endometrium,is also found in places outside the womb, the uterus. It can be found on ligament supports of the uterus and on nearby organs, such as the ovaries, bladder and bowel. Sometimes, it can also be found in more distant organs, such as the lungs or navel.
Endometriosis can appear as spots or patches, called implants, or cysts on the ovary. In mild cases, there may only be a few isolated implants, while in others the disease may be present throughout the pelvis. Endometriosis irritates surrounding tissue and can produce a web- like scar tissue, known as adhesions. The scar tissue can bind any of the pelvic organs to one another and, in severe cases, can cover them completely.

The disease can usually be treated with drugs or surgery. Generally, endometriosis can only be diagnosed at operation and, since some women have no symptoms, we can only guess at the true number of women affected. Some estimates suggest that up to 30% of women of reproductive age could have endometriosis. It used to be thought that endometriosis was more common in women who had never had children. It was called the ‘career woman’s disease’ because these women often have their families later. However, generalisation cannot be made, since endometriosis can effect any woman, from teenagers to the menopause. A woman with an affected close relative is more likely to have endometriosis herself and also more likely to have a severe disease. Current research is looking in to the genetic basis of the disease.

It is not known why some women get endometriosis, but its growth and spread are dependent on the female hormones produced each month by the ovaries in the reproductive cycle. The two hormones produced by the ovary are oestrogen and progesterone. Oestrogen is produced in the first half of the cycle and progesterone, as well as oestrogen, in the second. Each month in the middle if the cycle, a mature egg is released by the ovary, known as ovulation. The tube catches the egg and draws it inside. If the egg is fertilised it may embed in the lining of the womb, the endometrium, and pregnancy has commenced. If it is not fertilised, it is lost together with endometrium, as the period at the end of the month. Endometriosis also goes through a monthly cycle and grows under the influence of the hormone oestrogen. It will also have a “period” each month, but there is no escape for the blood, which remains and irritates the surrounding tissues.

What is the cause of endometriosis?

Several theories exist as to how endometriosis begins, including the theory or retrograde (backwards) menstruation. During a period, most of the menstrual blood comes out through the vagina. In most women, some blood passes backwards through the fallopian tubes into the abdominal cavity. Contained within the menstrual blood are fragments of the endometrium, and these can seed and grow in the peritoneal cavity. We do not know why these cells seed in some women and not in others. This theory is called retrograde menstruation.

What does it look like?

Early implants look like spots and pimples sprinkled on the pelvic surface. The implants may remain unchanged, becomes scar tissue or disappear over a period of months. In most women, endometriosis grows slowly and can remain stable for years. Endometriosis can form benign cysts on the ovaries, called endometriomas. With time, the blood darkens to a tarry colour, giving rises to the description ‘chocolate cyst’. These cysts may be smaller than a pea, or larger than a grapefruit. A woman may suddenly feel pain when large endometrioma bleeds or bursts. The spilled fluid may cause further irritation and the development of scar tissue.

In severe cases, the web-like scar tissue, adhesions, may bind the uterus, tubes ovaries and nearby intestines together. Endometriosis can grow into the walls of the intestine or into the tissue that separates the rectum from the vagina. Although it can invade neighbouring tissue, endometriosis is not a cancer.

What are the symptoms of endometriosis?

Some women with endometriosis are without symptoms, but others suffer with very painful periods, pain at other times of the month, pain during intercourse and infertility. These symptoms may occur alone, or in any combination and in varying degrees of severity. A peculiarity of endometriosis is that women with mild disease sometimes have the worst symptoms and women with severe disease occasionally have none. Painful periods, dysmenorrhoea, may be a symptom of endometriosis. Increasingly painful periods or severe pain in the days leading up to a period should be viewed as a possible warning sign of endometriosis. However, there are many women who suffer from painful periods who do not have endometriosis. Teenagers commonly complain of painful periods, but endometriosis is uncommon in this age group. Deep pelvic pain on opening the bowels often indicates severe endometriosis in the space between the womb and rectum.

Fertility

Most women with endometriosis will conceive without any problems. Some women never know that they have endometriosis, because they have only mild or no symptoms. Some women do have difficulty getting pregnant. In severe endometriosis, this is because of adhesions (scar tissue) form a barrier between the ovary and the tube. It may be possible to remove these adhesions surgically. If pregnancy doesn’t happen, the adhesions may be bypassed by IVF (test tube baby). In mild cases, it is debated whether endometriosis is the cause of infertility. It may be that all women will develop endometriosis if they have years of periods without a break. However, surgical treatment of endometriosis by cauterisation (diathermy), vaporisation by laser or cutting away (excision) has been shown to improve the chance of getting pregnant.
Medical treatment is not recommended, if fertility is the only issue because it doesn’t improve your chance of getting pregnant. It is normally only prescribed in relation to surgery to treat pain.

Pelvic pain

Pelvic pain typically starts in the second half of the month, gets worse as the period is due and is better when the period is finished. Not all pelvic pain is due to endometriosis. The larger bowel (colon) sits on either side next to the ovaries, and bowel pain can be mistaken for the pain of endometriosis.

Endometriosis can cause pain during intercourse a symptom called dyspareunia. The thrusting motion can cause pain in a tender nodule of endometriosis. Women with endometriosis can have irregular vaginal bleeding. Other symptoms of endometriosis are less common; endometriosis can grow on intestines, in the wall of the bladder, or in surgical scars. These implants may bleed into the bladder or bowel during a period.

Diagnosis

The diagnosis of endometriosis cannot be made from symptoms alone, since some women with endometriosis have no symptoms and not all pain due to endometriosis. A doctor may suspect the disease if a woman is having difficulty getting pregnant, or she has painful periods, pelvic pain or pain during intercourse. A family history of endometriosis in a close relative is also suggestive.

Vaginal examination

Vaginal examination can be helpful in making the diagnosis. The doctor may be able to feel tender spots of endometriosis or an enlarged ovary.

Laparoscopy - This is the only way to be sure endometriosis is present.

Laparoscopy is an operation, during which a thin telescope (A laparoscope) is inserted through a small incision near the navel. This enables the doctor to see inside the abdominal cavity, inspect the reproductive organs and diagnose endometriosis. The surgeon can check that the fallopian tubes are not blocked during the laparoscopy. This is done by flushing blue dye through the neck of the womb known as the cervix. If the tubes are open, dye will be seen passing out of the ends of the tubes. If minor degrees of endometriosis are seen at laparoscopy, it is sometimes possible to destroy it there and then, by cauterising it with heat (diathermy) or vaporising it with laser. The site of the endometriosis will influence whether this can be done.

Treatment

Treatment is tailored to the individual woman and aims to improve pain and / or infertility. It may involve hormone treatment, surgery or a combination of both. Treatment is effective in suppressing the disease and, hopefully, in providing long-term relief. It is probably best to think of this as a remission rather than a cure, as symptoms can recur over time. It has been claimed that pregnancy is a ‘natural cure’ for endometriosis. If you were planning to start a family in the near future, the doctor may advice you to go ahead. Some women with endometriosis have difficulty in falling pregnant. Medical treatment of endometriosis has not been shown to improve a woman’s chance of falling pregnant, but surgical treatment of mild endometriosis has been found to improve fertility. If a woman with endometriosis fails to get pregnant, in vitro fertilisation, the so-called test tube baby method, may be an option.

Hormone treatment

Pregnancy and the menopause are two ‘natural cures’ for endometriosis. In pregnancy, there are sustained high levels of oestrogen and, especially, progesterone; in the menopause, levels of oestrogen and progesterone are low. Treatment involves mimicking one or the other of these conditions. Both types of the treatment lead to changes in the lining of the womb, the endometrium, and in the endometriosis, which encourage its healing. Periods usually stop on treatment, it is not possible to eradicate the ovarian ‘chocolate cysts’ (endometrioma). Surgery is the primary treatment of such cysts.

Progestrogens

Some doctors use progestogens to treat endometriosis. These are progesterone-type drugs prescribed as pills or injections, usually for six months. Possible side effects include water retention and weight gain and irregular vaginal bleeding. The injections are contraceptive and may have a prolonged effect of up to one year after the last injection.

Gonadotrophin-releasing hormone agonists

(GnRH agonists)
Treatment is taken as an injection and is usually prescribed for six months, sometimes longer. They prevent oestrogen being produced by the ovaries and result in temporary and reversible menopause. Endometriosis shrinks during treatment and painful symptoms improve in 90%of women. Treatment is usually started during a period. Occasionally, there can be an increase in pain in the first month of treatment before symptoms start to improve (flare effect). At the end of the first month, you may have a period, sometimes heavier than usual, but usually your last one during treatment. Side effects are those of the menopause and may include hot flushes, mood changes, headaches, vaginal dryness and loss of bone calcium.

These normally start at the end of the first month of treatment. The loss of bone calcium is small and returns to normal within six months of stopping treatment. The side-effects and loss of bone calcium can be reduced by taking hormone replacement therapy, without affecting the treatment. Pain starts to improve in the second month of treatment. Treatment is usually contraceptive, but cannot be relied on. It is important to use contraceptive (the cap or condom) while taking either of the drugs, since pregnancy is not advised. Ninety per cent of the women are better after six months treatment. Unfortunately, as many as one in five women need another course of treatment within 12 months because their symptoms have returned.

Birth control pill

The birth control pill improves pain and is as good as GnRH agonist in relieving symptoms. It can be taken in the usual way with a seven-day break at the end of the packet. Alternatively, it can be taken continuously without any break or as four packets in a row with a seven-day break every three months (tricycling). Taken continuously, your periods will stop, but there may be some irregular vaginal bleeding. The birth control pill is thought to slow the growth of endometriosis, but this has not been fully investigated by laparoscopy.

Surgery

Some forms of severe endometriosis do not respond to drug treatment. Surgery may be required to remove scar tissue (adhesions), ovarian cysts (endometriomas) or nodules of endometriosis to relieve pain, or improve fertility.

Laparoscopic (keyhole) surgery

Keyhole surgery can be used to treat endometriosis, minimising adhesions. Endometriotic deposits may be destroyed by diathermy (cauterising with heat). Adhesions can be cut through by laparoscope with specially designed scissors. An experienced laparoscopic surgeon may remove Endometriomas. Large nodules of endometriosis need to be surgically removed, particularly if related to the bowel and vagina. Surgery improves pain, but it may take up to six months after surgery to feel the real benefit.

Hysterectomy

For women who have no success with other treatments and have completed their families, the womb and ovaries may be removed (hysterectomy and oophorectomy) to relieve severe and persisting pain. After hysterectomy alone (i.e. without removal of ovaries), there is a significant chance that endometriosis will recur. When this was studied, it was found that 13% of women had recurrence after three years and 40% after five years. The more severe the endometriosis, the more likely it is to recur. The chance of recurrence is much smaller if the ovaries are also removed at the time of hysterectomy. However, this leaves a woman in the menopause. To prevent the loss of bone calcium and menopausal symptoms due to oestrogen deficiency in the menopause, most women will need hormone replacement therapy. The majority of women with endometriosis can take hormone replacement therapy without problems.

Conclusion

Endometriosis is a disease affecting millions of women throughout the world. For many, the condition goes unnoticed, but for others it demands professional attention, especially when pain affects lifestyle or fertility is impaired. Your doctor will recommend the most appropriate course of treatment, based on your personal circumstances.

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