What is the management approach for dyspareunia (painful sexual intercourse)?

Management of Dyspareunia

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

Stepwise Treatment Algorithm

First-Line: Non-Hormonal Approach (4-6 weeks trial)

• 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 1, 2
• Use water-based or silicone-based lubricants specifically during sexual activity for immediate relief 1, 2
• Silicone-based products last longer than water-based or glycerin-based alternatives 1

Critical pitfall: Many women apply moisturizers only 1-2 times weekly, leading to inadequate symptom control—the evidence supports 3-5 times weekly application 1

Adjunctive Physical Therapies (can be started concurrently)

• Pelvic floor physical therapy improves sexual pain, arousal, lubrication, orgasm, and satisfaction—this should be offered to all women with dyspareunia or pelvic floor dysfunction 3, 1, 2, 4
• Vaginal dilators help with vaginismus and vaginal stenosis, particularly important for women treated with pelvic radiation therapy 3, 1, 2
• Cognitive behavioral therapy effectively improves sexual function and decreases anxiety related to pain 3, 2, 5
• Topical lidocaine applied to the vulvar vestibule before penetration addresses persistent introital pain 3, 1, 2

Second-Line: Low-Dose Vaginal Estrogen

Escalate to vaginal estrogen if conservative measures fail after 4-6 weeks OR if symptoms are severe at presentation. 1, 2

• Low-dose vaginal estrogen is the most effective treatment for dyspareunia related to vaginal atrophy, available as creams, tablets, or 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 1
• Treatment results in symptom relief in 80-90% of patients who complete therapy 1

Alternative Prescription Options (if vaginal estrogen contraindicated or ineffective)

• Vaginal DHEA (prasterone): FDA-approved for postmenopausal dyspareunia, improves sexual desire, arousal, pain, and overall function without clinically significant systemic estrogenic activity 1, 2
• Ospemifene (oral SERM): Effective for moderate to severe dyspareunia in postmenopausal women without current or history of breast cancer 3, 1, 2
• Intravaginal testosterone cream is safe and improves vaginal atrophy and sexual function in postmenopausal breast cancer survivors on aromatase inhibitors 1, 2

Special Population: Breast Cancer Patients

For women with breast cancer, non-hormonal options MUST be tried first at higher frequency (3-5 times per week). 1, 2

• For hormone-positive breast cancer patients not responding to conservative measures, low-dose vaginal estrogen can be considered only after thorough discussion of risks and benefits 3, 1, 2
• Estriol-containing preparations may be preferable for women on aromatase inhibitors because estriol is a weaker estrogen that cannot be converted to estradiol 1
• Vaginal estradiol may increase circulating estradiol in aromatase inhibitor users within 2 weeks, potentially reducing aromatase inhibitor efficacy 1
• Vaginal DHEA is an option for aromatase inhibitor users who haven't responded to previous treatments 3, 1, 2

Important caveat: Limited supportive data exists on vaginal DHEA in women with cancer history or on endocrine therapy, so risk/benefit is not fully known 3

Absolute Contraindications to Hormonal Treatment

• History of hormone-dependent cancers 1, 2
• Undiagnosed abnormal vaginal bleeding 1, 2
• Active or recent pregnancy 1, 2
• Active liver disease 1, 2

Common Clinical Pitfalls to Avoid

• Insufficient moisturizer frequency: Applying only 1-2 times weekly instead of the evidence-based 3-5 times weekly 1
• Internal-only application: Moisturizers must be applied to the vaginal opening and external vulva, not just internally 1
• Delayed escalation: If conservative measures fail after 4-6 weeks, escalate to vaginal estrogen rather than continuing ineffective therapy 1
• Overlooking pelvic floor dysfunction: All women with dyspareunia should be offered pelvic floor physical therapy evaluation 3, 4

Premenopausal Women with Low Desire

• Flibanserin is FDA-approved for acquired, generalized hypoactive sexual desire disorder in premenopausal women, resulting in approximately 1 additional satisfying sexual event every 2 months 1, 2
• Bremelanotide is FDA-approved for low sexual desire in premenopausal women 1