What are the treatment and investigation recommendations for a 24-year-old woman experiencing dyspareunia (painful sexual intercourse) with negative Sexually Transmitted Infection (STI) test results?

From the Guidelines

For a 24-year-old woman experiencing painful sex (dyspareunia) with negative STI testing, I strongly recommend a comprehensive approach starting with a thorough gynecological examination to identify the cause, and considering treatments such as pelvic floor physical therapy, topical vaginal therapies, or medications like ospemifene, as outlined in the most recent guidelines 1. The treatment approach should be individualized, taking into account the patient's specific symptoms, medical history, and preferences.

• A thorough gynecological examination is essential to identify potential causes of dyspareunia, such as vulvodynia, vaginismus, or endometriosis.
• Pelvic floor physical therapy can be beneficial in addressing muscle tension and improving sexual function, as suggested by the NCCN guidelines 1.
• Topical vaginal therapies, such as vaginal estrogen or ospemifene, can be effective in treating vaginal dryness and dyspareunia, as recommended by the NCCN guidelines 1.
• Medications like ospemifene, a selective estrogen receptor modulator, can be considered for postmenopausal women without a history of estrogen-dependent cancers, as suggested by the NCCN guidelines 1.
• Further investigations, such as a detailed pelvic exam or pelvic ultrasound, may be necessary to rule out underlying conditions like ovarian cysts or structural abnormalities.
• Psychological support and counseling can also be beneficial in addressing anxiety and discomfort associated with dyspareunia, as anxiety can create a cycle of tension and discomfort.
• A multidisciplinary approach involving gynecology, physical therapy, and sometimes psychology offers the best outcomes for this distressing condition that significantly impacts quality of life and relationships.
• The use of water-based lubricants during intercourse and over-the-counter pain relievers like ibuprofen 400mg before intercourse can provide immediate relief, as suggested by the ASCO guidelines 1.
• Vaginal dilators may be beneficial in the management of vaginismus and/or vaginal stenosis, and can be offered to anyone having pain with examinations and/or sexual activity, as recommended by the ASCO guidelines 1.

From the Research

Investigation Recommendations

• A thorough sexual history should be taken to understand the patient's risk factors and symptoms 2
• Screening tests for chlamydia, gonorrhea, syphilis, and HIV should be considered based on the patient's risk factors and symptoms 2, 3
• Nucleic acid amplification tests have high sensitivities and specificities for the diagnosis of gonorrhea, chlamydia, and trichomoniasis 4
• Serology remains the recommended method to diagnose syphilis, typically using sequential testing to detect treponemal and nontreponemal antibodies 4

Treatment Recommendations

• If an STI is suspected, treatment should be guided by the Centers for Disease Control and Prevention (CDC) Sexually Transmitted Diseases Treatment Guidelines 5, 3
• Ceftriaxone, doxycycline, penicillin, moxifloxacin, and the nitroimidazoles are effective treatments for gonorrhea, chlamydia, syphilis, Mycoplasma genitalium, and trichomoniasis, respectively 4, 3
• However, antimicrobial resistance limits oral treatment options for gonorrhea and Mycoplasma genitalium, and no cure is available for genital herpes 4

Consideration of Other Possible Causes

• Endometriosis may be a possible cause of painful sex, especially in women with a history of severe primary dysmenorrhea 6
• A history of oral contraceptive use for severe primary dysmenorrhea may be associated with an increased risk of endometriosis, especially deep infiltrating endometriosis 6