Can deep dyspareunia (painful intercourse) be the only symptom of endometriosis?

Deep Dyspareunia as the Only Symptom of Endometriosis

Yes, deep dyspareunia can be the only symptom of endometriosis, particularly in cases of deep infiltrating endometriosis, though this presentation is not typical of all endometriosis cases. 1

Understanding Deep Dyspareunia in Endometriosis

Deep dyspareunia (pain during deep penetration during intercourse) is a cardinal symptom of endometriosis that affects approximately 50% of women with the condition 2, 3. The relationship between deep dyspareunia and endometriosis has several important clinical characteristics:

• Pain mechanism: Deep dyspareunia in endometriosis is typically associated with deep infiltrating lesions that involve peritoneal surfaces innervated by peripheral spinal nerves 4
• Correlation with lesion depth: The depth of endometriotic lesions correlates with severity of pain, though there is little relationship between pain and the type of lesions seen during laparoscopy 4
• Isolated symptom possibility: While endometriosis often presents with multiple symptoms, deep dyspareunia can sometimes be the predominant or only symptom, especially in cases of deep infiltrating endometriosis 1

Classification of Deep Dyspareunia in Endometriosis

According to current research, deep dyspareunia in endometriosis can be classified into four types 2:

1. Type I: Directly due to endometriosis lesions
2. Type II: Related to a comorbid condition (e.g., interstitial cystitis)
3. Type III: Primary genito-pelvic pain penetration disorder
4. Type IV: Secondary to a combination of types I-III

Diagnostic Approach When Deep Dyspareunia is the Only Symptom

When a patient presents with deep dyspareunia as the only symptom:

1. Consider endometriosis in the differential diagnosis, especially if the pain:

   • Is exaggerated during menses 4
   • Occurs in a consistent location
   • Has been progressive over time

2. Diagnostic confirmation requires:

   • Surgical visualization of lesions (laparoscopy remains the gold standard) 1
   • Histologic examination to confirm endometrial lesions, especially those with non-classical appearance 4

3. Imaging studies:

   • Transvaginal ultrasound or pelvic MRI can help identify endometriomas and deep infiltrating endometriosis before treatment 1

Treatment Options

When deep dyspareunia is confirmed to be due to endometriosis:

1. First-line medical therapy options:

   • Progestin-only contraception (e.g., levonorgestrel-releasing IUD) - recommended for patients with contraindications to estrogen 1
   • Combined hormonal contraceptives in continuous regimen (standard starting dose: 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate) 1
   • Progestins such as norethindrone acetate, depot medroxyprogesterone acetate, and dienogest 1

2. Surgical options (for patients with persistent symptoms despite medical therapy):

   • Laparoscopic excision/ablation of endometriotic lesions provides significant pain reduction, particularly in the first six months 1
   • For deep infiltrating endometriosis specifically, surgical excision has been shown to improve not only deep dyspareunia but also quality of sex life 5

Important Clinical Considerations

• Response to treatment: Medical therapy effect on dyspareunia may be gradual but progressive, while surgical treatment often provides more immediate relief but may have partial recurrence of pain over time 6

• Recurrence rates: Up to 44% of women experience recurrence of symptoms within one year after surgery 4

• Treatment selection: For women with rectovaginal endometriotic lesions, surgery and progestin therapy appear equally effective for deep dyspareunia, while medical therapy performs better than excisional treatment in those without deeply infiltrating lesions 6

• Comorbid conditions: Always consider that deep dyspareunia may be multifactorial, with potential contributions from interstitial cystitis, pelvic congestion syndrome, or central sensitization 2, 5

Deep dyspareunia should be taken seriously as a potential indicator of endometriosis, even when it presents as an isolated symptom, and appropriate diagnostic evaluation should be pursued to guide effective treatment.