What are the treatment options for dyspareunia?

Treatment Options for Dyspareunia

The first-line treatment for dyspareunia is hormone-free lubricants and moisturizers, with low-dose estrogen-containing vaginal medication considered when non-hormonal measures are ineffective. 1

Diagnosis and Classification

Dyspareunia can be classified based on location:

• Entry/Superficial dyspareunia: Pain at vaginal entrance during penetration

  • Common causes: Vaginal dryness, vulvodynia, atrophy, inadequate lubrication, vaginismus 2

• Deep dyspareunia: Pain with deep penetration

  • Common causes: Endometriosis, pelvic congestion syndrome, interstitial cystitis, adhesions, adnexal pathology 3, 4

Treatment Algorithm

First-Line: Non-Pharmacological Approaches

1. Vaginal moisturizers and lubricants 1, 5

   • Moisturizers: Apply 2-3 times weekly
   • Lubricants (water-based gel, hyaluronic acid gel): Use during all sexual activity

2. Pelvic floor physical therapy 5, 6

   • Particularly effective for vaginismus and vulvodynia
   • Shown to significantly reduce pain and improve sexual function

3. Cognitive behavioral therapy 5

   • Addresses psychological factors that may perpetuate pain
   • Helps manage anxiety and sexual dysfunction

4. Regular physical exercise 5

   • Improves overall well-being and may reduce symptoms

5. Vaginal dilators 5

   • For gradual desensitization in cases of entry dyspareunia

Second-Line: Pharmacological Approaches

If non-pharmacological approaches are insufficient:

1. Topical lidocaine 5

   • For persistent introital pain and dyspareunia
   • Apply to painful areas before sexual activity

2. Low-dose estrogen-containing vaginal medication 1

   • Consider when hormone-free measures are ineffective
   • Use with caution in patients with hormone-sensitive cancers

3. Vaginal DHEA (prasterone) 5

   • FDA-approved for vaginal dryness
   • Improves sexual desire, arousal, pain, and overall sexual function
   • Minimal systemic effects

4. Ospemifene 1, 5

   • For moderate to severe dyspareunia in postmenopausal women
   • Contraindicated in women with hormone-sensitive cancers

Condition-Specific Treatments

For deep dyspareunia with identified causes:

1. Endometriosis

   • Medical therapies may improve symptoms
   • Laparoscopic excision of deep endometriotic lesions improves both dyspareunia and quality of sex life 3

2. Pelvic congestion syndrome

   • Pelvic vein embolization 3

3. Interstitial cystitis

   • Intravesical therapy 3

Special Considerations

For Cancer Patients

• Avoid systemic hormone therapy in women with hormone-sensitive breast cancer 5
• Low-dose vaginal estrogen may be considered for severe symptoms in breast cancer patients only after thorough discussion of risks/benefits 5
• Avoid paroxetine and fluoxetine in women with breast cancer taking tamoxifen due to drug interactions 5

For Menopausal Symptoms

• For vasomotor symptoms: venlafaxine, gabapentin, clonidine 1, 5
• For sleep disturbances: melatonin 1

Multidisciplinary Approach

A multidisciplinary approach integrating psychological skills training, pelvic floor physiotherapy, and medical management has shown strong efficacy for improving dyspareunia and all domains of sexual functioning 6. This approach resulted in:

• 53.8% of patients reporting significant improvements in dyspareunia
• Significant reductions in sex-related distress
• Improvements in sexual arousal and overall sexual functioning
• Improvements in sexual desire, lubrication, orgasmic function, and sexual satisfaction

Important Caveats

• Always evaluate abnormal bleeding before initiating vaginal estrogen therapy 5
• Be aware of potential drug interactions with concurrent medications 5
• Regular follow-up is essential to monitor treatment efficacy and adjust as needed 5
• Dyspareunia affects 10-28% of women during their lifetime and significantly impacts quality of life 7
• Collaboration between general practitioners, gynecologists, physiotherapists, and psychologists is crucial for optimal treatment outcomes 7