Dyspareunia in Women

 

Am Fam Physician. 2021 May 15;103(10):597-604.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/dyspareunia.

Author disclosure: Dr. Hill does not have a formal relationship with any pharmaceutical company to disclose. A public database revealed a listing for Intrarosa, but this was not a direct payment or a violation of our conflict-of-interest policy. Dr. Taylor has no relevant financial affiliations to disclose.

Dyspareunia is recurrent or persistent pain with sexual intercourse that causes distress. It affects approximately 10% to 20% of U.S. women. Dyspareunia may be superficial, causing pain with attempted vaginal insertion, or deep. Women with sexual pain are at increased risk of sexual dysfunction, relationship distress, diminished quality of life, anxiety, and depression. Because discussing sexual issues may be uncomfortable, clinicians should create a safe and welcoming environment when taking a sexual history, where patients describe the characteristics of the pain (e.g., location, intensity, duration). Physical examination of the external genitalia includes visual inspection and sequential pressure with a cotton swab, assessing for focal erythema or pain. A single-digit vaginal examination may identify tender pelvic floor muscles, and a bimanual examination can assess for uterine retroversion and pelvic masses. Common diagnoses include vulvodynia, inadequate lubrication, vaginal atrophy, postpartum causes, pelvic floor dysfunction, endometriosis, and vaginismus. 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.

Dyspareunia, recurrent or persistent painful sexual intercourse, is common and can affect women's mental and physical health and relationships.1,2 The prevalence of dyspareunia in the United States is approximately 10% to 20% and varies by age and population.3 Women with sexual pain are at increased risk of sexual dysfunction, relationship distress, diminished quality of life, anxiety, and depression.2,4 Many women seeking medical care for sexual pain report believing that their concerns are invalidated and dismissed.5 Dyspareunia is a complex disorder often involving both psychosocial and physical conditions, requiring a detailed genitourinary examination and clinician knowledge of risk factors and the multifactorial nature of the disorder. Recommendations for treating dyspareunia are determined by the patient's current anatomy.

Risk Factors

The Authors

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D. ASHLEY HILL, MD, is chair of the Department of Obstetrics and Gynecology at the AdventHealth Graduate Medical Education Program, Orlando, Fla.; a professor of obstetrics and gynecology at the University of Central Florida College of Medicine, Orlando; and medical director of AdventHealth Obstetrics and Gynecology, Central Florida Division, Orlando....

CHANTEL A. TAYLOR, MD, is a fellow in the Women's Health Junior Faculty fellowship at AdventHealth Orlando Family Medicine Residency.

Author disclosure: Dr. Hill does not have a formal relationship with any pharmaceutical company to disclose. A public database revealed a listing for Intrarosa, but this was not a direct payment or a violation of our conflict-of-interest policy. Dr. Taylor has no relevant financial affiliations to disclose.

Address correspondence to D. Ashley Hill, MD, 235 East Princeton St., Ste. 200, Orlando, FL 32804 (email: Ashley.Hill.MD@AdventHealth.com). Reprints are not available from the authors.

References

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1. Sorensen J, Bautista KE, Lamvu G, et al. Evaluation and treatment of female sexual pain: a clinical review. Cureus. 2018;10(3):e2379....

2. Oshinowo A, Ionescu A, Anim TE, et al. Dyspareunia and vulvodynia. In: Valovska AT, ed. Pelvic Pain Management. Oxford University Press; 2016:44–57.

3. Landry T, Bergeron S. How young does vulvo-vaginal pain begin? Prevalence and characteristics of dyspareunia in adolescents. J Sex Med. 2009;6(4):927–935.

4. De Graaff AA, Van Lankveld J, Smits LJ, et al. Dyspareunia and depressive symptoms are associated with impaired sexual functioning in women with endometriosis, whereas sexual functioning in their male partners is not affected. Hum Reprod. 2016;31(11):2577–2586.

5. Braksmajer A. Struggles for medical legitimacy among women experiencing sexual pain: a qualitative study. Women Health. 2018;58(4):419–433.

6. Latthe P, Mignini L, Gray R, et al. Factors predisposing women to chronic pelvic pain: systematic review. BMJ. 2006;332(7544):749–755.

7. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors [published correction appears in JAMA. 1999;281(13):1174]. JAMA. 1999;281(6):537–544.

8. Savoy M, O'Gurek D, Brown-James A. Sexual health history: techniques and tips. Am Fam Physician. 2020;101(5):286–293. Accessed December 9, 2020. https://www.aafp.org/afp/2020/0301/p286.html

9. Goldstein AT, Pukall CF, Brown C, et al. Vulvodynia: assessment and treatment. J Sex Med. 2016;13(4):572–590.

10. Fauconnier A, Dubuisson J-B, Foulot H, et al. Mobile uterine retroversion is associated with dyspareunia and dysmenorrhea in an unselected population of women. Eur J Obstet Gynecol Reprod Biol. 2006;127(2):252–256.

11. Edwards L. Vulvodynia. Clin Obstet Gynecol. 2015;58(1):143–152.

12. Gandhi J, Chen A, Dagur G, et al. Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management. Am J Obstet Gynecol. 2016;215(6):704–711.

13. Muniyappa R, Norton M, Dunn ME, et al. Diabetes and female sexual dysfunction: moving beyond “benign neglect.” Curr Diab Rep. 2005; 5(3):230–236.

14. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology. Female sexual dysfunction: ACOG practice bulletin clinical management guidelines for obstetrician gynecologists, number 213. Obstet Gynecol. 2019;134(1):e1–e18.

15. Faubion SS, Shuster LT, Bharucha AE. Recognition and management of nonrelaxing pelvic floor dysfunction. Mayo Clin Proc. 2012;87(2):187–193.

16. Meister MR, Shivakumar N, Sutcliffe S, et al. Physical examination techniques for the assessment of pelvic floor myofascial pain: a systematic review. Am J Obstet Gynecol. 2018;219(5):497.e1–497.e13.

17. Pacik PT, Geletta S. Vaginismus treatment: clinical trials follow up 241 patients. Sex Med. 2017;5(2):e114–e123.

18. Haefner HK, Collins ME, Davis GD, et al. The vulvodynia guideline. J Low Genit Tract Dis. 2005;9(1):40–51.

19. Han E, Nguyen L, Sirls L, et al. Current best practice management of interstitial cystitis/bladder pain syndrome. Ther Adv Urol. 2018;10(7):197–211.

20. Seehusen DA, Baird DC, Bode DV. Dyspareunia in women. Am Fam Physician. 2014;90(7):465–470. Accessed December 9, 2020. https://www.aafp.org/afp/2014/1001/p465.html

21. Palacios S. Managing urogenital atrophy. Maturitas. 2009;63(4):315–318.

22. Lethaby A, Ayeleke RO, Roberts H. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev. 2016;(8):CD001500.

23. Constantine G, Graham S, Portman DJ, et al. Female sexual function improved with ospemifene in postmenopausal women with vulvar and vaginal atrophy: results of a randomized, placebo-controlled trial. Climacteric. 2015;18(2):226–232.

24. Labrie F, Archer DF, Koltun W, et al.; VVA Prasterone Research Group. Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause. Menopause. 2018;25(11):1339–1353.

25. GoodRx. Accessed January 23, 2021 [zip code 66202]. https://www.goodrx.com

26. Paraiso MFR, Ferrando CA, Sokol ER, et al. A randomized clinical trial comparing vaginal laser therapy to vaginal estrogen therapy in women with genitourinary syndrome of menopause: the VeLVET Trial. Menopause. 2020;27(1):50–56.

27. U.S. Food and Drug Administration. FDA warns against use of energy-based devices to perform vaginal ‘rejuvenation’ or vaginal cosmetic procedures: FDA safety communication. Updated November 20, 2018. Accessed January 23, 2021. https://www.fda.gov/medical-devices/safety-communications/fda-warns-against-use-energy-based-devices-perform-vaginal-rejuvenation-or-vaginal-cosmetic

28. Lamvu G, Carrillo J, Witzeman K, et al. Musculoskeletal considerations in female patients with chronic pelvic pain. Semin Reprod Med. 2018;36(2):107–115.

29. Bornstein J, Goldstein AT, Stockdale CK, et al.; Consensus Vulvar Pain Terminology Committee of the International Society for the Study of Vulvovaginal Disease (ISSVD), the International Society for the Study of Women's Sexual Health (ISSWSH), and the International Pelvic Pain Society (IPPS). 2015 ISSVD, ISSWSH and IPPS consensus terminology and classification of persistent vulvar pain and vulvodynia. Obstet Gynecol. 2016;127(4):745–751.

30. Pukall CF, Goldstein AT, Bergeron S, et al. Vulvodynia: definition, prevalence, impact, and pathophysiological factors. J Sex Med. 2016;13(3):291–304.

31. Andrews JC. Vulvodynia interventions—systematic review and evidence grading. Obstet Gynecol Surv. 2011;66(5):299–315.

32. Signorello LB, Harlow BL, Chekos AK, et al. Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women. Am J Obstet Gynecol. 2001;184(5):881–888, discussion 888–890.

33. Leeman LM, Rogers RG. Sex after childbirth: postpartum sexual function. Obstet Gynecol. 2012;119(3):647–655.

34. Bergman I, Westergren Söderberg M, Ek M. Perineorrhaphy compared with pelvic floor muscle therapy in women with late consequences of a poorly healed second-degree perineal tear: a randomized controlled trial. Obstet Gynecol. 2020;135(2):341–351.

35. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2014.

36. Crowley T, Goldmeier D, Hiller J. Diagnosing and managing vaginismus. BMJ. 2009;338:b2284.

37. Heim LJ. Evaluation and differential diagnosis of dyspareunia. Am Fam Physician. 2001;63(8):1535–1544. Accessed January 23, 2021. https://www.aafp.org/afp/2001/0415/p1535.html

 

 

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