Dysorgasmia in women: Case report and preliminary assessment guide

Abstract

Dysorgasmia in women is an infrequent reason for consulting a clinician. In this article, the authors describe the case of a woman with right-sided pelvic pain immediately after orgasm. Dysorgasmia is likely to negatively impact sexual health but is rarely discussed in medical literature. Furthermore, assessment and treatment guidelines for clinicians are currently lacking. Therefore, the authors conducted a literature review and created a preliminary assessment guide, considering both medical and gray literature. A brief flowchart was developed which can facilitate the assessment of dysorgasmia in women for clinicians and improve the quality of care for patients. Further research on the etiology and pathophysiology of dysorgasmia in women is warranted, as is a more proactive attitude of clinicians to discuss sexual health. More guidance on diagnosis and treatment is needed.

Background

Pain during or after orgasm, also known as dysorgasmia, is an infrequent presenting complaint in primary care and sexual medicine.^1,2 In the medical literature, reported cases often concern male patients who experience ejaculatory pain after radical prostatectomy for prostate cancer, ² or an orgasm-related syndrome with debilitating symptoms, including allergic and psychological reactions. The latter is usually termed “postorgasmic illness syndrome” and can occur within seconds or hours after ejaculation.^{3 –5} It is a rare condition that is under-reported, resulting in a lack of understanding of its pathophysiology, prevalence, and treatment options.^3,5

In 2018, Goldstein and Komisaruk described its female counterpart, the female orgasmic illness syndrome. ⁶ This was defined by “rare aversive symptoms that have been reported to occur prior to, during, or following orgasm.” ⁶ They mention that there is an arbitrary division between two categories of symptoms. The first includes central aversive symptoms, such as confusion, anxiety, and insomnia, while the second includes peripheral aversive symptoms, such as constipation, muscle ache, abdominal pain, chills, and genital pain. ⁶ There is much individual variety in symptoms, and symptoms can last for minutes, hours, even up to days postorgasm. ⁶ Despite some case studies in the medical literature,^7,8 and a description of some examples of female orgasmic illness syndrome or dysorgasmia,^6,9 there are no guidelines for safe and effective medical management of these patients.

The following clinical encounter with a woman experiencing postorgasmic pain prompted the authors to review the literature and create a preliminary assessment guide to support clinicians and improve quality of care for patients.

Case presentation

Description

A 34-year-old woman with no remarkable medical history presented to her general practitioner in June 2022. When asking for a prescription refill of her vaginal contraceptive, she stated that for the last 3 months, she experienced excruciating, continuously stabbing right-sided pelvic pain immediately after orgasm. She reported being able to have penetrative intercourse without pain or concern. The pain only occurred after orgasm, lasted for 30 min to 1 h and frequently made it impossible to move about. Regular painkillers (acetaminophen, non-steroidal anti-inflammatory medication) proved ineffective.

Assessment and follow-up

The general practitioner assessed the pain with standard questioning. The patient stated that the pain started after switching contraceptive brands (NuvaRing to IzzyRing), both combined vaginal contraceptives (etonogestrel/ethinylestradiol). Due to this topic coming up at the end of the consultation, a clinical examination was not conducted. A prescription of a similar contraceptive was given out (Ringafema), and the patient was encouraged to visit again if the pain did not subside.

After 3 months, the patient visited for another problem and when asked about the pain, it appeared to have completely subsided after using the newly prescribed contraceptive ring. At this time, there was deemed to be no need for any further diagnostic workup.

Literature review

Methods

PubMed, Google Scholar, and Embase were searched using the terms “dysorgasmia” and “orgasm pain,” from the date of inception up to November 2023. Additional gray literature, such as informational websites and blogs, was also screened. Findings are reported following the CARE Case Report guidelines. ¹⁰

In the second part of this article, a potential approach is formulated based on the reviewed literature, when dealing with this problem in clinical practice. The Ethics Committee Research UZ/KU Leuven verified and approved the publication of this case report in February 2023 (ref. S67267).

Results

A total of eight publications were found, discussing the subject matter of dysorgasmia in women (Table 1). Literature concerning conditions relevant to periorgasmic pain in women was additionally reviewed.

Table 1.

Overview of publications on dysorgasmia in women.

Authors	Year	Report type	Title
Ajay et al. 8	2009	Poster abstract from World Congress of Gynecology and Obstetrics	Dysorgasmia or pain at orgasm: a case series
Chamberlain 11	2020	Sexual health web publication, medically reviewed by dr. Louise Wiseman	Why do I get cramps after sex? Everything you need to know about dysorgasmia
Goldstein and Komisaruk 6	2018	Chapter in textbook (Female Sexual Function and Dysfunction)	Pathophysiology and Medical Management of Female Orgasmic Illness Syndrome
Kilday and Finley 12	2016	Peer-reviewed case report	Robot-Assisted Excision of a Urachal Cyst Causing Dyspareunia and Dysorgasmia: Report of a Case
Reinert and Simon 9	2017	Review	“Did You Climax or Are You Just Laughing at Me?” Rare Phenomena Associated with Orgasm
University Hospitals (Cleveland, OH) 13	n.d.	Female sexual health web publication	Compassionate Care for Women with Dysorgasmia
Yong 7	2020	Peer-reviewed case report	Clinical Conundrum: A 33-Year-Old with Pain Post-Orgasm and a History of Endometriosis
Chiminacio et al. 14	2023	Peer-reviewed case report	Post-orgasm pain associated with endometriosis and complete resolution of symptoms after laparoscopic en-bloc peritonectomy, a case report

Since 2018, only two case reports about dysorgasmia in women could be identified.^7,14 Consequently, no information on the prevalence and age distribution of this condition was available. In the following section, the available evidence on the possible causes of this phenomenon is summarized. Non-academic literature related to women’s sexual health included additional hypotheses for the etiology of dysorgasmia in women.^8,11,13

Endometriosis

In a case study by Yong, ⁷ pain after orgasm in a 33-year-old woman was hypothesized to be caused by endometriosis. Another recent case study identified endometriosis of the posterior vaginal wall as the cause of dysorgasmia. ¹⁴ Endometriosis can be an important and common cause of lower abdominal or pelvic pain in women of reproductive age. ¹⁵ It has a myriad of presentations, ranging from asymptomatic to dyspareunia, to entirely disabling pain and infertility. ¹⁵

Contraceptive use

In some studies, the use of hormonal contraceptives has been associated with, among other things, decreased sexual pleasure, problems with vaginal lubrication, and pain during intercourse. ¹⁶ Other studies, however, reported that the use of vaginal contraceptives was less likely to lead to these problems.^17,18

Infection/pelvic inflammatory disease

Pelvic inflammatory disease (PID) is typically associated with lower abdominal pain coupled with some form of cervical or adnexal tenderness, dyspareunia, or postcoital bleeding, as well as general malaise or fever. ¹⁹ However, PID is difficult to diagnose because its symptoms can be mild and non-specific. ¹⁹ PID can stem from recurrent infections with Chlamydia trachomatis. ²⁰ Chlamydia infection by itself can also cause pain, which usually presents as a more generalized pain in the lower abdomen. ²⁰ Symptomatically related to PID is the pelvic congestion syndrome—the presence of pelvic varicose veins—which usually causes chronic rather than acute pelvic pain. ²¹

Any anomaly in the pelvic area could potentially cause dysorgasmia, because orgasm is associated with pelvic floor and uterine contractions. ²² Pelvic floor dysfunction could contribute to the development of sexual dysfunction, pain during sex, or dysorgasmia.^13,23

Ovarian and uterine abnormalities

Uterine, fallopian, or ovarian origins of dysorgasmia are also possible. Ovarian cysts and uterine fibroids are common causes of acute pelvic pain. ²⁴ Kilday and Finley also reported on dysorgasmia in a young woman caused by a urachal cyst. ¹²

Neurogenic causes

In a conference proceeding, Ajay et al. ⁸ introduced a case series on pain at orgasm in women. All patients discussed in this series had isolated pain at orgasm without the presence of a precipitating factor, and all had unremarkable medical histories. The authors presumed a neurological cause for the pain and treated it successfully with no more than 50 mg of amitriptyline, a tricyclic antidepressant commonly used for the treatment of chronic neuralgia. Sedation and weight gain are the most commonly reported side effects. ²⁵

Also, Goldstein and Komisaruk reported patients with inflammation of the afferent sensory pelvic nerve, due to sacral or lumbar spine pathology, which was responsible for dysorgasmia. ⁶

Discussion

Literature review

Dysorgasmia in women is a complex pathology for which clinical guidelines are lacking. Available evidence comes mainly from case reports and is scarce. From the medical and gray literature, the following possible causes were identified: endometriosis; contraceptive use; pelvic, ovarian or uterine anomalies; infection or PID; or a neurogenic origin. Based on this evidence, the authors propose an assessment guide to facilitate decision-making in clinical practice with both diagnostic and treatment considerations (Figure 1).

Figure 1.

Flowchart for a preliminary assessment guide for dysorgasmia in women.

PID: pelvic inflammatory disease; STI: sexually transmitted infection; EP: ectopic pregnancy; CT: computed tomography scan; MRI: magnetic resonance imaging.

Preliminary assessment guide and recommendations

When women mention sexual dysfunction, it is important to consider the physical, psychological, and social factors that might influence the presented problem.^11,13

In the case of dysorgasmia, it is recommended to start with a thorough review of the medical history. If not available, more information about sexual function and satisfaction, including the presence of dyspareunia, pelvic pain (acute or chronic), dysorgasmia or any systemic symptoms, should be gathered. In addition, the patient should be asked about any symptoms or signs related to endometriosis, uterine, or adnexal masses and, if the patient is sexually active, sexually transmitted infections (STIs), as well as contraceptive use and satisfaction.

With persisting or severe symptoms, exploration of spinal nerve pathology and referral for gynecologic ultrasound or imaging are warranted, as would treatment with analgesics or anti-inflammatory drugs (taken before sexual activity) or with low-dose amitriptyline. Follow-up at regular intervals is recommended and should not be left solely at the patient’s discretion.

However, in the absence of alarming features in the medical history, the authors suggest a conservative approach (see Figure 1).

Learning points

Clinicians should adopt a proactive attitude when it comes to sexual health care. Providing and obtaining permission to discuss any topics related to sexual health is crucial in improving quality of care. Patients are not inclined to bring up sexual complaints, especially with uncommon issues. As the main reason for consulting might be something completely unrelated, more attention to sexual health is warranted.

Using the preliminary assessment guide and recommendations, an alternative scenario for the assessment and follow-up of the described case became clear.

A thorough review of the medical history to check for past STIs is important. It appeared that our patient had previously tested positive for C. trachomatis three times: in May 2015, May 2016, and November 2021. The most recent cervical cytology, done in July 2021, was normal. In addition, particular attention would have been paid to her complaint, and regular follow-up would have been suggested. This would have clarified the evolution of the symptoms and the necessity of additional diagnostic workup.

Future research

Evidence about the etiology, pathophysiology, and treatment of dysorgasmia mainly comes from case reports. Because these are scarce and the physiology of orgasm is complex, more research is certainly warranted.

A validated assessment guide and clinical care pathway could be created using a Delphi study and co-creation with women with lived experience. The inclusion of a multidisciplinary panel of experts for the Delphi study, with representatives from primary care, gynecology, obstetrics, and sexology, is recommended.

Conclusion

In this case report, the case of a woman with pelvic pain after orgasm was described, along with the possible causes of dysorgasmia in women. A preliminary assessment guide was provided, along with a brief flowchart that aims to support clinicians to assess dysorgasmia and improve quality of care. Implementation of a validated assessment guide will raise awareness about the need for proactive discussions about women’s sexual health. Further research regarding the etiology, pathophysiology, and possible treatment of this condition is needed to provide adequate care.