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

Treatment of Dyspareunia

Start with non-hormonal vaginal moisturizers (3-5 times weekly) plus water-based lubricants during sexual activity, and if symptoms persist after 4-6 weeks or are severe at presentation, escalate to low-dose vaginal estrogen therapy. 1, 2

Stepwise Treatment Algorithm

First-Line: Non-Hormonal Approaches

Apply vaginal moisturizers 3-5 times per week (not the typical 2-3 times suggested on product labels) to the vagina, vaginal opening, and external vulva—not just internally. 2 This higher frequency is critical for adequate symptom control. 2

• Water-based or silicone-based lubricants should be used specifically during sexual activity for immediate relief of friction-related pain. 1, 2
• Hyaluronic acid gel with vitamin E and A can help prevent vaginal mucosal inflammation, dryness, bleeding, and fibrosis. 2
• Pelvic floor physical therapy improves sexual pain, arousal, lubrication, orgasm, and satisfaction, particularly when pelvic floor dysfunction contributes to dyspareunia. 1, 2, 3
• Vaginal dilators help with vaginismus, vaginal stenosis (especially after pelvic radiation), and allow women to identify painful areas in a non-sexual setting. 1, 2

Second-Line: Prescription Hormonal Options (If No Response After 4-6 Weeks)

Low-dose vaginal estrogen is the most effective treatment for vaginal dryness leading to dyspareunia and should be initiated when conservative measures fail. 1, 2 Available formulations include:

• Vaginal estradiol tablets (10 μg daily for 2 weeks, then twice weekly). 2
• Vaginal estradiol cream applied as directed. 1, 2
• Sustained-release vaginal estradiol ring for continuous delivery. 1, 2

A large cohort study of nearly 50,000 breast cancer patients followed for up to 20 years showed no increased risk of breast cancer-specific mortality with vaginal estrogen use. 2

Alternative Prescription Options

Vaginal DHEA (prasterone) is FDA-approved for postmenopausal dyspareunia and improves sexual desire, arousal, pain, and overall sexual function. 1, 2 This is particularly useful for women on aromatase inhibitors who haven't responded to previous treatments. 1, 2

Ospemifene (oral SERM) is FDA-approved for moderate to severe dyspareunia in postmenopausal women without current or history of breast cancer. 1, 2 Large trials demonstrate improvement in vaginal dryness and pain. 2

Topical lidocaine applied to the vulvar vestibule before vaginal penetration effectively treats persistent introital pain. 1, 2

Adjunctive Therapies

• Cognitive behavioral therapy (CBT) has been shown to improve sexual functioning and can help alleviate anxiety that impacts sexual function. 1
• Integrative therapies such as yoga and meditation may help with associated anxiety symptoms. 1
• Pelvic floor (Kegel) exercises decrease anxiety, discomfort, and lower urinary tract symptoms. 1

Special Considerations for Cancer Patients

For women with hormone-positive breast cancer, non-hormonal options must be tried first at higher frequency (3-5 times per week). 2 If symptoms persist and significantly impact quality of life, low-dose vaginal estrogen can be considered only after thorough discussion of risks and benefits. 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 Vaginal estradiol may increase circulating estradiol within 2 weeks in aromatase inhibitor users, potentially reducing treatment efficacy. 2

Vaginal DHEA (prasterone) is specifically recommended for women on aromatase inhibitors who have not responded to previous treatments, though limited safety data exists for this population. 1, 2

Contraindications to Hormonal Treatment

Hormonal therapies are contraindicated in women with: 2

• Current or history of hormone-dependent cancers
• Undiagnosed abnormal vaginal bleeding
• Active or recent pregnancy
• Active liver disease
• Recent thromboembolic events

Common Pitfalls to Avoid

Insufficient frequency of moisturizer application leads to inadequate symptom control—many women apply moisturizers only 1-2 times weekly when 3-5 times weekly is needed. 2

Applying moisturizers only internally results in incomplete relief—products must be applied to the vaginal opening and external vulva, not just inside the vagina. 2

Delaying treatment escalation prolongs ineffective therapy—escalate to vaginal estrogen if conservative measures fail after 4-6 weeks, or immediately if symptoms are severe at presentation. 1, 2

Failing to recognize variable vaginal estrogen absorption raises concerns in patients with breast cancer history—always discuss risks and benefits thoroughly. 2

Not addressing pelvic floor dysfunction when present—many women with dyspareunia have overlapping pelvic floor issues that respond to physical therapy. 1, 3