How to evaluate a female patient complaining of dyspareunia?

Evaluation of Female Patients with Dyspareunia

The evaluation of dyspareunia should begin with a thorough assessment of pain characteristics (location, timing, quality), followed by a targeted physical examination to identify specific causes such as vulvodynia, vaginal atrophy, inadequate lubrication, pelvic floor dysfunction, or endometriosis.

Initial Assessment

• Create a safe and welcoming environment for discussing sexual health concerns, as patients may feel uncomfortable sharing these intimate details 1
• Obtain a detailed pain history including:
  • Location (entry/superficial vs. deep) 2
  • Timing (primary vs. acquired) 1
  • Quality (burning, sharp, aching) 1
  • Relationship to sexual activity (before, during, after) 2
• Assess for contributing factors:
  • Inadequate lubrication 1
  • Hormonal status (menopause, breastfeeding) 3
  • Medication effects 1
  • History of trauma or sexual assault 4
  • Relationship factors 2

Physical Examination

External Genital Examination

• Perform visual inspection of the vulva for:
  • Erythema, lesions, or anatomical abnormalities 1
  • Signs of dermatologic conditions 1
• Conduct cotton swab test:
  • Apply sequential pressure with cotton swab to vulvar vestibule 1
  • Map areas of tenderness to identify focal pain 1

Vaginal Examination

• Single-digit examination to assess:
  • Pelvic floor muscle tone and tenderness 1
  • Vaginal atrophy (thinning, pallor, decreased rugae) 3
  • Presence of scarring or stenosis 4
• Speculum examination to evaluate:
  • Vaginal discharge or infection 4
  • Cervical abnormalities 4

Bimanual Examination

• Assess for:
  • Uterine position (retroversion) 1
  • Adnexal masses or tenderness 2
  • Pelvic floor muscle spasm 1
  • Tenderness suggestive of endometriosis or pelvic inflammatory disease 4

Common Diagnoses and Specific Evaluation

Vulvodynia

• Characterized by burning pain at the vaginal entrance 1
• Positive cotton swab test with localized tenderness 2
• Rule out infectious causes with appropriate cultures 4

Vaginal Atrophy

• Common in postmenopausal women or those on certain medications 3
• Physical findings include pale, thin vaginal tissue with decreased rugae 3
• May affect up to 40% of postmenopausal women 3

Inadequate Lubrication

• Often associated with hormonal changes, medications, or insufficient arousal 1
• Assess for vaginal dryness during examination 1

Pelvic Floor Dysfunction

• Characterized by involuntary muscle spasm (vaginismus) 1
• May be primary or secondary to other painful conditions 2
• Assess for muscle tenderness and spasm during single-digit examination 1

Endometriosis

• Consider in women with deep dyspareunia and cyclic pelvic pain 1
• Tenderness on examination, especially with uterine mobility 4
• May require laparoscopy for definitive diagnosis 4

Pelvic Inflammatory Disease (PID)

• Consider in women with risk factors for sexually transmitted infections 4
• Evaluate for minimum criteria: lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness 4
• Additional criteria include fever, abnormal discharge, elevated inflammatory markers 4

Special Considerations

Postmenopausal Women

• Evaluate for vulvovaginal atrophy, which affects up to 40% of postmenopausal women 3
• Consider the role of estrogen deficiency in symptom development 3
• Assess for other age-related changes that may contribute to pain 4

Cancer Survivors

• Women with history of pelvic cancer treatment may experience treatment-related dyspareunia 4, 5
• Evaluate for radiation-induced changes, surgical scarring, or hormone therapy effects 4, 5
• Consider the psychological impact of cancer diagnosis and treatment on sexual function 4

Transgender and Gender-Diverse Patients

• Use trauma-informed approach to examination 4
• Consider unique factors such as chest binding, genital tucking, or gender-affirming surgeries 4
• Be aware of higher rates of sexual assault and trauma in this population 4

Laboratory and Additional Testing

• Consider testing for:
  • Vaginal infections (wet mount, cultures) 4
  • Sexually transmitted infections when indicated 4
  • Hormonal status in perimenopausal or menopausal women 3
• Additional testing based on suspected etiology:
  • Pelvic ultrasound for suspected structural abnormalities 2
  • Laparoscopy for suspected endometriosis 4
  • Referral to specialist for complex cases 6

Clinical Pitfalls to Avoid

• Failing to screen for dyspareunia due to discomfort with sexual health topics 6
• Attributing all sexual pain to psychological causes without adequate physical evaluation 2
• Missing comorbid conditions that may contribute to pain (e.g., interstitial cystitis, irritable bowel syndrome) 2
• Overlooking the impact of medications on sexual function 1
• Neglecting to assess for history of sexual trauma, which may influence both symptoms and response to examination 4