Andrew T. Goldstein, MD
Lara J. Burrows, MD, MSc
The Center for Vulvovaginal Disorders, Washington, DC
Female sexual pain (dyspareunia) may present in a variety of ways and stems from many causes. Dyspareunia may have substantial impact on a woman’s relationships and quality of life. The estimated prevalence of dyspareunia varies widely due to discrepancies in the ways in which populations are studied, what definitions and outcome measures are utilized, and overall study design. Furthermore, there is disagreement among professional organizations with regards to how dyspareunia is defined. Nevertheless, it seems apparent from several large trials that the approximately one out of every five or six women experiences significant dyspareunia.
A broad definition of dyspareunia is “pain associated with sexual intercourse which includes pain with attempted or completed vaginal entry”. Painful intercourse may be thought of as “introital” – meaning pain upon penile entry, or “deep” which describes pain with thrusting during sexual intercourse. Although dyspareunia can be caused by a multitude of conditions, the most common cause of dyspareunia in menopausal women is atrophic vaginitis and the most common causes in pre-menopausal women are vestibulodynia, interstitial cystitis, pelvic floor hypertonus, vulvar dermatologic conditions, and endometriosis.
Specific causes of dyspareunia
Estimated to occur in 10-40% of postmenopausal women, atrophic vaginitis describes symptomatic vaginal atrophy due to low estrogen levels. This occurs most commonly with menopause and aging, but can result in younger women due to hypothalamic amenorrhea, hyperprolactinemia, lactation, and usage of anti-estrogenic medications. Occasionally, usage of extra-low dose contraceptive pills and cancer therapy may cause similar symptoms.
During the reproductive years, estrogen plays a major role in maintaining the normal vaginal environment. This includes a thickened, rugated vaginal surface, increased blood flow and lubrication, lactobacillus-dominant flora, and a low (<4.5) pH. With estrogen withdrawal during menopause, significant changes occur in the vagina, resulting in the tissue becoming pale, thin, and less flexible. The physiological changes occurring in vaginal atrophy expose menopausal women to potential dyspareunia in several ways. Vaginal dryness causes increased friction during intercourse. The thin vaginal walls are friable and become prone to mechanical damage and formation of petechiae, ulcerations and tears with sexual activity. With longstanding estrogen deficiency, the vagina may become shorter, narrower, and less elastic. All of these changes increase the likelihood of trauma, infection and pain.
Estrogen therapy, both systemic and topical, is the most effective treatment for atrophic vaginitis, but some authors advocate lubricants and moisturizers as first line therapy. Because the overall dose of estrogen is lower and is associated with less systemic absorption than oral or transdermal preparations, intravaginal estrogen therapy is generally considered safer and can be less concerning to patients. Estradiol creams, tablets, and rings are equally efficacious for the treatment of vaginal atrophy.
Vestibulodynia (formerly called The Vulvar Vestibulitis Syndrome) refers to pain which is limited specifically to the vulvar vestibule, thereby causing introital dyspareunia. Vestibulodynia is characterized by: severe pain upon vestibular touch or attempted vaginal entry, tenderness to pressure localized within the vulvar vestibule, and physical findings limited to vestibular erythema. Primary vestibulodynia (PVD) is defined as introital dyspareunia dating from coitarche, whereas secondary vestibulodynia describes women who have introital dyspareunia that developed after a period of comfortable sexual relations, tampon use, or speculum examinations. The difference in clinical history suggests that primary and secondary vestibulodynia may have separate etiologies. As the diagnosis of vestibulodynia is derived from signs and symptoms, not from a defined pathophysiology, it is likely that there are multiple etiologies for this disorder.
Studies suggest that some cases of vestibulodynia are caused by a proliferation of C-afferent nociceptors in the vestibular mucosa. It has been shown that there can be a ten-fold increase in the density of these nerve endings in the vestibular mucosa of women with PVD. Possible causes of this proliferation have also been examined, and support has been found for some specific triggers. For example, mast cells can induce this neuronal hyperplasia via nerve growth factor and heparanase, possibly in response to an allergen such as topical antifungal creams or seminal fluid. In addition, certain genetic polymorphisms may predispose some affected women to an exaggerated inflammatory response leading to neuronal proliferation. Additionally, as some women with primary vestibulodynia also have hyperpathia in the umbilicus (which is also embryologically derived from the primitive urogenital sinus), a congenital neuronal hyperplasia may be involved. Additional data implicates hormonal alterations as a potential cause of vestibulodynia. Specifically, it has been shown that the relative risk of developing vestibulodynia is 6.6 in women who have used oral contraceptive pills. The exact mechanism by which hormonal alterations might cause vestibulodynia is not known, but it has been suggested that decreased free testosterone caused by elevated sex-hormone binding globulin in oral contraceptive users may be partially responsible.
Depending on the patient and the etiology of the vestibulodynia, treatment options include topical lidocaine, local interferon, hormonal therapies, tricyclic antidepressants, biofeedback, botulinum toxin, and surgery.
Interstitial Cystitis/PainfulBladder Syndrome
Interstitial cystitis/painful bladder syndrome (IC/PBS) is a chronic disease characterized by bladder pain, frequency, nocturia, and urinary urgency. It is a potential cause of female sexual pain that is frequently overlooked by clinicians. The exact etiology of IC/PBS is unknown; it is thought to be initiated by a deficiency in the glycosaminoglycans of the bladder urothelium. The prevalence of IC/PBS varies depending on criteria used to diagnose the condition; a recent community-based study assessed the prevalence to be 17.5% among women.
IC/PBS can be difficult to identify, as the symptoms may overlap with other urologic and gynecologic conditions. To date, the diagnosis of IC/PBS is symptom-based and there is no single pathognomonic entity that secures the diagnosis. In addition to the aforementioned symptoms, researches are also finding that women with IC/PBS may also experience vaginal burning and vulvodynia. These authors also found that one third of women with IC/PBS avoid sexual intercourse due to unbearable pain during intercourse.
Treatment of IC/PBS can be challenging. Treatment options include dietary changes, instillations of steroids, heparin, and lidocaine directly into the bladder, oral medications including tricyclic antidepressants, anti-histamines, and pentosanpolysulfate sodium, and hydrodistention of the bladder.
Pelvic Floor Hypertonus
Pelvic Floor Hypertonus (also called Levator Ani Spasm), or the chronic spasm of the muscles of the female pelvic floor (levator ani muscles), is becoming increasingly recognized as a cause of chronic pelvic pain and dyspareunia in women. Pelvic floor muscle spasm may occur as a primary event or secondary to other physical or psychological factors (i.e. vaginismus.) This condition may be treated with pelvic floor physical therapy where the therapist employs are variety of techniques, including myofascial release, biofeedback, and electrical stimulation. Sex therapy, cognitive behavior therapy and vaginal dilators may be used in women with vaginismus. Recently, the use of botulinum toxin type A has been shown to be highly effective in achieving relaxation of the pelvic floor muscles and successfully treats associated sexual pain.
Vulvar Dermatologic Conditions
There are many dermatologic conditions which may affect the vulva and cause symptoms, including dyspareunia. The most common dermatologic disorders which affect the female vulva include allergic or irritant dermatitis, lichen sclerosus, and erosive lichen planus. Fissuring of the posterior fourchette may also be considered in this category, although it is not a true dermatitis. The best way in which to diagnose one of these conditions is with a careful physical examination (aided by a colposcope) and vulvar biopsy evaluated by a dermatopathologist.
Endometriosis is the most common cause of chronic pelvic pain in women. Symptoms of endometriosis include recurrent painful menstrual cycles which may become more severe with time, infertility, chronic lower abdominal and back pain and deep dyspareunia. Current medical treatments for endometriosis include oral contraceptives, progestins, androgenic agents, gonadotropin releasing hormone analogues, as well as surgical excision of the endometriotic lesions.
There is considerable variation in how female sexual pain is defined as well as diversity in how women who suffer from this condition present for medical care. There are many causes of dyspareunia and frequently there may be more than one cause for a given patient. Providers who care for these patients should possess not only the necessary medical knowledge, but also empathy and compassion.
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