What are the treatment options for dyspareunia?

Treatment Options for Dyspareunia

The first-line treatment for dyspareunia is hormone-free lubricants and moisturizers, with progression to low-dose vaginal estrogen for those who don't respond to conservative measures. 1

Causes and Assessment

Dyspareunia (painful sexual intercourse) is commonly caused by:

• Vaginal dryness/atrophy
• Pelvic floor muscle dysfunction
• Vulvodynia/vulvar vestibulitis
• Psychological factors
• Hormonal changes (especially in cancer survivors or postmenopausal women)
• Medical conditions (endometriosis, pelvic inflammatory disease)

Treatment Algorithm

Step 1: Non-Hormonal Approaches (First-Line)

• Vaginal moisturizers and lubricants

  • Water-based gels for daily comfort 1
  • Silicone-based lubricants for longer duration 1
  • Hyaluronic acid gels 1

• Pelvic floor physical therapy

  • Particularly effective for muscle-related dyspareunia 2, 3
  • Includes pelvic floor muscle training, manual therapy, and trigger point release 2
  • Significant improvements in pain scores and sexual function demonstrated in randomized controlled trials 2, 3

• Vaginal dilators

  • Beneficial for vaginismus and vaginal stenosis 1
  • Particularly important for women treated with pelvic radiation therapy 1

Step 2: For Persistent Symptoms (Second-Line)

• Low-dose vaginal estrogen (pills, rings, or creams)

  • Effective for treating vaginal dryness, itching, discomfort 1
  • For women with hormone-sensitive cancers (e.g., breast cancer), only after thorough risk-benefit discussion 1

• Topical anesthetics

  • Lidocaine for persistent introital pain and dyspareunia 1
  • Application to vulvar vestibule before vaginal penetration 1

• Vaginal DHEA (prasterone)

  • FDA-approved for dyspareunia in postmenopausal women 1
  • Improves sexual desire, arousal, pain, and overall sexual function 1
  • Caution in women with history of breast cancer 1

Step 3: Additional Options (Third-Line)

• Ospemifene

  • FDA-approved for moderate to severe dyspareunia in postmenopausal women without breast cancer history 1
  • Not recommended for women with hormone-sensitive cancers 1

• Psychological interventions

  • Cognitive behavioral therapy 1
  • Sexual counseling and psychoeducational support 1
  • Particularly important for addressing anxiety and negative expectations 4

• Multidisciplinary approach

  • Combining psychological skills training, pelvic floor physiotherapy, and medical management 5
  • Shown to significantly reduce dyspareunia and improve sexual functioning 5

Special Considerations

For Cancer Survivors

• Avoid systemic hormone therapy for breast cancer survivors 1
• Low-dose vaginal estrogen may be considered for hormone-positive breast cancer patients after thorough risk-benefit discussion 1
• For women on aromatase inhibitors experiencing arthralgia that interferes with intimacy, pain relievers should be offered 1

For Persistent or Complex Cases

• Referral to specialists (sexual health specialist, urogynecologist, psychotherapist) 1
• Consider interdisciplinary treatment programs that address both physical and psychological aspects 5

Pitfalls to Avoid

1. Ignoring psychological factors: Even when dyspareunia has a clear physical cause, psychological factors often perpetuate the pain cycle 4, 6

2. Focusing only on hormonal treatments: Non-hormonal approaches should be exhausted first, especially in women with hormone-sensitive cancers 1

3. Overlooking pelvic floor dysfunction: Muscle tension and trigger points are common contributors to dyspareunia that respond well to physical therapy 2, 3

4. Delaying treatment: Early intervention prevents the development of chronic pain patterns and secondary sexual dysfunction 6

5. Not addressing partner concerns: Including partners in education and treatment planning improves outcomes 5