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Dyspareunia

Basics

Description

  • Recurrent/persistent genital or pelvic pain during sexual activity

  • Pain may be superficial (with insertion) or deep

  • Complex, multifactorial origin: physical + psychosocial

  • Now classified under Genito-Pelvic Pain/Penetration Disorder (DSM-5)

Epidemiology

  • >50% of sexually active women experience dyspareunia at some point

  • 10–20% prevalence in US

  • Common in menopause and postpartum

  • Affects women > men

Etiology & Pathophysiology

Vulvovaginal Causes

  • Lichen sclerosus, lichen planus

  • Vaginal dryness: menopause, oophorectomy, diabetes, meds

  • Vaginitis, vaginismus, vulvodynia

  • Contact dermatitis, trauma

Uterine/Adnexal Causes

  • Endometriosis, ovarian masses, retroverted uterus

  • Pelvic adhesions, PID

Iatrogenic/Postpartum

  • Episiotomy, C-section, instrumental delivery

  • Hysterectomy, D&C, breastfeeding

Bladder/Pelvic Floor

  • Interstitial cystitis, pelvic floor dysfunction

Psychological

  • Depression, anxiety, PTSD

  • History of sexual abuse

Medications

  • GnRH agonists, SERMs, tamoxifen, aromatase inhibitors

  • Danazol, progestins

Trauma

  • Female genital mutilation

  • Obstetric/perineal trauma

Risk Factors

  • Young age, white race, lower SES

  • Menopausal/postpartum state

  • Psychological disorders

  • History of abuse

  • IBS, fibromyalgia, musculoskeletal conditions

Pregnancy Considerations

  • Common during late pregnancy and postpartum

  • Breastfeeding, fatigue, delivery trauma increase risk

  • Episiotomy does not prevent dyspareunia and may worsen it

Associated Conditions

  • Vaginismus

  • Vulvodynia

Diagnosis

DSM-5 Criteria

  • Pain during/attempted penetration

  • Anxiety or fear about anticipated pain

  • Pelvic floor tightening with penetration attempts

  • Symptoms persist ≥6 months and cause distress

  • Not better explained by other conditions

History

  • Detailed sexual history

  • Assess trauma, abuse, menstrual status

  • Medications, psychosocial context, obstetric history

Physical Exam

  • Inspection/palpation of vulva, vagina, urethra, uterus

  • Rectovaginal and pelvic floor muscle exam

  • Cotton swab testing for localized pain ("clock-face" mapping)

  • Musculoskeletal assessment: levator ani, obturator internus, piriformis

Differential Diagnosis

  • Refer to full list under Etiology

  • Often multifactorial: may coexist with other forms of sexual dysfunction

Investigations

  • None routinely unless organic disease suspected

  • As indicated:

    • Cultures

    • Microscopy, biopsy

Treatment

General Measures

  • Treat underlying cause if identified

  • Multidimensional care: physical + psychologic

Non-Pharmacologic

  • CBT, mindfulness, couples therapy

  • Pelvic floor physical therapy

  • Self-dilation with OTC or prescribed kits

  • Vaginal lubricants/moisturizers (especially hyaluronic acid, polycarbophil)

  • Vaginal estrogen for genitourinary syndrome of menopause

  • Hygiene education, avoid irritants

Pharmacologic

First-Line (Etiology-based)

  • Antibiotics/antifungals/antivirals for infection

  • Lubricants/moisturizers for dryness

  • Topical vaginal estrogen (cream, tablet, ring) preferred over systemic

  • Non-estrogen alternatives: ospemifene, prasterone (esp. in breast cancer history)

  • SSRIs for depression

  • NSAIDs, topical anesthetics for pain

  • TCAs, gabapentin for neuropathic pain

  • Trigger point injections, botox for localized pain

  • Tamsulosin in certain cases (observational)

Referral

  • To pelvic floor therapy, sexual medicine, psychiatry if needed

Surgical Options

  • Laparoscopic excision (endometriosis, adhesions)

  • Surgical vestibulectomy (refractory vestibulitis)

  • Avoid unapproved vaginal laser/“rejuvenation” procedures outside research settings

Complementary & Alternative Medicine

  • Sitz baths

  • Perineal massage

  • Antioxidants (e.g. for endometriosis)

Ongoing Care

Follow-Up

  • Every 6–12 months post-resolution

  • Adjust therapy based on improvement

Diet

  • High-fiber diet if constipation contributes

Patient Education

  • Explain muscle relaxation, Kegel exercises

  • Emphasize partner communication, sexual function awareness

Prognosis

  • Good with appropriate treatment

  • Dependent on underlying cause and patient adherence

Clinical Pearls

  • Always assess whether pain is pre-, during, or post-intercourse

  • DSM-5 includes both vaginismus and dyspareunia under one entity

  • Low-dose vaginal estrogen is the preferred hormonal treatment

  • Psychologic therapy + pelvic floor therapy are often essential

  • Episiotomy increases dyspareunia risk and should not be routine