Reasoning GP · Algorithm · 1-page summary
Dyspareunia (painful sex)
For: adults with pain on or during sex, in primary care. Not for: confirmed PID, vulval disease or menopause already under care (use the PID, vulvar disorders and menopause protocols). Young people, FGM, assault or coercion → safeguarding (block 2).
Core rule: separate superficial (entry) from deep pain and examine with consent: a cervix that looks malignant, a pelvic mass or a possible ectopic changes the route today. Ask sensitively whether sex is consensual and whether the patient feels safe.
0Stop — call 999 now
- Haemodynamic instability or peritonism — suspected ruptured ectopic or ovarian cyst, or ovarian torsion (acute severe unilateral pelvic pain ± vomiting) → 999
- Sexual assault with immediate danger, serious injury or risk to another person → 999 / ED
1Triage by pattern — superficial vs deep is the key step
| Pattern | Think |
|---|---|
| Superficial (entry) | GSM, vulvodynia, vaginismus, lichen sclerosus/planus, STI |
| Deep (pelvis) | Endometriosis (most important), PID, cyst, fibroids, IBS |
| Lifelong | Vaginismus, vestibulodynia, structural |
| Cyclical | Endometriosis (± dysmenorrhoea, subfertility) |
| One partner only | Relationship, sexual trauma, fear of pregnancy |
2Screen — one row is enough
- Possible pregnancy + pain (ectopic not excluded) or acute severe unilateral pain (torsion) → Immediate hospital
- Fever/systemic illness + adnexal mass or marked tenderness (TOA, severe PID) → Same-day hospital. Other pelvic mass → same-day USS + gynaecology.
- Cervix consistent with cancer → consider Suspected cancer pathway; do not wait for screening. PCB, normal cervix → urgent gynaecology/colposcopy (local).
- Ascites or pelvic/abdominal mass not obviously fibroids; unexplained PMB ≥55 (not HRT) → Suspected cancer pathway. PMB <55 or unexplained vulval lump, ulcer or bleeding → consider it.
- Persistent bloating, satiety, pelvic or urinary symptoms: ≥40 → CA125 (age-specific threshold → urgent USS); ≤39 → consider urgent USS.
- Safeguarding: assault → SARC/ISVA; abuse → safeguarding lead; FGM under 18 → police (101) by next working day + safeguarding.
3Assess — consent, chaperone, patient in control
☐ Pregnancy test if could be pregnant ☐ Vulval inspection ☐ Cotton-swab test once infection/dermatoses considered ☐ Speculum (cervix, discharge) + bimanual (CMT, adnexal mass) ☐ NAAT chlamydia, gonorrhoea, trichomonas; HIV + syphilis (offer in PID) ☐ Transvaginal USS if endometriosis suspected, even with a normal exam.
Do not: force examination; use CA125 for endometriosis; take a smear for symptoms.
4Classify — only if the screen is negative
- Endometriosis — deep pain + cyclical dysmenorrhoea ± subfertility → TVUS and empirical treatment in parallel.
- GSM — postmenopausal or hypo-oestrogenic (lactation, oophorectomy); dryness, burning → vaginal oestrogen.
- Vulvodynia / vaginismus — entry pain, normal skin, positive swab test; or involuntary spasm → pelvic floor, psychosexual.
- Lichen sclerosus — white atrophic plaques, fissures, architectural change → clobetasol; biopsy if atypical or not responding.
- PID / STI — discharge, cervical motion and adnexal tenderness → treat on clinical suspicion.
- Uncertain — say so: a normal examination does not exclude endometriosis, vulvodynia or pelvic-floor dysfunction → review.
5Treat today — doses: NICE/SPC, BNF, local formulary
- PID: ceftriaxone 1 g IM once + doxycycline 100 mg BD + metronidazole 400 mg BD for 14 days; do not wait for NAATs; partner notification via sexual health.
- GSM: offer vaginal oestrogen (estradiol 10 mcg daily for 2 weeks, then twice weekly), alone or with moisturisers/lubricants. Breast cancer → non-hormonal first, then consider with the breast-cancer team.
- Endometriosis: paracetamol and/or NSAID + combined hormonal contraception or progestogen, after discussing fertility.
- Lichen sclerosus: clobetasol 0.05% daily 4 weeks, alternate days 4 weeks, twice weekly 4 weeks; emollient. Vulvodynia: avoid irritants, lubricants; no opioids.
6Refer routinely
- Gynaecology: endometriosis treatment ineffective or not tolerated, daily life affected, persistent, or pelvic signs. Endometrioma or deep disease → specialist centre.
- Pelvic-floor physio + psychosexual therapy: vaginismus, pelvic-floor dysfunction, postnatal pain.
- Vulval clinic: LS, LP or vulvodynia not responding. Fertility services early if endometriosis and wishing to conceive.
7Never reassure by
- A normal pelvic examination or TVUS — it does not exclude endometriosis.
- A previous negative cervical screen — it does not exclude cancer or justify delay.
- A normal CA125 — it does not exclude ovarian cancer.
- Painful periods and deep dyspareunia as “normal” — they need investigation.
- Repeated antifungals for negative swabs — think dermatitis, LS, vulvodynia.
- “It's psychological” — psychosexual factors coexist with physical causes.
8Safety-net — say it, then document it
999 “Call 999 if you get sudden severe pain low in your tummy and feel faint or collapse, or if you are in danger.” Same day: “Contact us today if you get a fever with pelvic pain or discharge, bleeding after sex, a new lump or swelling, pain that changes quickly, or you feel unsafe. If you could be pregnant and have pain, go to hospital now.”
Review: often under-disclosed — invite return. PID moderate/severe at 72 h; others 2–6 weeks; endometriosis and LS at 3 months; stable LS yearly (new lump or ulcer → urgent biopsy).
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies; pregnancy excluded
Consent and safety asked; safeguarding acted on
Superficial vs deep set; examined or exam planned
Swabs, TVUS or treatment arranged, results owner set
Safety-net given; review booked
Summary of the full Reasoning GP dyspareunia algorithm, which holds the detail on vulvodynia, vaginismus, candida, examination and follow-up. Sources: NICE NG73, NG12 (updated April 2026), NG23; BASHH PID 2019 and vulvovaginal candidiasis 2019; BAD lichen sclerosus 2018; RCOG GTG 53. Clinical reference — follow local sexual-health, gynaecology and safeguarding pathways and check doses: NICE/SPC, BNF.