What are the treatments for dyspareunia (pain during intercourse) in females?

Treatment of Female Dyspareunia (Pain During Intercourse)

Start with non-hormonal vaginal moisturizers applied 3-5 times weekly (not just 2-3 times) combined with water-based lubricants during sexual activity; if symptoms persist after 4-6 weeks, escalate to low-dose vaginal estrogen therapy, which is the most effective treatment for vaginal dryness-related dyspareunia. 1

Initial Non-Hormonal Approach

Over-the-Counter Options

• Apply vaginal moisturizers 3-5 times per week to the vagina, vaginal opening, and external vulva—this higher frequency is critical as many women under-apply at only 1-2 times weekly, leading to treatment failure 1
• Use water-based or silicone-based lubricants specifically during sexual activity for immediate relief 2, 1
• Hyaluronic acid gel with vitamins E and A can help prevent vaginal mucosal inflammation, dryness, and bleeding 1
• Topical vitamin D or E may provide symptom relief, though evidence is limited 2, 1

Physical and Behavioral Therapies

• Pelvic floor physical therapy improves sexual pain, arousal, lubrication, orgasm, and satisfaction 2, 1
• Vaginal dilators help with vaginismus, vaginal stenosis, and allow identification of painful areas in a non-sexual setting 2, 1
• Cognitive behavioral therapy has been shown effective at improving sexual function 2
• Topical lidocaine applied to the vulvar vestibule before penetration can help with persistent introital pain 2, 1

Prescription Treatment Options (When Non-Hormonal Measures Fail After 4-6 Weeks)

Vaginal Estrogen Therapy (Most Effective)

• Low-dose vaginal estrogen (tablets, creams, or sustained-release rings) is the most effective treatment for vaginal dryness, itching, discomfort, and painful intercourse 2, 1
• Typical dosing: 10 μg estradiol tablet daily for 2 weeks, then twice weekly 1
• A large cohort study of nearly 50,000 breast cancer patients showed no increased risk of breast cancer-specific mortality with vaginal estrogen use 1
• Treatment results in symptom relief in 80-90% of patients who complete therapy 1

Alternative Prescription Options

• Vaginal DHEA (prasterone): FDA-approved in 2016 for postmenopausal dyspareunia; improves sexual desire, arousal, pain, and overall sexual function without clinically important systemic estrogenic activity 2, 1
• Ospemifene (oral SERM): FDA-approved in 2013 for moderate to severe dyspareunia in postmenopausal women; effectively treats vaginal dryness and dyspareunia in large trials 2, 1
• Intravaginal testosterone cream: Safe and improves vaginal atrophy and sexual function in postmenopausal women 2, 1

For Premenopausal Women with Low Desire

• Flibanserin: FDA-approved in 2015 for acquired, generalized hypoactive sexual desire disorder in premenopausal women; results in approximately 1 additional satisfying sexual event every 2 months 2, 1

Special Considerations for Breast Cancer Patients

Treatment Algorithm for Hormone-Positive Breast Cancer

• First-line: Non-hormonal options (moisturizers 3-5 times weekly, lubricants, pelvic floor therapy) 2, 1
• Second-line: If symptoms persist and significantly impact quality of life, low-dose vaginal estrogen can be considered after thorough discussion of risks and benefits 2, 1
• For patients on aromatase inhibitors: Estriol-containing preparations may be preferable as estriol is a weaker estrogen that cannot be converted to estradiol 2, 1
• Alternative for aromatase inhibitor users: Vaginal DHEA is an option for those who haven't responded to previous treatments 1

Important Caveats

• Small retrospective studies suggest vaginal estrogens do not adversely affect breast cancer outcomes 1
• Vaginal estradiol may increase circulating estradiol in aromatase inhibitor users within 2 weeks, potentially reducing efficacy 1
• Hormone replacement therapy is contraindicated for systemic use due to the endocrine character of the disease 2

Contraindications to Hormonal Treatment

Absolute contraindications include 1:

• History of hormone-dependent cancers (for systemic therapy; vaginal estrogen requires individualized risk-benefit discussion)
• Undiagnosed abnormal vaginal bleeding
• Active or recent pregnancy
• Active liver disease

Common Pitfalls to Avoid

• Insufficient moisturizer frequency: Many women apply only 1-2 times weekly when 3-5 times weekly is needed for adequate symptom control 1
• Internal-only application: Moisturizers must be applied to the vaginal opening and external vulva, not just inside the vagina 1
• Delayed escalation: If conservative measures fail after 4-6 weeks, escalate to vaginal estrogen rather than continuing ineffective therapy 1
• Assuming purely psychological etiology: Always rule out organic causes (vaginal atrophy, inadequate lubrication, vaginismus, vulvodynia, endometriosis, infections) before considering psychiatric intervention 3, 4

When to Reassess

• Evaluate symptom improvement at 6-12 weeks after initiating treatment 1
• If symptoms persist despite appropriate treatment, consider referral to a sexual health specialist or gynecologist for further evaluation 2