Individualizing treatment for dyspareunia

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The most important component of caring for women who report painful sexual exchange with vaginal penetration is for the clinician to simply bring up the topic during an office visit, according to Gloria Bachmann, MD, director of the Women's Health Institute at Rutgers Robert Wood Johnson Medical School in New Jersey.

“Even though our society understands there are sexual concerns and problems caused by life cycle and medical conditions, women are still often reluctant to bring up the topic,” Dr. Bachmann told Contemporary OB/GYN. “Therefore, we as healthcare providers can assist these patients by discussing sexual health and asking if patients have discomfort with any type of sexual exchange.”

Dr. Bachmann emphasized that sexual exchange is not always limited to heterosexual partner exchange. “Women may have pain or tenderness with self-stimulation,” she said. Similarly, the sexual exchange may be in a same-sex partnership, for which there also may be complaints of pain with touching or vaginal penetration.

“When we bring up the topic of sexual health first, women become more comfortable in reporting if they are having any issues or concerns in that area,” said Dr. Bachmann, a professor of ob/gyn and medicine at the medical school.

At her own practice, Dr. Bachmann will sometimes bring up areas of sexual health that may or may not pertain to a particular patient. “It is always better to be more inclusive with reasons for sexual pain than non-inclusive,” she said. 

For example, a menopausal patient has a high likelihood that loss of estrogen in the genital area is causing dyspareunia. “But that should not preclude a clinician from bringing up other reasons why women experience sexual pain,” Dr. Bachmann said.

As a result, a menopausal patient may be prompted to share that she has had issues with vulvodynia or a vaginal laceration during childbirth, and despite vaginal use of estrogen or prasterone does not experience adequate relief of sexual pain.

For patients with severe arthritis, intervention may not be possible vaginally. “Thus taking a full history is important to understand where the patient is in terms of her health, and what interventions will be feasible for her,” Dr. Bachmann said. 

Likewise, for the postmenopausal patient reporting dyspareunia and who is already using a moisturizer or lubricant, a prescription intervention is indicated, especially when moderate to severe genitourinary syndrome of menopause (GSM) is noted on vaginal exam. 

However, regardless of the intervention prescribed, it is important that there is a follow-up appointment anywhere from 8 to 10 weeks later, “so that the woman does not feel at a loss if the intervention prescribed is not working to her satisfaction,” Dr. Bachmann said. “But if there is any issue before the follow-up appointment, it should be stressed to the patient that she is always welcome to come back sooner.”

During the follow-up appointment for the patient with GSM who has been given an intervention, such as vaginal estrogen for dyspareunia and continues to have pain, it is critical to perform a second comprehensive pelvic examination to evaluate for other causes. 

“Other etiologies may be diagnosed like tender point tenderness over a prior childbirth vaginal laceration,” Dr. Bachmann said. “With this new pelvic exam finding, management considerations will expand to include pelvic floor therapy, instruction in the use of vaginal dilators or even surgical scar revision.” 

Continuity of management is key for all suspected causes of dyspareunia. “When you prescribe a management option, you need to let the women know that it may not be initially effective for her particular case,” Dr. Bachmann said. “The last thing you want to do is set up a scenario in which the woman expects that if she does not get relief with the first intervention, that there is nothing else left for her.”

Practitioners also need to return to the basics. “Dyspareunia is a common problem in women and we are going to manage the pain until the patient feels comfortable,” Dr. Bachmann said. “But like many pain conditions, management will never fit into a one-size-fits-all solution.”