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 for daily maintenance. 2 Combine this with water-based or silicone-based lubricants specifically during sexual activity for immediate relief. 1, 2

• Water-based lubricants are the standard recommendation, though silicone-based products may last longer than water-based or glycerin-based alternatives. 2
• Hyaluronic acid gel with vitamin E and A can help prevent vaginal mucosal inflammation, dryness, bleeding, and fibrosis. 2
• This approach is particularly important as the initial step for women with hormone-positive breast cancer or those on aromatase inhibitors. 1, 2

Second-Line: Low-Dose Vaginal Estrogen

If symptoms do not improve after 4-6 weeks of consistent non-hormonal therapy, or if symptoms are severe at presentation, escalate to low-dose vaginal estrogen. 1, 2

• Vaginal estrogen is the most effective treatment for vaginal dryness leading to dyspareunia. 1, 2
• Available formulations include vaginal tablets (e.g., 10 μg estradiol daily for 2 weeks, then twice weekly), creams, and sustained-release rings. 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
• For women with hormone-positive breast cancer who are symptomatic and not responding to conservative measures, low-dose vaginal estrogen can be considered after thorough discussion of risks and benefits. 1, 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 have not responded to previous treatments. 1, 2

Ospemifene (oral selective estrogen receptor modulator) may be offered to postmenopausal women without current or history of breast cancer who experience dyspareunia or vaginal atrophy. 1, 2 However, it has not been evaluated in women with a history of cancer or on endocrine therapy, so the risk/benefit is not fully known for this population. 1

Adjunctive Physical Therapies

Pelvic floor physical therapy should be offered to women with pain or other pelvic floor dysfunction, as it can improve sexual pain, arousal, lubrication, orgasm, and satisfaction. 1, 2, 3

Vaginal dilators may benefit women with vaginismus and/or vaginal stenosis, particularly those treated with pelvic radiation therapy. 1, 2 They help increase vaginal depth and accommodation and allow women to identify painful areas in a non-sexual setting. 1, 2

Topical lidocaine can be applied to the vulvar vestibule before vaginal penetration for persistent introital pain and dyspareunia. 1, 2

Psychosocial Interventions

Cognitive behavioral therapy (CBT) has been shown to be effective at improving sexual functioning and can help alleviate associated symptoms like anxiety that impact sexual function. 1

Special Considerations for Cancer Patients

For women with breast cancer, non-hormonal options must be tried first at higher frequency (3-5 times per week). 2 If vaginal estrogen is needed, 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 in aromatase inhibitor users within 2 weeks of use, potentially reducing the efficacy of aromatase inhibitors. 2 However, small retrospective studies suggest vaginal estrogens do not adversely affect breast cancer outcomes. 2

Common Pitfalls to Avoid

• Insufficient frequency of moisturizer application: Many women apply moisturizers only 1-2 times weekly when 3-5 times weekly is needed for adequate symptom control. 2
• Applying only internally: Moisturizers need to be applied to the vaginal opening and external vulva, not just inside the vagina. 2
• Delaying treatment escalation: If conservative measures fail after 4-6 weeks, escalate to vaginal estrogen rather than continuing ineffective therapy. 2
• Not addressing pelvic floor dysfunction: Many women with dyspareunia have associated pelvic floor dysfunction that requires specific physical therapy. 1, 3

Contraindications to Hormonal Treatment

Vaginal estrogen is contraindicated in women with: 2

• Current or history of hormone-dependent cancers (relative contraindication requiring thorough risk/benefit discussion)
• Undiagnosed abnormal vaginal bleeding
• Active or recent pregnancy
• Active liver disease