The definition of dyspareunia is painful intercourse. This can mean pain at the vaginal opening upon insertion, or pain inside the vagina, during deeper penetration. This can mean pain just at the initiation of intercourse, pain during intercourse or pain afterwards. There are many different causes of painful intercourse. A physical examination is often necessary to determine the cause. Vulvovaginal atrophy is a leading cause of painful intercourse in post-menopausal women. Atrophy is the condition caused by a lack of estrogen in the vaginal area, which can cause vaginal dryness, itching, burning, irritation, lack of elasticity and pliability, which can all lead to discomfort with intercourse. Typical treatments focus on the replenishment of vaginal estrogen by way of estrogen creams, tablets, etc. Women who are unable to take estrogen (i.e. breast cancer survivors) or women who are not interested in taking estrogen supplementation may be interested in vaginal laser therapy [link to vaginal laser therapy]. Pelvic floor muscle spasm is a relatively common cause of painful intercourse in both pre- and post-menopausal women – refer to the section of pelvic floor muscle spasm for more detail. Another, less common cause of dyspareunia is vaginal scar tissue. Vaginal scar tissue can be painful. There are many different treatment options available, including pelvic floor physical therapy, medications, trigger point injections or vaginal laser therapy. A physical examination by a urogynecologist can help determine which treatment is appropriate.