What are the causes of female dyspareunia (painful sexual intercourse)?

From the Guidelines

Female dyspareunia should be treated with a comprehensive approach, including pelvic floor physical therapy, vaginal dilators, and topical prescription medications, such as vaginal estrogen or ospemifene, to alleviate symptoms and improve quality of life. The treatment of female dyspareunia depends on the underlying cause, which should be identified through a thorough medical history and physical examination. For survivors with sexual dysfunction, pelvic floor dysfunction is a common associated condition, and pelvic physical therapy (ie, pelvic floor muscle training) can be an effective treatment, as it may improve sexual pain, arousal, lubrication, orgasm, and satisfaction 1. Vaginal dilators are also an option for survivors with pain during sexual activity and those with vaginal stenosis from pelvic radiation, although evidence for their effectiveness is limited.

Treatment Options

• Topical estrogen therapy, such as estradiol vaginal cream 0.01%, applied 2-3 times weekly, can help restore vaginal tissues and alleviate symptoms of vaginal dryness and dyspareunia 1.
• Ospemifene, an FDA-approved selective estrogen receptor modulator (SERM), has been shown to effectively treat vaginal dryness and dyspareunia in postmenopausal women, and may be considered as an option for survivors without a history of estrogen-dependent cancers 1.
• Vaginal androgens, such as DHEA, can also be considered for vaginal dryness or pain with sexual activity, although safety data for their use in survivors of hormonally mediated cancers are limited 1.
• Pelvic floor physical therapy is beneficial for muscle tension disorders, typically requiring 8-12 weekly sessions.

Important Considerations

• A thorough medical history and physical examination are essential to identify the underlying cause of dyspareunia and develop an effective treatment plan.
• Patients should be advised to avoid irritants like scented products and to practice gentle, gradual intercourse with adequate foreplay.
• Psychological factors should also be addressed, and cognitive behavioral therapy may be helpful in managing symptoms and improving quality of life.
• Pain during intercourse is not normal and should not be ignored, as early intervention leads to better outcomes and prevents the development of chronic pain cycles.

From the Research

Definition and Prevalence of Dyspareunia

• Dyspareunia is defined as recurrent or persistent pain with sexual intercourse that causes distress, affecting approximately 10% to 20% of U.S. women 2.
• It can be superficial, causing pain with attempted vaginal insertion, or deep, and may be associated with various underlying conditions such as vulvodynia, inadequate lubrication, vaginal atrophy, and pelvic floor dysfunction 2.

Diagnosis and Evaluation

• Diagnosis of dyspareunia involves a thorough sexual history, physical examination of the external genitalia, and assessment of pelvic floor muscle function 2.
• Common diagnostic procedures include visual inspection, sequential pressure with a cotton swab, single-digit vaginal examination, and bimanual examination to identify tender pelvic floor muscles, uterine retroversion, and pelvic masses 2.

Treatment Options

• Treatment of dyspareunia is focused on the underlying cause and may include lubricants, pelvic floor physical therapy, topical analgesics, vaginal estrogen, cognitive behavior therapy, vaginal dilators, modified vestibulectomy, or onabotulinumtoxinA injections 2.
• Physical therapy interventions, such as pelvic floor muscle training, thermotherapy, and myofascial release, have been shown to be effective in improving pain, quality of life, and sexual function in women with dyspareunia 3, 4.
• Electrotherapy and electrotherapy combined with pelvic floor muscle training have also been found to be effective in reducing pain and improving quality of life in women with dyspareunia 4.

Associated Conditions and Comorbidities

• Dyspareunia is often associated with other conditions, such as vulvodynia, vaginismus, and pelvic floor dysfunction, which can contribute to the complexity of diagnosis and treatment 5, 6.
• Women with dyspareunia are at increased risk of sexual dysfunction, relationship distress, diminished quality of life, anxiety, and depression, highlighting the need for a comprehensive and multidisciplinary approach to treatment 2.