Dyspareunia: Keys to biopsychosocial evaluation and treatment planning

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doi:doi: 10.12788/jfp.0365

Applied Evidence

Dyspareunia: Keys to biopsychosocial evaluation and treatment planning

J Fam Pract. 2022 March;71(2):E3-E11 | doi: 10.12788/jfp.0365

By

Adrienne A. Williams, PhD

Asking the questions identified here can guide your care. Knowing which treatment options are—and aren’t—supported by the evidence is also key.

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PRACTICE RECOMMENDATIONS

› Screen all patients for sexual dysfunctions, as patients often do not report symptoms on their own. B

› Refer patients with dyspareunia for psychotherapy to address both pain and psychosocial causes and sequela of dyspareunia. A

› Refer patients with dyspareunia for pelvic floor physical therapy to address pain and sexual functioning. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

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2. Seehusen DA, Baird DC, Bode DV. Dyspareunia in women. Am Fam Phys. 2014;90:465-470.

3. Sorensen J, Bautista KE, Lamvu G, et al. Evaluation and treatment of female sexual pain: a clinical review. Cureus. 2018;10:e2379.

4. MacNeill C. Dyspareunia. Obstet Gynecol Clin North Am. 2006;33:565-77.

5. Latthe P, Latthe M, Say L, et al. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health. 2006;6:177.

6. Steege JF, Zolnoun DA. Evaluation and treatment of dyspareunia. Obstet Gynecol. 2009;113:1124-1136.

7. Williams AA, Williams M. A guide to performing pelvic speculum exams: a patient-centered approach to reducing iatrogenic effects. Teach Learn Med. 2013;25:383-391.

8. Ünlü Z, Yentur A, Çakil N. Pudendal nerve neuropathy: An unknown-rare cause of pelvic pain. Arch Rheumatol. 2016;31:102-103.

9. Dewitte M, Borg C, Lowenstein L. A psychosocial approach to female genital pain. Nat Rev Urol. 2018;15:25-41.

10. Masters WH, Johnson VE. Human Sexual Inadequacy. 1st ed. Little, Brown; 1970.

11. Rathus SA, Nevid JS, Fichner-Rathus L. Human Sexuality in a World of Diversity. 5th ed. Allyn and Bacon; 2002.

12. Bailey BE, Freedenfeld RN, Kiser RS, et al. Lifetime physical and sexual abuse in chronic pain patients: psychosocial correlates and treatment outcomes. Disabil Rehabil. 2003;25:331-342.

13. Yehuda R, Lehrner A, Rosenbaum TY. PTSD and sexual dysfunction in men and women. J Sex Med. 2015;12:1107-1119.

14. Postma R, Bicanic I, van der Vaart H, et al. Pelvic floor muscle problems mediate sexual problems in young adult rape victims. J Sex Med. 2013;10:1978-1987.

15. Binik YM, Bergeron S, Khalifé S. Dyspareunia and vaginismus: so-called sexual pain. In: Leiblum SR, ed. 4th ed. Principles and Practice of Sex Therapy. The Guilford Press; 2007:124-156.

16. Ayling K, Ussher JM. “If sex hurts, am I still a woman?” The subjective experience of vulvodynia in hetero-sexual women. Arch Sex Behav. 2008;37:294-304.

17. Pazmany E, Bergeron S, Van Oudenhove L, et al. Body image and genital self-image in pre-menopausal women with dyspareunia. Arch Sex Behav. 2013;42:999-1010.

18. Maillé DL, Bergeron S, Lambert B. Body image in women with primary and secondary provoked vestibulodynia: a controlled study. J Sex Med. 2015;12:505-515.

19. Ryan L, Hawton K. Female dyspareunia. BMJ. 2004;328:1357.

20. Waldura JF, Arora I, Randall AM, et al. Fifty shades of stigma: exploring the health care experiences of kink-oriented patients. J Sex Med. 2016;13:1918-1929.

21. Hinchliff S, Gott M. Seeking medical help for sexual concerns in mid- and later life: a review of the literature. J Sex Res. 2011;48:106-117.

22. Banaei M, Kariman N, Ozgoli G, et al. Prevalence of postpartum dyspareunia: a systematic review and meta-analysis. Int J Gynaecol Obstet. 2021;153:14-24.

23. Kroenke K, Spitzer RL. The PHQ-9: A new depression diagnostic and severity measure. Psychiatr Ann. 2002;32:509-515.

24. Spitzer RL, Kroenke K, Williams JB, et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166:1092-1097.

25. U.S. Department of Veterans Affairs. PTSD: National Center for PTSD. Life events checklist for DSM-5 (LEC-5). Accessed February 3, 2022. www.ptsd.va.gov/professional/assessment/te-measures/life_events_checklist.asp

26. Weathers FW, Litz BT, Keane TM, et al. The PTSD checklist for DSM-5 (PCL-5). 2013. Accessed February 3, 2022. www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp

27. Rosen R, Brown C, Heiman J, et al. The female sexual function index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000;26:191-208.

28. Melzack R. The short-form McGill Pain Questionnaire. Pain. 1987;30:191-197.

29. Hassam T, Kelso E, Chowdary P, et al. Sexual assault as a risk factor for gynaecological morbidity: an exploratory systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2020;255:222-230.

30. Hamlin AA, Sheeder J, Muffly TM. Brief versus thong hygiene in obstetrics and gynecology (B-THONG): a survey study. J Obstet Gynaecol Res. 2019;45:1190-1196.

31. Foster DC, Kotok MB, Huang LS, et al. Oral desipramine and topical lidocaine for vulvodynia: a randomized controlled trial. Obstet Gynecol. 2010;116:583-593.

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33. Cheong YC, Smotra G, Williams AC. Non-surgical interventions for the management of chronic pelvic pain. Cochrane Database Syst Rev. 2014;(3):CD008797.

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35. Bergeron S, Binik YM, Khalifé S, et al. A randomized comparison of group cognitive-behavioral therapy, surface electromyographic biofeedback, and vestibulectomy in the treatment of dyspareunia resulting from vulvar vestibulitis. Pain. 2001;91:297-306.

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Dyspareunia is persistent or recurrent pain before, during, or after sexual contact and is not limited to cisgender individuals or vaginal intercourse.^1-3 With a prevalence as high as 45% in the United States,^2-5 it is one of the most common complaints in gynecologic practices.^5,6

Causes and contributing factors

There are many possible causes of dyspareunia.^2,4,6 While some patients have a single cause, most cases are complex, with multiple overlapping causes and maintaining factors.^4,6 Identifying each contributing factor can help you appropriately address all components.

Physical conditions. The range of physical contributors to dyspareunia includes inflammatory processes, structural abnormalities, musculoskeletal dysfunctions, pelvic organ disorders, injuries, iatrogenic effects, infections, allergic reactions, sensitization, hormonal changes, medication effects, adhesions, autoimmune disorders, and other pain syndromes (TABLE 1^2-4,6-11).

Inadequate arousal. One of the primary causes of pain during vaginal penetration is inadequate arousal and lubrication.^1,2,9-11 Arousal is the phase of the sexual response cycle that leads to genital tumescence and prepares the genitals for sexual contact through penile/clitoral erection, vaginal engorgement, and lubrication, which prevents pain and enhances pleasurable sensation.^9-11

While some physical conditions can lead to an inability to lubricate, the most common causes of inadequate lubrication are psychosocial-behavioral, wherein patients have the same physical ability to lubricate as patients without genital pain but do not progress through the arousal phase.^9-11 Behavioral factors such as inadequate or ineffective foreplay can fail to produce engorgement and lubrication, while psychosocial factors such as low attraction to partner, relationship stressors, anxiety, or low self-esteem can have an inhibitory effect on sexual arousal.^1,2,9-11 Psychosocial and behavioral factors may also be maintaining factors or consequences of dyspareunia, and need to be assessed and treated.^1,2,9-11

Psychological trauma. Exposure to psychological traumas and the development of posttraumatic stress disorder (PTSD) have been linked with the development of pain disorders in general and dyspareunia specifically. Most patients seeking treatment for chronic pain disorders have a history of physical or sexual abuse.¹² Changes in physiologic processes (eg, neurochemical, endocrine) that occur with PTSD interfere with the sexual response cycle, and sexual traumas specifically have been linked with pelvic floor dysfunction.^13,14 Additionally, when PTSD is caused by a sexual trauma, even consensual sexual encounters can trigger flashbacks, intrusive memories, hyperarousal, and muscle tension that interfere with the sexual response cycle and contribute to genital pain.¹³

Vaginismus is both a physiologic and psychological contributor to dyspareunia.^1,2,4 Patients experiencing pain can develop anxiety about repeated pain and involuntarily contract their pelvic muscles, thereby creating more pain, increasing anxiety, decreasing lubrication, and causing pelvic floor dysfunction.^1-4,6 Consequently, all patients with dyspareunia should be assessed and continually monitored for symptoms of vaginismus.

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