What are the treatment options for dyspareunia (painful sexual intercourse)?

Treatment Options for Dyspareunia (Painful Sexual Intercourse)

For women experiencing dyspareunia, a stepwise approach should be followed, starting with hormone-free lubricants and moisturizers, progressing to vaginal dilators, pelvic floor physical therapy, and if needed, low-dose vaginal estrogen or other pharmacological interventions. 1, 2

First-Line Treatment Options

• Hormone-free lubricants should be used during all sexual activity to reduce friction and discomfort 1, 2
• Regular use of vaginal moisturizers improves vulvovaginal tissue quality and provides ongoing relief from dryness and discomfort 1, 3
• Silicone-based lubricants may last longer than water-based or glycerin-based products and can be considered for persistent vaginal dryness 2, 3

Second-Line Treatment Options

• Vaginal dilators are beneficial for managing vaginismus and/or vaginal stenosis, particularly important for women treated with pelvic radiation therapy 1, 2
• Pelvic floor physical therapy should be offered to women with pain or other pelvic floor issues, as it can improve sexual pain, arousal, lubrication, and satisfaction 1, 2, 4
• Cognitive behavioral therapy and pelvic floor exercises may be useful to decrease anxiety, discomfort, and lower urinary tract symptoms 1, 2

Pharmacological Options

• For women whose symptoms are more severe or unresponsive to conservative measures, low-dose vaginal estrogen can be considered 1
• For women with hormone-positive breast cancer who are symptomatic and not responding to conservative measures, low-dose vaginal estrogen can be considered after a thorough discussion of risks and benefits 1, 2
• Vaginal DHEA (prasterone) is an option for women with current or history of breast cancer who are on aromatase inhibitors and have not responded to previous treatments 1, 2
• Lidocaine can be offered for persistent introital pain and dyspareunia 1, 2
• Ospemifene (a selective estrogen receptor modulator) may be offered to postmenopausal women without current or history of breast cancer who are experiencing dyspareunia 1, 2

Special Considerations

• The cause of dyspareunia may be multifactorial, including vaginal atrophy, inadequate lubrication, vaginismus, vulvodynia, endometriosis, pelvic adhesions, or infections 5, 6
• Location of pain helps determine treatment approach: entry pain suggests vulvodynia, atrophy, inadequate lubrication, or vaginismus; deep pain suggests endometriosis, pelvic adhesions, or adnexal pathology 5, 7
• For women with breast cancer, non-hormonal options should be tried first, and if vaginal estrogen is needed, a thorough discussion of risks and benefits should occur 1, 2
• Estriol-containing preparations may be preferable for women on aromatase inhibitors as estriol is a weaker estrogen that cannot be converted to estradiol 1, 2

Treatment Algorithm

1. Begin with hormone-free options: daily vaginal moisturizers for maintenance and water-based lubricants for sexual activity 2, 3
2. If insufficient relief after 2-4 weeks, add pelvic floor physical therapy and vaginal dilators 2, 4
3. For persistent symptoms, consider pharmacological options based on patient characteristics:
   • For women without hormone-sensitive cancers: low-dose vaginal estrogen or ospemifene 1, 2
   • For women with hormone-sensitive cancers: vaginal DHEA or lidocaine 1, 2
4. Regular assessment of response to treatment and overall sexual function is important 3, 7

Common Pitfalls to Avoid

• Failing to recognize that dyspareunia often has both physical and psychological components that need to be addressed 5, 8
• Not discussing risks and benefits thoroughly with patients, especially those with a history of breast cancer 2
• Overlooking the importance of pelvic floor dysfunction in dyspareunia, which can be effectively treated with physical therapy 1, 4
• Not considering that vaginal estrogen absorption is variable, which raises concerns in patients with a history of breast cancer 2