From the Guidelines
Dyspareunia, or painful intercourse, should be evaluated and treated with a comprehensive approach that addresses the underlying causes, such as vulvodynia, endometriosis, or vaginal atrophy.
Evaluation
The evaluation of dyspareunia involves a comprehensive medical history, physical examination, and diagnostic testing to identify underlying causes, as well as assessment of sexual functioning using standardized questionnaires, such as the Female Sexual Function Index and Brief Index of Sexual Functioning–Women 1.
Treatment
Treatment may include:
- Topical therapies, such as lidocaine 5% ointment applied 30 minutes prior to intercourse, to alleviate pain
- Hormonal therapies, including estrogen cream 0.01% applied intravaginally 2-3 times weekly, to address vaginal atrophy and promote healing
- Pelvic floor physical therapy to treat pelvic floor dysfunction, which can cause urinary and bowel incontinence, pelvic pain, and sexual dysfunction 1
- Vaginal dilators to increase vaginal depth and accommodation, and allow patients to discover what hurts and what does not in a nonsexual setting 1
- Vaginal androgens, such as DHEA, to reduce dyspareunia in postmenopausal individuals, although safety data are limited 1
- Ospemifene, a selective estrogen receptor modulator, to treat vaginal dryness and dyspareunia in postmenopausal women without a history of estrogen-dependent cancers 1
- Flibanserin, an FDA-approved medication, to treat acquired, generalized hypoactive sexual desire disorder 1
- Cognitive behavioral therapy and pelvic floor exercises to decrease anxiety and discomfort, and improve sexual functioning 1
- Vaginal moisturizers, gels, and oils to alleviate symptoms such as vaginal dryness and sexual pain, although data on these over-the-counter products are limited 1
- Topical anesthetics, such as lidocaine, to help with vaginal pain 1
- Nonhormonal, water-based lubricants and moisturizers to treat vaginal dryness and dyspareunia 1 It is essential to address the underlying causes of dyspareunia and to consider a multidimensional treatment plan that includes physiologic, psychologic, and interpersonal approaches 1. Referrals to specialists, such as psychotherapy, sexual/couples counseling, gynecologic care, and sexual health specialists, may be necessary to address complex sexual dysfunction 1.
From the Research
Evaluation of Dyspareunia
- Dyspareunia is recurrent or persistent pain with sexual intercourse that causes distress, affecting approximately 10% to 20% of U.S. women 2.
- The evaluation of dyspareunia involves taking a sexual history, where patients describe the characteristics of the pain, and a physical examination of the external genitalia, including visual inspection and sequential pressure with a cotton swab 2, 3.
- The physical examination may also include a single-digit vaginal examination to identify tender pelvic floor muscles and a bimanual examination to assess for uterine retroversion and pelvic masses 2.
- Common diagnoses include vulvodynia, inadequate lubrication, vaginal atrophy, postpartum causes, pelvic floor dysfunction, endometriosis, and vaginismus 2, 3.
Treatment of Dyspareunia
- Treatment is focused on the cause and may include lubricants, pelvic floor physical therapy, topical analgesics, vaginal estrogen, cognitive behavior therapy, vaginal dilators, modified vestibulectomy, or onabotulinumtoxinA injections 2.
- In postmenopausal women, dyspareunia is often multifactorial and requires a thorough history, a targeted physical examination, and coordination of multiple disciplines, including medical professionals, pelvic floor physical therapists, and sex therapists 4, 5.
- Treatment options for postmenopausal women with dyspareunia include lubricants, moisturizers, vaginal estrogen, ospemifene, dehydroepiandrosterone, local testosterone therapy, cannabidiol, and fractional CO2 laser treatments 5.
- For women with vulvodynia, treatment options with the highest level of evidence include oral desipramine with 5% lidocaine cream, intravaginal diazepam tablets with intravaginal transcutaneous electric nerve stimulation (TENS), botulinum toxin type A 50 units, and multimodal physical therapy 6.