A third of women in their 30s reported dyspareunia as a chronic problem, according to one study. Gynaecologist Dr Claudine Domoney provides an update on diagnosis and management
Sex is the ultimate psychosomatic activity – a combination of mind and body – so sexual pain is frequently a manifestation not only of physical processes but also psychological pain.
Somatisation of distress commonly affects sexuality and up to 90% of women attending with gynaecological complaints have a sexual issue.1
One study reported that two-thirds of a group of women in their 30s complained of dyspareunia, half of whom reported it as a chronic problem.2 Older women complain of dyspareunia less often and with more specific difficulties with lubrication and sensitivity.3
Vulval pain syndrome is less prevalent but often devastating and prevalence estimates range from 2-10%.
Women frequently develop adaptive and defensive responses to sexual pain – from vaginismus to loss of libido, arousal or orgasmic disorders.
Vaginismus can be secondary to a psychogenic cause or a defence reaction against pain and its true prevalence is difficult to ascertain.
The Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) categorises dyspareunia and vaginismus as sexual pain disorders, although there have been reports that DSM-V may reclassify sexual pain disorders as pain disorders.
But for GPs, the most important differentiation to make is between those women who can be managed in primary care and those who need to be referred.
Finding out if the problem is lifelong or acquired, or generalised or situational, only helps prognostically.
A more pragmatic approach is to identify the women who can't have a smear taken or use tampons – as opposed to those with occasional pain with a particular partner or position. This helps target appropriate management.
Vulval pain disorders frequently cause secondary desire and arousal difficulties or apareunia with a consequential significant impact on relationships and self esteem.
Superficial versus deep pain
Dyspareunia is commonly divided into superficial and deep pain. This doesn't help distinguish between the physical cause and the predominantly psychological. But determining the woman's idea of her pain, where it came from, when it started and why she has decided to present now are key features of the history.
Minimising invasive investigations and medicalisation of her pain may help to address the underlying issues, but rapid referral where appropriate reduces long-term sexual problems.
Superficial pain can be related to inflammatory, muscular, iatrogenic, traumatic or neurological causes, skin/mucosal adhesions or atrophy secondary to oestrogen deficiency changes.
These are typically linked to childbirth and peri- or postmenopausal surgery. Vaginal infections can cause pain that develops into a chronic pain cycle.
Vulval pain disorders may prevent any penetration. Unfortunately, no specific cause is found for many of these disorders. Careful examination and documentation of point tenderness (pain mapping), vaginal muscle reaction and vaginal discharge, including swabs where appropriate, may detect the root cause.
Deep pain is related to infection, adhesions secondary to infection, previous surgery or other gynaecological processes, endometriosis, ovarian pathology and bowel disorders.
Identifying where the pain is – and under what circumstances it is reproducible – will help decide who needs referral for further investigation.
An ultrasound scan to exclude any contributing pelvic mass can identify those needing diagnostic laparoscopy. Directed scanning by specialist gynaecological sonographers or gynaecologists improves detection of physical pathology and minimises unnecessary laparoscopies.
Any association with other disease features will lower the threshold for specialist management. For example, significant dysmenorrhoea and deep dyspareunia increase the chance of detecting endometriosis at laparoscopy.
General and pelvic assessment may disclose the underlying cause and reveal the woman's reaction to internal examination.
Triple swabs – high vaginal, endocervical and endocervical chlamydia – are mandatory in sexually active women with deep dyspareunia.
Treatment is often symptom orientated for superficial pain and aetiology orientated for deep. Superficial dyspareunia may be alleviated by appropriate lubricants such as Sylk, Durex Play or almond oil. Water-based lubricants may be too sticky and increase friction.
Lubricants can help a woman feel less anxious about the anticipation of pain and so feel more aroused. Encouragement of foreplay until the pelvic floor can relax, testing digitally and practising contraction then relaxation of the pelvic floor can make penetration easier. Local anaesthetic gels used 20 to 30 minutes before penetration can occasionally help.
If genital or mucosal atrophy due to oestrogen deficiency is a factor – either at the menopause or postpartum – then topical oestrogens will be very useful. This can also decrease post-intercourse cystitis. Replens MD, a vaginal remoisturiser, is a non-hormonal alternative for those who wish to avoid hormones.
Medications used for other chronic pain disorders, such as low dose amitryptilline and gabapentin, are often useful in vulval pain disorders.
Treatment of any infection causing both deep and superficial dyspareunia may resolve some symptoms. But there may be residual pain from adhesions, or as a result of guilt or shame associated with an STI. Careful general and pelvic examination should elicit different responses depending on the source of pain.
Perineal massage is helpful for women with post-childbirth and operative scarring as well as to those who ‘fear' their genitals and are uncomfortable touching them. Specialist women's health physiotherapists may be helpful for these women.
Surgery, injections of steroid and local anaesthetic in perineal ‘trigger points' may be helpful in rare cases.
Vaginal trainers or dilators are frequently used to ‘desensitise' the vaginal muscles and retrain those with spasm, but digital self-examination or by partner may be more useful for some.
Deep dyspareunia may be managed by evaluation of the possible causes and elimination of infection. If no cause is identified on ultrasound scan, this may be reassuring to the woman.
But if not, then a trial of treatment – antibiotics or continuous combined oral contraceptive pill (tricycled) – may be appropriate before considering referral.
Laparoscopy with adhesiolysis or ablation of endometriotic deposits and ovarian cysts may alleviate deep symptoms. This should be considered without delay as sexual problems that go on to cause long-term symptoms can develop rapidly. Women who have had laparoscopies with no abnormal findings need support. Treatment of any bowel disorder found, particularly irritable bowel syndrome, will help.
Every consultation should include brief details of relationship and psychosexual factors even if an organic cause is determined, as the impact of any sexual pain disorder on future sexual life can be enormous. Referral to a psychosexual specialist should be considered.
Dr Claudine Domoney is consultant obstetrician and gynaecologist at Chelsea and Westminster Hospital and chair of the Institute of Psychosexual Medicine
Competing interests Dr Domoney has received honoraria for lecturing from Astellas, Pfizer and NovoNordisk
Endoscopic view of uterine adhesions (pink strands) attaching the uterus (centre) to the abdominal wall (top) Uterine adhesions