Dr. Ashley Hill on Dyspareunia in Women

D. Ashley Hill, MD, Medical Director of Obstetrics and Gynecology at AdventHealth Medical Group and Associate Director of the AdventHealth Graduate Medical Education Program's Department of Obstetrics and Gynecology, and AdventHealth family medicine physician Chantel A. Taylor, MD, published an article in American Family Physicians about dyspareunia in women. Defined as recurrent or persistent painful sexual intercourse, dyspareunia is a common condition that affects approximately 10 to 20 percent of women in the United States. While it can negatively affect women’s mental and physical health as well as their relationships, many who seek medical care for it report that they feel their concerns are dismissed. Left undiagnosed or untreated, dyspareunia can lead to sexual dysfunction, anxiety, depression, relationship distress and diminished quality of life.

Dr. Hill and Dr. Taylor encourage clinicians to understand the multiple risk factors for dyspareunia which include younger age, white race, lower socioeconomic status, depression, anxiety, low sexual satisfaction and a history of sexual abuse. In addition, women in the postpartum, perimenopausal or postmenopausal periods are also at increased risk as are those who have had a vacuum-assisted or forceps vaginal delivery, have had pelvic floor surgery or are breastfeeding. In addition, dyspareunia can occur with other conditions that cause pelvic pain, including fibromyalgia, irritable bowel syndrome and musculoskeletal disorders.

Clinicians should create safe and welcoming environments where they can take a complete sexual history and patients feel comfortable discussing their sexuality, including any symptoms they are experiencing and the location, intensity and duration of any pain. Physical examination is also critical to effectively diagnosing dyspareunia and should include visual inspection as well as sequential pressure with a cotton swab to assess for focal erythema or pain. In addition, a single-digit vaginal examination may be necessary to identify tender pelvic floor muscles, and a bimanual examination can assess for uterine retroversion and pelvic masses.

Causes of dyspareunia can be multifactorial and combining the patient history with the physical examination helps to determine the cause. Common diagnoses include inadequate lubrication, vaginal atrophy, pelvic floor dysfunction, vulvodynia, postpartum causes, vaginismus and endometrioses. Treatment focuses 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.

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