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Women's Sexual Health in Midlife and Beyond

(Published May 2005)

Female Sexual Pain Disorders

Female sexual pain disorders are divided into three main categories: dyspareunia, vaginismus, and other pain-related disorders.

Diagnostic Criteria

Dyspareunia has most recently been defined as “persistent or recurrent pain with attempted or complete vaginal entry and/or penile-vaginal intercourse.”1 This definition now includes pain during penetration, not just during attempts at penetration. A woman’s decision not to have intercourse should not change the diagnosis, according to the panelists gathered by the American Foundation for Urologic Disease. Vaginismus is defined as “persistent difficulties to allow vaginal entry of a penis, a finger, and/or any object, despite the woman’s expressed wish to do so. There is variable involuntary pelvic muscle contraction, (phobic) avoidance, and anticipation/fear/experience of pain. Structural or other physical abnormalities must be ruled out/addressed.” The panelists revised this definition because they noted that vaginal spasm has never been documented, despite the inclusion of spasm in earlier definitions. Rather, they preferred the definition to specify that involuntary contractions may occur. They noted that vaginismus typically prevents the full entry of a penis, etc., but that vaginal entry still may occur and cause discomfort and pain. Other pain-related sexual disorders can be related to a host of anatomic abnormalities, inflammatory conditions, infections, vestibulitis, genital mutilation or trauma, surgery for prolapse or incontinence, and endometriosis.2 Dyspareunia also can be a common occurrence after a long period without sexual intercourse, as may occur when a male partner is successfully treated for long-standing erectile dysfunction.3

Dyspareunia is estimated to affect 14.4 percent of women annually, according to the National Health and Social Life Survey,4 and vaginismus affects 15 percent to 17 percent of women presenting to a sex therapy clinic.2,5 The most common cause of sexual pain disorders among middle-aged and older women is atrophic vaginitis. For instance, in a postmenopausal population in the Netherlands, 27 percent of the women surveyed reported vaginal dryness, soreness, and dyspareunia.2,6 It can be difficult to differentiate between the two disorders because symptoms can overlap (e.g., pain can both prevent penetration and cause muscle contractions). The cause of the disorders is unknown but can be related to medical conditions—dyspareunia is the only female sexual disorder in which organic factors figure largely—as well as the ubiquitous psychological and relationship factors.2

Examination of the genitals needs to be approached with gentleness and constant interaction with the patient about painful areas. Examination with a speculum may be difficult or impossible at first, because patients may involuntarily contract their pelvic-floor muscles in anticipation of pain.2

Treating Sexual Pain Disorders

Vaginal or oral estrogen and lubricants can be prescribed to enhance comfort with penetration for women with vaginal atrophy. In light of the Women’s Health Initiative findings, hormone therapy is indicated in the short-term management of menopausal symptoms at the lowest possible dose.8 This has complicated therapy, requiring that each woman make the decision about the risks and benefits of hormone therapy for herself in consultation with her provider.

Beyond treatment of medical conditions such as atrophic vaginitis and endometriosis, patients suffering from sexual pain disorders may benefit from psychological counseling and education. Instruction in progressive muscle relaxation, use of vaginal dilators to increase vault caliber, and regular penetration (if and when possible) also may be warranted.7,9

References

  1. Basson R, Leiblum S, Brotto L, et al. Definitions of women’s sexual dysfunction reconsidered: advocating expansion and revision. J Psychosom Obstet Gynecol 2003;24:221-229.
  2. Anastasiadis AG, Salomon L, Ghafar MA, et al. Female sexual dysfunction: state of the art. Curr Urol Rep 2002;3:484-491.
  3. Kingsberg SA. The impact of aging on sexual function in wo-men and their partners. Arch Sex Behav 2002;31(5):431-437.
  4. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999;281:537-544.
  5. Spector JP, Carey MP. Incidence and prevalence of sexual dysfunctions: a critical review. Arch Sex Behav 1990;19:389-409.
  6. Van Geelen JM, van de Weijer PH, Arnolds H. Urogenital symptoms and their resulting discomfort in non-institutionalized 50-to-75-year-old Dutch women [in Dutch]. Ned Tijdschr Geneeskd 1996;140:713-716.
  7. Walton B, Thorton T. Female sexual dysfunction. Curr Wom Health Rep 2003;3:319-326.
  8. Hays J, Ockene JK, Brunner RL, et al. Effects of estrogen plus progestin on health-related quality of life. N Engl J Med 2003;348:1839-1854.
  9. Phillips NA. Female sexual dysfunction: evaluation and treatment. Am Fam Physician 2000;62:127-136, 141-142.